Efficacy and Safety of Different Laser Types in Periodontal Flap Microsurgery: A Systematic Review and Network Meta-Analysis

Introduction: Periodontitis, a chronic inflammatory disease, may necessitate surgical intervention when non-surgical methods are ineffective. This systematic review and network meta-analysis investigates the efficacy and safety of various laser types in periodontal flap microsurgery, consolidating clinical trial results on diode lasers, which show promising yet variable outcomes. Methods: The review was registered in PROSPERO and follows the PRISMA 2020 reporting guidelines. Search strategy was carried out in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Directory of Open Access journals (DOAJ), PubMed, which yielded 15 randomised controlled trials. The data extraction was conducted, followed by both qualitative and quantitative analysis, by assessing risk of bias using Cochrane RoB-2 tool, and network meta-analysis. Results: In the qualitative analysis, out of the 15 studies two showed high risk of bias (RoB), four studies showed low risk and nine studies showed moderate risk. Network meta-analysis was conducted including nine studies, for pocket depth, clinical attachment level (CAL), Gingival Index (GI) and Plaque Index (PI), which demonstrated a connected evidence structure. Effect size ( Z ) for probing depth (PD) = 4.23 ( P < 0.0001), CAL = 1.45 ( P = 0.15), GI = 1.78 ( P = 0.08) and PI = 1.39 ( P = 0.17). Conclusions: The combined evidence shows that both erbium and diode lasers offer tangible advantages in periodontal flap microsurgery, particularly with respect to postoperative comfort, early healing, and soft-tissue response. Erbium lasers seem to be more flexible because they may be used on both soft and hard tissues. Diode lasers constituted majority of available evidence, and have powerful biostimulatory and antibacterial effects. The superiority of any given wavelength remains indeterminate owing to inadequate head-to-head experiments and the lack of protocol standardization.