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Tratamiento ortodóntico para los dientes frontales superiores prominentes (maloclusión de clase II) en niños y adolescentes

Appendices

Appendix 1. Cochrane Oral Health's Trials Register search strategy

From April 2013, searches of Cochrane Oral Health's Trials Register were conducted using the Cochrane Register of Studies and the search strategy below:

#1 (orthodontic*:ti,ab) AND (INREGISTER)
#2 ((appliance* or device*):ti,ab) AND (INREGISTER)
#3 ((function* or remov* or fix* or intraoral or "intra oral" or intra‐oral or extraoral or "extra oral" or extra‐oral):ti,ab) AND (INREGISTER)
#4 ((brace* or band* or wire* or headgear* or "head gear*" or head‐gear* ):ti,ab) AND (INREGISTER)
#5 (#2 and #3) AND (INREGISTER)
#6 (("activator appliance*" or Frankel or "twin* block*" or FR‐II or "growth modif*" or "Two phase"):ti,ab) AND (INREGISTER)
#7 ((orthopedic and dental):ti,ab) AND (INREGISTER)
#8 ((orthopaedic and dental):ti,ab) AND (INREGISTER)
#9 (#1 or #4 or #5 or #6 or #7 or #8) AND (INREGISTER)
#10 ((retrognathi* or "posterior occlusion*"):ti,ab) AND (INREGISTER)
#11 (("class II" and malocclusion*):ti,ab) AND (INREGISTER)
#12 ((distocclusion* or disto‐occlusion* or distoclusion* or "prominent upper front teeth" or overjet* or over‐jet* or "over jet*"):ti,ab) AND (INREGISTER)
#13 (("Class 2" and malocclusion*):ti,ab) AND (INREGISTER)
#14 (#10 or #11 or #12 or #13) AND (INREGISTER)
#15 (#9 and #14) AND (INREGISTER)

Previous searches of Cochrane Oral Health's Trials Register were conducted using the Procite software and the search strategy below:

(orthodontic* or (appliance* and (function* or remov* or fix* or intraoral or "intra oral" or intra‐oral or extraoral or "extra oral" or extra‐oral)) or brace* or band* or wire* or headgear* or "head gear*" or head‐gear* or (device and (function* or remov* or fix* or intraoral or "intra oral" or intra‐oral or extraoral or "extra oral" or extra‐oral)) or "activator appliance*" or Frankel or "twin* block*" or FR‐II or "growth modif*" or "Two phase" or (orthopedic and dental) or (orthopaedic and dental)) AND (retrognathi* or "posterior occlusion*" or ("class II" and malocclusion*) or ("Class 2" and malocclusion*) or distocclusion* or disto‐occlusion* or distoclusion* or "prominent upper front teeth" or overjet* or over‐jet* or "over jet*")

Appendix 2. Cochrane Central Register of Controlled Trials (CENTRAL) search strategy

#1 MeSH descriptor Orthodontics explode all trees
#2 ((appliance* in All Text near/5 function* in All Text) or (appliance* in All Text near/5 remov* in All Text) or (appliance* in All Text near/5 fix* in All Text) or (appliance* in All Text near/5 intraoral in All Text) or (appliance* in All Text near/5 "intra oral" in All Text) or (appliance* in All Text near/5 intra‐oral in All Text) or (appliance* in All Text near/5 extraoral in All Text) or (appliance* in All Text near/5 "extra oral" in All Text) or (appliance* in All Text near/5 extra‐oral in All Text))
#3 ((device* in All Text near/5 function* in All Text) or (device* in All Text near/5 remov* in All Text) or (device* in All Text near/5 fix* in All Text) or (device* in All Text near/5 intraoral in All Text) or (device* in All Text near/5 "intra oral" in All Text) or (device* in All Text near/5 intra‐oral in All Text) or (device* in All Text near/5 extraoral in All Text) or (device* in All Text near/5 "extra oral" in All Text) or (device* in All Text near/5 extra‐oral in All Text))
#4 (orthodontic* in All Text and (brace* in All Text or band* in All Text or wire* in All Text) )
#5 (orthodontic* in All Text and (extract* in All Text or remov* in All Text) )     
#6 (orthodontic* in All Text and (headgear* in All Text or "head gear*" in All Text or head‐gear in All Text) )
#7 "activator appliance*" in All Text        
#8 (Frankel in All Text or "twin* block*" in All Text or FR‐II in All Text)
#9 ( (growth in All Text near/3 modif* in All Text) and (jaw* in All Text or maxilla* in All Text or mandib* in All Text) )
#10 (two‐phase in All Text and (treatment in All Text or therapy in All Text) and (orthodontic* in All Text or malocclusion* in All Text) )    
#11 ( (orthopedic* in All Text or orthopaedic* in All Text) and (dental in All Text or orthodontic* in All Text or facial in All Text) )
#12 (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11)    
#13 MeSH descriptor Malocclusion, Angle Class II this term only
#14 MeSH descriptor Retrognathism this term only
#15 ( ("class II" in All Text near/3 malocclusion* in All Text) or ("class 2" in All Text near/3 malocclusion* in All Text) ) #16 (posterior in All Text near/3 occlusion* in All Text)    
#17 (distoclusion* in All Text or disto‐occlusion* in All Text or distocclusion* in All Text)
#18 retrognath* in All Text
#19 "prominent upper front teeth" in All Text
#20 (overjet* in All Text or "over jet*" in All Text or over‐jet* in All Text)
#21 (#13 or #14 or #15 or #16 or #17 or #18 or #19 or #20)        
#22 (#12 and #21)

