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Cochrane Database of Systematic Reviews

Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children and adolescents

Information

DOI:
https://doi.org/10.1002/14651858.CD003452.pub4Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 13 March 2018see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Oral Health Group

Copyright:
  1. Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Klaus BSL Batista

    Correspondence to: Department of Preventive and Public Dentistry, Rio de Janeiro State University, Rio de Janeiro, Brazil

    [email protected]

  • Badri Thiruvenkatachari

    School of Dentistry, The University of Manchester, Manchester, UK

  • Jayne E Harrison

    Orthodontic Department, Liverpool University Dental Hospital, Liverpool, UK

  • Kevin D O'Brien

    Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK

Contributions of authors

The original review (2007) was conceived by Jayne E Harrison (JH), Kevin D O'Brien (KOB) and Bill Shaw (Cochrane Oral Health). Sylvia Bickley (Cochrane Oral Health) developed the search strategy and undertook the electronic searches. JH and KOB screened the search results, retrieved papers and undertook the risk of bias assessment of the papers and data extraction. KOB and Helen V Worthington (HW) undertook the data analysis. KOB, HW and JH wrote the original review.

The first update (2013) was co‐ordinated by Badri Thiruvenkatachari (BT) and KOB. Anne Littlewood (Cochrane Oral Health) developed the search strategy and undertook the electronic searches. All review authors screened the search results and retrieved papers, undertook the risk of bias assessment of the papers and extracted data from them. BT and KOB analysed the data and interpreted the results. BT and KOB wrote the results, conclusions and discussion sections of the review.

The current update (2017) was co‐ordinated by Klaus BSL Batista (KB), BT and KOB. Anne Littlewood (Cochrane Oral Health) developed the search strategy and undertook the electronic searches. KB, BT and JH screened the search results and retrieved papers, undertook the risk of bias assessment of the papers and extracted data from them. KB, BT and KOB wrote the results, conclusions and discussion sections of the review.

Sources of support

Internal sources

  • The Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK.

  • School of Dentistry, The University of Manchester, UK.

  • Manchester Academic Health Sciences Centre (MAHSC) and NIHR Manchester Biomedical Research Centre, UK.

External sources

  • NHS National Primary Dental Care R&D programme PCD97‐303, UK.

  • Cochrane Oral Health Global Alliance, Other.

    The production of Cochrane Oral Health reviews has been supported financially by our Global Alliance since 2011 (oralhealth.cochrane.org/partnerships‐alliances). Contributors over the past year have been the American Association of Public Health Dentistry, USA; the British Association for the Study of Community Dentistry, UK; the British Society of Paediatric Dentistry, UK; the Canadian Dental Hygienists Association, Canada; the Centre for Dental Education and Research at All India Institute of Medical Sciences, India; the National Center for Dental Hygiene Research & Practice, USA; New York University College of Dentistry, USA; NHS Education for Scotland, UK; and the Swiss Society for Endodontology, Switzerland.

  • National Institute for Health Research (NIHR), UK.

    This project was supported by the NIHR, via Cochrane Infrastructure funding to Cochrane Oral Health. The views and opinions expressed herein are those of the review authors and do not necessarily reflect those of the Systematic Reviews Programme, the NIHR, the NHS or the Department of Health.

Declarations of interest

Klaus BSL Batista: no interest to declare.
Kevin O'Brien was involved in acquiring funding, running and reporting of the UK (11‐14) 2003, UK (Mixed) 2009 and Banks 2004 trials; however, he was not involved in the quality assessment of these trials.
Badri Thiruvenkatachari and Helen Worthington (author on previous versions) are among the authors of UK (Mixed) 2009; however, they were not involved in the risk of bias assessment of this trial. Helen V Worthington is a Co‐ordinating Editor with Cochrane Oral Health.
Badri Thiruvenkatachari and Kevin O'Brien were involved in running and reporting the Thiruvenkatachari 2010 (Dynamax) study; however, they were not involved in the quality assessment of this trial.
Jayne E Harrison: no interest to declare. Dr Harrison is an Editor with Cochrane Oral Health.

Acknowledgements

Current update (2017): our thanks to Osama Alali (University of Damascus), Ahmad Burhan (Al‐Baath University), Sherif Elkordy (Cairo University) and Emina Čirgić (University of Gothenburg) for providing additional data for this review. We would like to thank Janet Lear (Cochrane Oral Health) for her help to find some papers and Professors Chengge Hua, Chunjie Li and Huimin Hu for their translation support from Chinese. We thank Laura MacDonald, Anne Littlewood, Dr Fang Hua, Professor Anne‐Marie Glenny and Professor Helen Worthington of Cochrane Oral Health, copy editor Jason Elliot‐Smith, and external referees Professor Ross Hobson and Dr Philipe Amat.

Previous versions: we are very grateful to Helen Worthington for her work on previous versions of this review. Thanks to Anne Littlewood (Cochrane Oral Health) for her help in conducting the searches, and to Luisa Fernandez Mauleffinch (Cochrane Oral Health) for editorial management of the review. Thanks to Bill Shaw for his initial advice; Bill Proffit, Kitty Tulloch (University of North Carolina), Tim Wheeler, Sue McGorry (University of Florida), David Morris, Danny Op Heij and Urban Hagg for providing additional data for this review; John Scholey for undertaking some of the handsearching and Sue Pender for retrieving, copying and collating the full papers. We would also like to thank Susan Furness (Cochrane Oral Health) and all those who have provided comments and editorial input.

Version history

Published

Title

Stage

Authors

Version

2018 Mar 13

Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children and adolescents

Review

Klaus BSL Batista, Badri Thiruvenkatachari, Jayne E Harrison, Kevin D O'Brien

https://doi.org/10.1002/14651858.CD003452.pub4

2013 Nov 13

Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children

Review

Badri Thiruvenkatachari, Jayne E Harrison, Helen V Worthington, Kevin D O'Brien

https://doi.org/10.1002/14651858.CD003452.pub3

2007 Jul 18

Orthodontic treatment for prominent upper front teeth in children

Review

Jayne E Harrison, Kevin D O'Brien, Helen V Worthington

https://doi.org/10.1002/14651858.CD003452.pub2

2002 Jan 21

Orthodontic treatment for prominent upper front teeth in children

Protocol

Jayne E Harrison, Kevin D O'Brien, Helen V Worthington, Sylvia R Bickley, John M Scholey, W C. Shaw, Bill C Shaw

https://doi.org/10.1002/14651858.CD003452

Differences between protocol and review

In the last update of this review, we decided to include only truly randomised controlled trials. Quasi‐randomised trials and controlled clinical trials were excluded.

In this update, we made minor modifications to the objectives and outcomes for clarity. We added 'and adolescents' to the title. We clarified that early treatment was two‐phase and that the age range for late treatment was 'around' 12 to 16 years. We moved New Zealand study in late treatment category as the authors felt the participants were treated in one phase.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

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