Dental developmental stage affects the treatment outcome of maxillary protraction in skeletal Class III children: A systematic review and meta-analysis

Miao, Wei; Zhou, Dan; Li, Chunjie; Chen, Lichun; Guan, Min; Peng, Yiran; Mei, Li

doi:10.21307/aoj-2021-004

Figures & Tables

Meta-analysis between primary dentition and early mixed dentition.
The efficacy assessment of the primary dentition group for Class III malocclusion versus the early mixed dentition group. The comparison was performed using five indices. 1: Angle SNA. The primary dentition group presented a greater increase in SNA than the early mixed dentition group (MD = 1.23, 95% CI = 0.19 – 2.27, P = 0.02). 2: Angle SNB. There were no significant differences in SNB between the primary dentition group and the early mixed dentition group (MD = -0.61, 95% CI = -1.76 – 0.54, P = 0.30). 3: Angle ANB. The primary dentition group presented a greater increase in ANB than the early mixed dentition group (MD = 1.80, 95% CI = 0.39 – 3.20, P = 0.01). 4: SN/GoGn angle. The primary dentition group presented a greater increase in SN/GoGn angle than the early mixed dentition group (MD = 0.82, 95% CI = 0.29 – 1.34, P = 0.002). 5: ANS-Me length. The primary dentition group showed a greater increase in ANS-Me length than the early mixed dentition group (MD = 1.57 mm, 95% CI = 0.65 – 2.49, P < 0.001). — Meta-analysis between primary dentition and early mixed dentition. The efficacy assessment of the primary dentition group for Class III malocclusion versus the early mixed dentition group. The comparison was performed using five indices. 1: Angle SNA. The primary dentition group presented a greater increase in SNA than the early mixed dentition group (MD = 1.23, 95% CI = 0.19 – 2.27, P = 0.02). 2: Angle SNB. There were no significant differences in SNB between the primary dentition group and the early mixed dentition group (MD = -0.61, 95% CI = -1.76 – 0.54, P = 0.30). 3: Angle ANB. The primary dentition group presented a greater increase in ANB than the early mixed dentition group (MD = 1.80, 95% CI = 0.39 – 3.20, P = 0.01). 4: SN/GoGn angle. The primary dentition group presented a greater increase in SN/GoGn angle than the early mixed dentition group (MD = 0.82, 95% CI = 0.29 – 1.34, P = 0.002). 5: ANS-Me length. The primary dentition group showed a greater increase in ANS-Me length than the early mixed dentition group (MD = 1.57 mm, 95% CI = 0.65 – 2.49, P < 0.001).

Meta-analysis between early mixed dentition and late mixed dentition.
The efficacy assessment of the early mixed dentition group for Class III malocclusion versus the late mixed dentition group. The comparison was performed using six indices. 1: Angle SNA. There were no significant differences in SNA between the two groups (MD = -0.39, 95% CI = -0.82 – 0.05, P = 0.08). 2: Angle SNB. The early mixed dentition group presented a greater decrease in SNB than the late mixed dentition group (MD = -0.45, 95% CI = -0.85 – -0.06, P = 0.03). 3: Angle ANB. There were no significant differences in ANB between the two groups (MD = 0.01, 95% CI = -0.47 – 0.48, P = 0.98). 4: SN/GoGn angle. There were no significant differences in SN/GoGn angle between the two groups (MD = -0.21, 95% CI = -0.42 – 0.00, P = 0.05). 5: ANS-Me length. The late mixed dentition group presented a greater increase in ANS-Me length than the early mixed dentition group (MD = -1.13, 95% CI = -1.45 – -0.80, P <0.001). 6: overjet. The late mixed dentition group presented a greater increase in overjet than the early mixed dentition group (MD = -0.74, 95% CI = -0.98 – -0.50, P < 0.001). — Meta-analysis between early mixed dentition and late mixed dentition. The efficacy assessment of the early mixed dentition group for Class III malocclusion versus the late mixed dentition group. The comparison was performed using six indices. 1: Angle SNA. There were no significant differences in SNA between the two groups (MD = -0.39, 95% CI = -0.82 – 0.05, P = 0.08). 2: Angle SNB. The early mixed dentition group presented a greater decrease in SNB than the late mixed dentition group (MD = -0.45, 95% CI = -0.85 – -0.06, P = 0.03). 3: Angle ANB. There were no significant differences in ANB between the two groups (MD = 0.01, 95% CI = -0.47 – 0.48, P = 0.98). 4: SN/GoGn angle. There were no significant differences in SN/GoGn angle between the two groups (MD = -0.21, 95% CI = -0.42 – 0.00, P = 0.05). 5: ANS-Me length. The late mixed dentition group presented a greater increase in ANS-Me length than the early mixed dentition group (MD = -1.13, 95% CI = -1.45 – -0.80, P <0.001). 6: overjet. The late mixed dentition group presented a greater increase in overjet than the early mixed dentition group (MD = -0.74, 95% CI = -0.98 – -0.50, P < 0.001).