Appendix 3. MEDLINE Ovid search strategy

1. exp Orthodontics/      
2. (appliance$ adj5 (function$ or remova$ or fix$)).mp.                                   
3. (orthodontic$ and (brace$ or band$ or wire$)).mp.                          
4. (orthodontic$ and (extract$ or remov$)).mp.                                    
5. (orthodontic$ and (headgear$ or "head gear$" or head‐gear$)).mp.            
6. (device$ adj5 (function$ or remova$ or fix$)).mp.               
7. ((appliance$ or device$) adj5 (intraoral or "intra oral" or intra‐oral or extraoral or "extra oral" or extra‐oral)).mp.     
8. (activator adj appliance$).mp.                                   
9. (Frankel or "twin$ block$" or FR‐II).mp.                                
10. ((growth adj3 modif$) and (jaw$ or maxilla$ or mandible$ or mandibular)).mp.
11. (two‐phase and (treatment or therapy) and (orthodontic$ or malocclusion$)).mp.
12. ((orthopedic$ or orthopaedic$) and (dental or orthodontic$ or facial)).mp.
13. or/1‐12                                    
14. Malocclusion, Angle Class II/                         
15. Retrognathism/                                  
16. (("class II" or "class 2") adj3 malocclusion$).mp.                              
17. (posterior adj3 occlusion$).mp.                                 
18. (distoclusion$ or disto‐occlusion$ or distocclusion$).mp.                             
19. retrognath$.mp.                                 
20. (prominent adj3 upper adj3 teeth).mp.                                  
21. (overjet$ or "over jet$" or over‐jet$).mp.                               
22. or/14‐21                                  
23. 13 and 22

The above subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of theCochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011] (Lefebvre 2011).

1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1‐8
10. exp animals/ not humans.sh.
11. 9 not 10

Appendix 4. Embase Ovid search strategy

1. exp Orthodontics/                  
2. (appliance$ adj5 (function$ or remova$ or fix$)).mp.                                   
3. (orthodontic$ and (brace$ or band$ or wire$)).mp.                          
4. (orthodontic$ and (extract$ or remov$)).mp.                                    
5. (orthodontic$ and (headgear$ or "head gear$" or head‐gear$)).mp.            
6. (device$ adj5 (function$ or remova$ or fix$)).mp.                           
7. ((appliance$ or device$) adj5 (intraoral or "intra oral" or intra‐oral or extraoral or "extra oral" or extra‐oral)).mp.      
8. (activator adj appliance$).mp.                                   
9. (Frankel or "twin$ block$" or FR‐II).mp.                                
10. ((growth adj3 modif$) and (jaw$ or maxilla$ or mandible$ or mandibular)).mp.                              
11. (two‐phase and (treatment or therapy) and (orthodontic$ or malocclusion$)).mp.                          
12. ((orthopedic$ or orthopaedic$) and (dental or orthodontic$ or facial)).mp.  
13. or/1‐12                                    
14. Retrognathia/                         
15. (("class II" or "class 2") adj3 malocclusion$).mp.                              
16. (posterior adj3 occlusion$).mp.                                 
17. (distoclusion$ or disto‐occlusion$ or distocclusion$).mp.                             
18. retrognath$.mp.                                 
19. (prominent adj3 upper adj3 teeth).mp.                                  
20. (overjet$ or "over jet$" or over‐jet$).mp.                               
21. or/14‐20                                  
22. 13 and 21

The above subject search was linked to adapted version of the Cochrane Embase Project filter for identifying RCTs in Embase Ovid (see http://www.cochranelibrary.com/help/central‐creation‐details.html for information):

1. Randomized controlled trial/
2. Controlled clinical study/
3. Random$.ti,ab.
4. randomization/
5. intermethod comparison/
6. placebo.ti,ab.
7. (compare or compared or comparison).ti.
8. ((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparing or comparison)).ab.
9. (open adj label).ti,ab.
10. ((double or single or doubly or singly) adj (blind or blinded or blindly)).ti,ab.
11. double blind procedure/
12. parallel group$1.ti,ab.
13. (crossover or cross over).ti,ab.
14. ((assign$ or match or matched or allocation) adj5 (alternate or group$1 or intervention$1 or patient$1 or subject$1 or participant$1)).ti,ab.
15. (assigned or allocated).ti,ab.
16. (controlled adj7 (study or design or trial)).ti,ab.
17. (volunteer or volunteers).ti,ab.
18. trial.ti.
19. or/1‐18
20. (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.)
21. 19 not 20

Appendix 5. US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) search strategy

“class II malocclusion”
retrognath*
overjet or “posterior occlusion”
“prominent upper front teeth”

Appendix 6. World Health Organization International Clinical Trials Registry Platform search strategy

“class II malocclusion” or “class 2 malocclusion”
retrognath*
overjet or “posterior occlusion”
“prominent upper front teeth”

Study flow diagram
Figures and Tables -
Figure 1

Study flow diagram

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 1 Outcomes at the end of phase I: functional versus observation.
Figures and Tables -
Analysis 1.1

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 1 Outcomes at the end of phase I: functional versus observation.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 2 Incidence of new incisal trauma during phase I treatment: functional versus observation.
Figures and Tables -
Analysis 1.2

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 2 Incidence of new incisal trauma during phase I treatment: functional versus observation.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 3 Outcomes at the end of phase I: headgear versus observation.
Figures and Tables -
Analysis 1.3

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 3 Outcomes at the end of phase I: headgear versus observation.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 4 Incidence of new incisal trauma during phase I treatment: headgear versus observation.
Figures and Tables -
Analysis 1.4

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 4 Incidence of new incisal trauma during phase I treatment: headgear versus observation.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 5 Outcomes at the end of phase II: functional (2‐phase) versus adolescent (1‐phase) treatment.
Figures and Tables -
Analysis 1.5

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 5 Outcomes at the end of phase II: functional (2‐phase) versus adolescent (1‐phase) treatment.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 6 Incidence of new incisal trauma by the end of phase II treatment: functional (2‐phase) versus adolescent (1‐phase) treatment.
Figures and Tables -
Analysis 1.6

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 6 Incidence of new incisal trauma by the end of phase II treatment: functional (2‐phase) versus adolescent (1‐phase) treatment.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 7 Outcomes at the end of phase II: headgear (2‐phase) versus adolescent (1‐phase) treatment.
Figures and Tables -
Analysis 1.7

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 7 Outcomes at the end of phase II: headgear (2‐phase) versus adolescent (1‐phase) treatment.

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 8 Incidence of new incisal trauma by the end of phase II treatment: headgear (2‐phase) versus adolescent (1‐phase) treatment.
Figures and Tables -
Analysis 1.8

Comparison 1 Early orthodontic treatment: two‐phase versus one‐phase treatment, Outcome 8 Incidence of new incisal trauma by the end of phase II treatment: headgear (2‐phase) versus adolescent (1‐phase) treatment.

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 1 Outcomes at the end of phase I: headgear versus functional.
Figures and Tables -
Analysis 2.1

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 1 Outcomes at the end of phase I: headgear versus functional.

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 2 Incidence of new incisal trauma during phase I treatment: headgear versus functional.
Figures and Tables -
Analysis 2.2

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 2 Incidence of new incisal trauma during phase I treatment: headgear versus functional.