Meta-analysis between late mixed dentition and early permanent dentition.
The efficacy assessment of the late mixed dentition group for Class III malocclusion versus the early permanent dentition group. The comparison was performed using six indices. 1: Angle SNA. There were no significant differences in SNA between the two groups (MD = 0.61, 95% CI = -0.16 – 1.38, P = 0.12). 2: Angle SNB. There were no significant differences in SNB between the two groups (MD =-0.10, 95% CI = -0.79 – 0.59, P = 0.78). 3: Angle ANB. There were no significant differences in ANB between the two groups (MD = 0.75, 95% CI = -0.48 – 1.99, P = 0.23). 4: SN/GoGn angle. There were no significant differences in SN/GoGn angle between the two groups (MD = 0.67, 95% CI = -0.83 – 2.18, P = 0.38). 5: overjet. There were no significant differences in overjet between the two groups (MD = 0.38, 95% CI = -0.45 – 1.22, P = 0.37). 6: Wits. There were no significant differences in Wits between the two groups (MD = -0.37, 95%CI = -2.07 – 1.32, P = 0.67). — Meta-analysis between late mixed dentition and early permanent dentition. The efficacy assessment of the late mixed dentition group for Class III malocclusion versus the early permanent dentition group. The comparison was performed using six indices. 1: Angle SNA. There were no significant differences in SNA between the two groups (MD = 0.61, 95% CI = -0.16 – 1.38, P = 0.12). 2: Angle SNB. There were no significant differences in SNB between the two groups (MD =-0.10, 95% CI = -0.79 – 0.59, P = 0.78). 3: Angle ANB. There were no significant differences in ANB between the two groups (MD = 0.75, 95% CI = -0.48 – 1.99, P = 0.23). 4: SN/GoGn angle. There were no significant differences in SN/GoGn angle between the two groups (MD = 0.67, 95% CI = -0.83 – 2.18, P = 0.38). 5: overjet. There were no significant differences in overjet between the two groups (MD = 0.38, 95% CI = -0.45 – 1.22, P = 0.37). 6: Wits. There were no significant differences in Wits between the two groups (MD = -0.37, 95%CI = -2.07 – 1.32, P = 0.67).