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 3 Outcomes at the end of phase II: headgear versus functional.
Figures and Tables -
Analysis 2.3

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 3 Outcomes at the end of phase II: headgear versus functional.

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 4 Incidence of new incisal trauma by the end of phase II treatment: headgear versus functional appliance.
Figures and Tables -
Analysis 2.4

Comparison 2 Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional), Outcome 4 Incidence of new incisal trauma by the end of phase II treatment: headgear versus functional appliance.

Comparison 3 Late orthodontic treatment: functional versus no treatment, Outcome 1 Final overjet.
Figures and Tables -
Analysis 3.1

Comparison 3 Late orthodontic treatment: functional versus no treatment, Outcome 1 Final overjet.

Comparison 3 Late orthodontic treatment: functional versus no treatment, Outcome 2 Final ANB.
Figures and Tables -
Analysis 3.2

Comparison 3 Late orthodontic treatment: functional versus no treatment, Outcome 2 Final ANB.

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 1 Twin Block versus other functional appliances (R‐appliance, Bionator, Bite‐Jumping appliance, Dynamax and Herbst).
Figures and Tables -
Analysis 4.1

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 1 Twin Block versus other functional appliances (R‐appliance, Bionator, Bite‐Jumping appliance, Dynamax and Herbst).

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 2 Twin Block conventional versus other Twin Block modifications.
Figures and Tables -
Analysis 4.2

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 2 Twin Block conventional versus other Twin Block modifications.

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 3 Functional (Activator) versus prefabricated functional myobrace appliance (PFA).
Figures and Tables -
Analysis 4.3

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 3 Functional (Activator) versus prefabricated functional myobrace appliance (PFA).

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 4 Functional (Activator) versus fixed functional (FORSUS FRD EZ).
Figures and Tables -
Analysis 4.4

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 4 Functional (Activator) versus fixed functional (FORSUS FRD EZ).

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 5 Fixed functional (FORSUS FRD) versus fixed functional with mini‐implants (FMI).
Figures and Tables -
Analysis 4.5

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 5 Fixed functional (FORSUS FRD) versus fixed functional with mini‐implants (FMI).

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 6 Fixed functional (FORSUS FRD) versus fixed functional with mini‐implants (FMI) ‐ patient satisfaction with results.
Figures and Tables -
Analysis 4.6

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 6 Fixed functional (FORSUS FRD) versus fixed functional with mini‐implants (FMI) ‐ patient satisfaction with results.

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 7 R‐appliance versus AIBP.
Figures and Tables -
Analysis 4.7

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 7 R‐appliance versus AIBP.

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 8 Removable functional appliance versus fixed functional appliance.
Figures and Tables -
Analysis 4.8

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 8 Removable functional appliance versus fixed functional appliance.

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 9 FORSUS versus intermaxillary elastics.
Figures and Tables -
Analysis 4.9

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 9 FORSUS versus intermaxillary elastics.

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 10 FMA stepwise (SWG) versus FMA single step (SSG).
Figures and Tables -
Analysis 4.10

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 10 FMA stepwise (SWG) versus FMA single step (SSG).

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 11 Harvold Activator versus Frankel function regulator.
Figures and Tables -
Analysis 4.11

Comparison 4 Late orthodontic treatment: different types of appliances used for late treatment, Outcome 11 Harvold Activator versus Frankel function regulator.

Summary of findings for the main comparison. Early treatment (two‐phase: phase one in childhood and phase two in adolescence) versus late treatment (one‐phase in adolescence) with functional appliance

Early treatment (two‐phase: phase one in childhood and phase two in adolescence) versus late treatment (one‐phase in adolescence) with functional appliance

Patient or population: children and/or adolescents (age ≤ 16 years) receiving orthodontic treatment to correct prominent upper front teeth

Intervention: early treatment with functional appliance

Comparison: late treatment with functional appliance

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Late treatment with functional appliance

Early treatment with functional appliance

Overjet (mm)

(smaller value better)

Follow‐up at end of orthodontic treatment

Mean final overjet ranged across control groups from 2.6 mm to 4.3 mm

Mean final overjet 0.21 mm more (0.10 mm less to 0.51 mm more)

343 (3)

⊕⊕

low2 3

The functional appliance reduced overjet compared to no treatment at the end of the first phase of early treatment (MD −4.17, −4.61 to −3.73; 432 participants).

Incidence of incisal trauma

Follow‐up at end of orthodontic treatment

298 per 10001

192 per 1000 (123 to 288)

OR 0.56 (0.33 to 0.95)

332 (3)

⊕⊕⊕

moderate2

ANB (°)

Follow‐up at end of orthodontic treatment

Mean final ANB ranged across control groups from 3.7° to 4.0°

Mean final ANB 0.02° less (0.47° less to 0.43° more)

347 (3)

⊕⊕⊕

moderate2

The functional appliance improved ANB at the end of the first phase of early treatment when compared with no treatment (MD −0.89, −1.38 to −0.40; 419 participants).

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Based on average in control groups
2 Downgraded as 2 of the 3 studies were at high risk of bias
3 Downgraded due to heterogeneity (Chi² = 5.23, degrees of freedom (df) = 2 (P value = 0.07); I² = 62%)

Figures and Tables -
Summary of findings for the main comparison. Early treatment (two‐phase: phase one in childhood and phase two in adolescence) versus late treatment (one‐phase in adolescence) with functional appliance
Summary of findings 2. Early treatment (two‐phase: phase 1 in childhood and phase 2 in adolescence) with headgear appliance versus late treatment (one‐phase in adolescence) with headgear

Early treatment (two‐phase: phase 1 in childhood and phase 2 in adolescence) with headgear appliance versus late treatment (one‐phase in adolescence) with headgear

Patient or population: children and/or adolescents (age ≤ 16 years) receiving orthodontic treatment to correct prominent upper front teeth

Intervention: early treatment with headgear

Comparison: late treatment with headgear

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Late treatment with headgear

Early treatment with headgear

Overjet (mm)

(smaller value better)

Follow‐up at end of orthodontic treatment

Mean final overjet ranged across control groups from 2.4 mm to 3.48 mm

Mean final overjet in the 2‐phase treatment group was 0.22 mm less (0.56 mm less to 0.12 mm more)

238 (2)

⊕⊕

low2

Headgear reduced overjet compared to no treatment at the end of the first phase of early treatment (MD −1.07, −1.63 to −0.51; 278 participants).

Incidence of incisal trauma

Follow‐up at end of orthodontic treatment

367 per 10001

207 per 1000 (126 to 317)

OR 0.45 (0.25 to 0.80)

237 (2)

⊕⊕

low2

ANB (°)

Follow‐up at end of orthodontic treatment

Mean final ANB ranged across control groups from 3.3° to 4.0°

Mean final ANB 0.27° less (0.80° less to 0.26° more)

231 (2)

⊕⊕

low2

Headgear improved ANB compared to no treatment at the end of the first phase of early treatment (MD −0.72, −1.18 to −0.27; 277 participants).

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; MD: mean difference; OR: odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Based on average in control groups
2 Downgraded twice as both studies at high risk of bias

Figures and Tables -
Summary of findings 2. Early treatment (two‐phase: phase 1 in childhood and phase 2 in adolescence) with headgear appliance versus late treatment (one‐phase in adolescence) with headgear
Summary of findings 3. Late treatment (one‐phase in adolescence) with functional appliance versus no treatment for prominent upper front teeth (Class II malocclusion)

Late treatment (one‐phase in adolescence) with functional appliance versus no treatment for prominent upper front teeth (Class II malocclusion)

Patient or population: adolescents (age between 12 and 16 years) receiving orthodontic treatment to correct prominent upper front teeth
Intervention: late treatment in adolescence with different types of functional appliances
Comparison: no treatment

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

No treatment

Late treatment with functional appliances

Fixed functional appliances

Overjet (mm)

(smaller value better)

Follow‐up at end of orthodontic treatment

Mean final overjet ranged from 7.47 to 10.56 mm

Mean final overjet was 5.46 mm lower
(6.63 lower to 4.28 lower)

61
(2)

⊕⊕⊝⊝
low1

Incidence of incisal trauma

Not measured

ANB (°)

Follow‐up at end of orthodontic treatment

Mean final ANB ranged from 6.30° to 7.92°

Mean final ANB was 0.53° lower
(1.27 lower to 0.22 lower)

89
(3)

⊕⊕⊝⊝
low2

Removable functional appliances

Overjet (mm)

(smaller value better)