Meta-analysis between early mixed dentition and early permanent dentition.
The efficacy assessment of the early mixed dentition group for Class III malocclusion versus the early permanent dentition group. The comparison was performed using three indices. 1: Angle SNA. The early mixed dentition group presented a greater increase in SNA than the early permanent dentition group (MD = 1.02, 95% CI = 0.05 – 2.0, P = 0.04). 2: Angle SNB. There were no significant differences in SNB between the two groups (MD = -0.69, 95% CI = -2.08 – 0.70, P = 0.33). 3: Angle ANB. The early mixed dentition group presented a greater increase in ANB than the early permanent dentition group (MD = 1.89, 95% CI = 1.27 – 2.50, P < 0.001). — Meta-analysis between early mixed dentition and early permanent dentition. The efficacy assessment of the early mixed dentition group for Class III malocclusion versus the early permanent dentition group. The comparison was performed using three indices. 1: Angle SNA. The early mixed dentition group presented a greater increase in SNA than the early permanent dentition group (MD = 1.02, 95% CI = 0.05 – 2.0, P = 0.04). 2: Angle SNB. There were no significant differences in SNB between the two groups (MD = -0.69, 95% CI = -2.08 – 0.70, P = 0.33). 3: Angle ANB. The early mixed dentition group presented a greater increase in ANB than the early permanent dentition group (MD = 1.89, 95% CI = 1.27 – 2.50, P < 0.001).

Meta-analysis between primary dentition and late mixed dentition.
The efficacy assessment of the primary dentition group for Class III malocclusion versus the late mixed dentition group. The comparison was performed using three indices. 1: Angle SNA. The primary dentition group presented a greater increase in SNA than the late mixed dentition group (MD = 0.62, 95% CI = 0.03 – 1.21, P = 0.04). 2: Angle SNB. There were no significant differences in SNB between the two groups (MD = -0.44, 95% CI = -0.91 – 0.70, P = 0.04). 3: Angle ANB. The primary dentition group presented a greater increase in ANB than the late mixed dentition group (MD = 1.21, 95% CI = 0.51 – 1.92, P < 0.001). — Meta-analysis between primary dentition and late mixed dentition. The efficacy assessment of the primary dentition group for Class III malocclusion versus the late mixed dentition group. The comparison was performed using three indices. 1: Angle SNA. The primary dentition group presented a greater increase in SNA than the late mixed dentition group (MD = 0.62, 95% CI = 0.03 – 1.21, P = 0.04). 2: Angle SNB. There were no significant differences in SNB between the two groups (MD = -0.44, 95% CI = -0.91 – 0.70, P = 0.04). 3: Angle ANB. The primary dentition group presented a greater increase in ANB than the late mixed dentition group (MD = 1.21, 95% CI = 0.51 – 1.92, P < 0.001).

Risk of bias of the included studies assessed by ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions)_

Study	Bias due to confounding	Bias in selection of participants into the study	Bias in classification of interventions	Bias due to deviations from intended interventions	Bias due to missing data	Bias in measurement of outcomes	Bias in selection of the reported result	Overall risk of bias
Kajiyama 2004	Moderate	Moderate	Low	Low	Low	No information	Low	Moderate
Lee 2010	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Saadia 2000	Serious	Moderate	Low	Low	Low	No information	Low	Serious
Saadia 2001	Serious	Moderate	Low	Low	Low	No information	Low	Serious
Fareen 2017	Low	Low	Low	Low	Low	Low	Low	Low
Atalay 2010	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Cha 2003	Moderate	Serious	Low	Low	Low	Low	Low	Serious
Wang 2002	Serious	Serious	Low	Low	Low	Low	Low	Serious
Baccetti 2000	Moderate	Low	Low	Low	Low	No information	Low	Moderate
Baccetti 1998	Low	Low	Low	Low	Low	No information	Low	Low
Merwin 1997	Serious	Serious	Low	Low	Low	Low	Low	Serious
Liu 2013	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Yuksel 2001	Moderate	Moderate	Low	Low	Low	No information	Low	Moderate
Takada 1993	Moderate	Moderate	Low	Low	Low	Low	Low	Moderate
Baik 1995	Moderate	Moderate	Low	Low	Low	Moderate	Low	Moderate
Kapust 1998	Low	Low	Low	Low	Low	Low	Low	Low