Follow‐up at end of orthodontic treatment

Mean final overjet ranged from 7.8 to 9.9 mm

Mean final overjet was 4.62 mm lower (5.33 lower to 3.92 lower)

122
(3)

⊕⊕⊝⊝
low3

Incidence of incisal trauma

Not measured

ANB (°)

Follow‐up at end of orthodontic treatment

Mean final ANB ranged from 6.5° to 6.53°

Mean final ANB was 2.37° lower
(3.01 lower to 1.74 lower)

99
(2)

⊕⊕⊝⊝
low3

1 Downgraded one level as both studies were at unclear risk of bias and one level because of very high heterogeneity (I² = 95%)

2 Downgraded one level as the three studies were at unclear risk of bias and one level for moderate heterogeneity (I² = 51%)

3 Downgraded two levels as both studies were at high risk of bias

Figures and Tables -
Summary of findings 3. Late treatment (one‐phase in adolescence) with functional appliance versus no treatment for prominent upper front teeth (Class II malocclusion)
Summary of findings 4. Late treatment (one‐phase in adolescence): comparison among different types of appliances used for treatment of prominent upper front teeth (Class II malocclusion)

Late treatment (one‐phase in adolescence): comparison among different types of appliances used for treatment of prominent upper front teeth (Class II malocclusion)

Patient or population: adolescents (age between 12 and 16 years) receiving orthodontic treatment to correct prominent upper front teeth
Intervention: late treatment in adolescence with different types of appliances
Comparison: Twin Block

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect (95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Different types of appliances

Twin Block

Overjet (mm)

(smaller value better)

Follow‐up at end of orthodontic treatment

Mean final overjet ranged from 2.68 mm to 4.40 mm

Mean final overjet was 0.08 mm higher
(0.6 lower to 0.76 higher)

259
(4)

⊕⊕⊝⊝
low1 2

Incidence of Incisal trauma

Not measured

ANB (°)

Follow‐up at end of orthodontic treatment

Mean final ANB ranged from 3.63° to 5.00°

Mean final ANB was −0.56° lower
(0.96 lower to 0.16 lower)

320
(6)

⊕⊕⊝⊝
low3 4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: Confidence interval; MD: Mean

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded as 2 of 4 studies were at high risk of bias

2 Dowgraded due to heterogeneity (heterogeneity: Tau² = 0.25; Chi² = 6.61, df = 3 (P = 0.09); I² = 55%)

3 Downgraded as 3 of 6 studies were at high risk of bias

4 Downgraded as the interventions in the comparison groups were not similar

Figures and Tables -
Summary of findings 4. Late treatment (one‐phase in adolescence): comparison among different types of appliances used for treatment of prominent upper front teeth (Class II malocclusion)
Summary of findings 5. Late treatment (one‐phase in adolescence): comparison among different types of appliances used for treatment of prominent upper front teeth (Class II malocclusion)

Late treatment in adolescence (one‐phase): comparison among different types of appliances used for treatment of prominent upper front teeth (Class II malocclusion)

Patient or population: adolescents (age between 12 and 16 years) receiving orthodontic treatment to correct prominent upper front teeth

Intervention: Removable funtional appliance
Comparison: Fixed funtional appliance

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect (95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Fixed functional appliance

Removable functional appliance

Overjet (mm)

(smaller value better)

Follow‐up at end of orthodontic treatment

Mean final overjet ranged from 0.95 mm to 3.53 mm

Mean final overjet was 0.74 mm higher (0.15 lower to 1.33 higher)

154
(2)

⊕⊕⊝⊝
low1 2

Incidence of Incisal trauma

Not measured

ANB (°)

Follow‐up at end of orthodontic treatment

Mean final ANB ranged from 4.40° to 5.88°

Mean final ANB was 1.04° lower
(1.6 lower to 0.49 lower)

185
(3)

⊕⊕⊝⊝
low3 4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: Confidence interval; MD: Mean difference

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded due to inconsistency (interventions were not similar between studies)

2 Downgraded twice as both studies were at high risk of bias

3 Downgraded due to inconsistency (interventions were not similar between studies)

4 Downgraded twice as 3 trials were at high risk of bias

Figures and Tables -
Summary of findings 5. Late treatment (one‐phase in adolescence): comparison among different types of appliances used for treatment of prominent upper front teeth (Class II malocclusion)
Comparison 1. Early orthodontic treatment: two‐phase versus one‐phase treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Outcomes at the end of phase I: functional versus observation Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Final overjet

3

432

Mean Difference (IV, Fixed, 95% CI)

‐4.17 [‐4.61, ‐3.73]

1.2 Final ANB

3

419

Mean Difference (IV, Fixed, 95% CI)

‐0.89 [‐1.38, ‐0.40]

1.3 PAR score

2

349

Mean Difference (IV, Fixed, 95% CI)

‐10.52 [‐12.32, ‐8.71]

1.4 Self concept

1

135

Mean Difference (IV, Fixed, 95% CI)

‐3.63 [‐7.66, 0.40]

2 Incidence of new incisal trauma during phase I treatment: functional versus observation Show forest plot

2

281

Odds Ratio (M‐H, Fixed, 95% CI)

0.72 [0.35, 1.49]

3 Outcomes at the end of phase I: headgear versus observation Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 Final overjet

2

278

Mean Difference (IV, Fixed, 95% CI)

‐1.07 [‐1.63, ‐0.51]

3.2 Final ANB

2

277

Mean Difference (IV, Fixed, 95% CI)

‐0.72 [‐1.18, ‐0.27]

4 Incidence of new incisal trauma during phase I treatment: headgear versus observation Show forest plot

2

285

Odds Ratio (M‐H, Fixed, 95% CI)

0.76 [0.37, 1.54]

5 Outcomes at the end of phase II: functional (2‐phase) versus adolescent (1‐phase) treatment Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5.1 Final overjet

3

343

Mean Difference (IV, Fixed, 95% CI)

0.21 [‐0.10, 0.51]

5.2 Final ANB

3

347

Mean Difference (IV, Fixed, 95% CI)

‐0.02 [‐0.47, 0.43]

5.3 PAR score

3

360

Mean Difference (IV, Fixed, 95% CI)

0.62 [‐0.66, 1.91]

5.4 Self concept

1

132

Mean Difference (IV, Fixed, 95% CI)

‐0.83 [‐3.97, 2.31]

6 Incidence of new incisal trauma by the end of phase II treatment: functional (2‐phase) versus adolescent (1‐phase) treatment Show forest plot

3

332

Odds Ratio (M‐H, Fixed, 95% CI)

0.56 [0.33, 0.95]

7 Outcomes at the end of phase II: headgear (2‐phase) versus adolescent (1‐phase) treatment Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7.1 Final overjet

2

238

Mean Difference (IV, Fixed, 95% CI)

‐0.22 [‐0.56, 0.12]

7.2 Final ANB

2

231

Mean Difference (IV, Fixed, 95% CI)

‐0.27 [‐0.80, 0.26]

7.3 PAR score

2

177

Mean Difference (IV, Fixed, 95% CI)

‐1.55 [‐3.70, 0.60]

8 Incidence of new incisal trauma by the end of phase II treatment: headgear (2‐phase) versus adolescent (1‐phase) treatment Show forest plot

2

237

Odds Ratio (M‐H, Fixed, 95% CI)

0.45 [0.25, 0.80]

Figures and Tables -
Comparison 1. Early orthodontic treatment: two‐phase versus one‐phase treatment
Comparison 2. Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Outcomes at the end of phase I: headgear versus functional Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Final overjet

2

271

Mean Difference (IV, Fixed, 95% CI)

0.75 [0.21, 1.29]

1.2 Final ANB

2

271

Mean Difference (IV, Fixed, 95% CI)

‐0.04 [‐0.49, 0.41]

2 Incidence of new incisal trauma during phase I treatment: headgear versus functional Show forest plot

2

282

Odds Ratio (M‐H, Fixed, 95% CI)

1.02 [0.48, 2.17]

3 Outcomes at the end of phase II: headgear versus functional Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 Final overjet

2

225

Mean Difference (IV, Fixed, 95% CI)

‐0.21 [‐0.57, 0.15]

3.2 Final ANB

2

222

Mean Difference (IV, Fixed, 95% CI)

‐0.17 [‐0.67, 0.34]

3.3 PAR score

2

224

Mean Difference (IV, Fixed, 95% CI)

‐0.81 [‐2.21, 0.58]

4 Incidence of new incisal trauma by the end of phase II treatment: headgear versus functional appliance Show forest plot

2

226

Odds Ratio (M‐H, Fixed, 95% CI)