Characteristics of the included studies_

Study	Location	Study design	Dentition (year of age)	Sample size	Appliance
Kajiyama 2004	Japan	CCT	Primary (5.6)Early mixed (8.7)	Primary (N=34)Early mixed (N=29)	FM
Lee 2010	South Korea	CCT	Primary (6.1)Early mixed (8.4)	Primary (N=26)Early (N=23)	FM
Saadia 2000	Mexico	CCT	Primary (3-6)Early mixed (6-9)Late mixed (9-12)	Primary (N=38)Early mixed (N=55)Late mixed (N=19)	FM+RME
Saadia 2001	Mexico	CCT	Primary (3-6)Early mixed (6-9)Late mixed (9-12)	Primary (N=38)Early mixed (N=55)Late mixed (N=19)	FM+RME
Fareen 2017	Malaysia	CCT	Early mixed (8-9)Late mixed (10-11)	Early mixed (N=20)Late mixed (N=26)	FM
Atalay 2010	Turkey	CCT	Early mixed (8.18)Late mixed (11.75)	Early mixed (N=15)Late mixed (N=15)	FM
Cha 2003	South Korea	CCT	Early mixed (9.82)Late mixed (11.31)Early permanent (13.07)	Early mixed (N=34)Late mixed (N=32)Early permanent (N=19)	FM+RME
Wang 2002	China	CCT	Early mixed (7.3)Late mixed (11.7)	Early mixed (N=32)Late mixed (N=11)	FM+RME
Baccetti 2000	Italy	CCT	Early mixed (5.5-7.8)Late mixed (7.8-10)	Early mixed (N=16)Late mixed (N=13)	FM+RME
Baccetti 1998	Italy	CCT	Early mixed (6.9)Late mixed (10.3)	Early mixed (N=23)Late mixed (N=23)	FM+RME
Merwin 1997	Hong Kong	CCT	Early mixed (6.8)Late mixed (10.2)	Early mixed (N=15)Late mixed (N=15)	FM+RME
Liu 2013	China	CCT	No information (8-15)	Late mixed (N=14)Early permanent (N=15)	FM
Yuksel 2001	Turkey	CCT	Late mixed (9.8)Early permanent (12.6)	Late mixed (N=17)Early permanent (N=17)	FM
Takada 1993	Japan	CCT	Early mixed (7.8)Late mixed (10.3)Early permanent (12)	Early mixed (N=20)Late mixed (N=22)Early permanent (N=19)	FM
Baik 1995	South Korea	CCT	Early mixed (<10)Late mixed (10-12)Early permanent (>12)	Early mixed (N=11)Late mixed (N=21)Early permanent (N=15)	FM+RME
Kapust 1998	America	CCT	Primary dentition (4-7)Early mixed (7-10)Late mixed (10-14)	Primary dentition (N=15)Early mixed (N=32)Late mixed (N=16)	FM+RME

Search strategy used for PubMed_

	Search history	Number of results
#1	Maxillary protraction OR facemask OR face mask OR facial mask OR reverse headgear	6340
#2	Class III OR Class 3	189199
#3	Malocclusion, Angle class III [Mesh]	3528
#4	#2 OR #3	189199
#5	Primary dentition OR deciduous dentition	15204
#6	Early mixed dentition OR late mixed dentition OR mixed dentition OR early permanent dentition	3589
#7	#5 OR #6	17327
#8	#1 AND #4 AND #7	78

Egger’s test for the analysis of small study effects on publication bias_

	SNA	SNB	ANB	SN/GoGn	ANS/Me	Overjet
Primary dentition vs early mixed dentition	0.539	0.704	0.639	0.054	N/A	N/A
Early mixed dentition vs late mixed dentition	0.099	0.217	0.195	0.022*	0.001*	0.313
Late mixed dentition vs early permanent dentition	0.764	0.144	0.576	0.207	N/A	0.220

Dental developmental stage affects the treatment outcome of maxillary protraction in skeletal Class III children: A systematic review and meta-analysis

Figures & Tables

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Risk of bias of the included studies assessed by ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions)_

Characteristics of the included studies_

Search strategy used for PubMed_

Egger’s test for the analysis of small study effects on publication bias_

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