0.78 [0.42, 1.47]

Figures and Tables -
Comparison 2. Early orthodontic treatment: two‐phase appliance 1 (headgear) versus appliance 2 (functional)
Comparison 3. Late orthodontic treatment: functional versus no treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Final overjet Show forest plot

5

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Fixed functional

2

61

Mean Difference (IV, Fixed, 95% CI)

‐5.46 [‐6.63, ‐4.28]

1.2 Removable functional

3

122

Mean Difference (IV, Fixed, 95% CI)

‐4.62 [‐5.33, ‐3.92]

2 Final ANB Show forest plot

5

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

2.1 Fixed functional

3

89

Mean Difference (IV, Fixed, 95% CI)

‐0.53 [‐1.27, 0.22]

2.2 Removable functional

2

99

Mean Difference (IV, Fixed, 95% CI)

‐2.37 [‐3.01, ‐1.74]

Figures and Tables -
Comparison 3. Late orthodontic treatment: functional versus no treatment
Comparison 4. Late orthodontic treatment: different types of appliances used for late treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Twin Block versus other functional appliances (R‐appliance, Bionator, Bite‐Jumping appliance, Dynamax and Herbst) Show forest plot

6

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Final overjet

4

259

Mean Difference (IV, Random, 95% CI)

0.08 [‐0.60, 0.76]

1.2 Final ANB

6

320

Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.96, ‐0.16]

2 Twin Block conventional versus other Twin Block modifications Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

2.1 Final overjet

2

196

Mean Difference (IV, Fixed, 95% CI)

‐0.23 [‐0.67, 0.22]

3 Functional (Activator) versus prefabricated functional myobrace appliance (PFA) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 Final overjet

1

97

Mean Difference (IV, Fixed, 95% CI)

‐0.60 [‐1.63, 0.43]

4 Functional (Activator) versus fixed functional (FORSUS FRD EZ) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

4.1 Final overjet

1

24

Mean Difference (IV, Fixed, 95% CI)

2.19 [0.58, 3.80]

4.2 Final ANB

1

24

Mean Difference (IV, Fixed, 95% CI)

‐1.74 [‐3.28, ‐0.20]

5 Fixed functional (FORSUS FRD) versus fixed functional with mini‐implants (FMI) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5.1 Final overjet

1

29

Mean Difference (IV, Fixed, 95% CI)

‐0.36 [‐1.07, 0.35]

5.2 Final ANB

2

60

Mean Difference (IV, Fixed, 95% CI)

0.22 [‐0.86, 1.30]

6 Fixed functional (FORSUS FRD) versus fixed functional with mini‐implants (FMI) ‐ patient satisfaction with results Show forest plot

1

32

Odds Ratio (M‐H, Fixed, 95% CI)

0.18 [0.01, 3.97]

7 R‐appliance versus AIBP Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7.1 Final ANB

1

50

Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐0.99, 0.39]

8 Removable functional appliance versus fixed functional appliance Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8.1 Final overjet

2

154

Mean Difference (IV, Fixed, 95% CI)

0.74 [0.15, 1.33]

8.2 Final ANB

3

185

Mean Difference (IV, Fixed, 95% CI)

‐1.04 [‐1.60, ‐0.49]

9 FORSUS versus intermaxillary elastics Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9.1 Final overjet

1

28

Mean Difference (IV, Fixed, 95% CI)

0.28 [‐0.35, 0.91]

9.2 Final ANB

1

28

Mean Difference (IV, Fixed, 95% CI)

‐0.90 [‐1.96, 0.16]

10 FMA stepwise (SWG) versus FMA single step (SSG) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

10.1 Final overjet

1

34

Mean Difference (IV, Fixed, 95% CI)

0.23 [‐0.26, 0.72]

10.2 Final ANB

1

34

Mean Difference (IV, Fixed, 95% CI)

‐0.69 [‐1.19, ‐0.19]

11 Harvold Activator versus Frankel function regulator Show forest plot

1

25

Mean Difference (IV, Fixed, 95% CI)

‐2.93 [‐5.37, ‐0.49]

11.1 Overjet change

1

25

Mean Difference (IV, Fixed, 95% CI)

‐2.93 [‐5.37, ‐0.49]

Figures and Tables -
Comparison 4. Late orthodontic treatment: different types of appliances used for late treatment