Class II Functional Orthopaedic Treatment PDF

Journal of Oral Rehabilitation Journal of Oral Rehabilitation 2015 42; 624--642 Review Class II functional orthopaedic treatment: a systematic review of systematic reviews
†1, R. BUCCI*1, L. FRANCHI‡, R. RONGO*, A. MICHELOTTI* & V. D ’ A N T O* R. M A R T I N A * *...

Journal of Oral Rehabilitation Journal of Oral Rehabilitation 2015 42; 624--642 Review Class II functional orthopaedic treatment: a systematic review of systematic reviews
†1, R. BUCCI*1, L. FRANCHI‡, R. RONGO*, A. MICHELOTTI* & V. D ’ A N T O* R. M A R T I N A * *Department of Neuroscience, Reproductive Sciences and Oral Sciences, School of Orthodontics and Temporoman- dibular disorders, University of Naples “Federico II”, Naples, †Dentist Unit, Department of Pediatric Surgery, “Bambino Ges u” Children Hospital, Rome, and ‡Department of Surgery and Translational Medicine-Orthodontics, University of Florence, Florence, Italy SUMMARY This Systematic Review (SR) aims to assess reviewed several functional appliances, as a group. the quality of SRs and Meta-Analyses (MAs) on The mean AMSTAR score was 6 (ranged 2–10). Six functional orthopaedic treatment of Class II SRs included only controlled clinical trials (CCTs), malocclusion and to summarise and rate the three SRs included only randomised controlled trials reported effects. Electronic and manual searches (RCTs), four SRs included both CCTs and RCTs and were conducted until June 2014. SRs and MAs one SR included also expert opinions. There was focusing on the effects of functional orthopaedic some evidence of reduction of the overjet, with treatment of Class II malocclusion in growing different appliances except from headgear; there was patients were included. The methodological quality some evidence of small maxillary growth restrain of the included papers was assessed using the with Twin Block and headgear; there was some AMSTAR (Assessment of Multiple Systematic evidence of elongation of mandibular length, but the Reviews). The design of the primary studies included clinical relevance of this results is still questionable; in each SR was assessed with Level of Research there was insufficient evidence to determine an Design scoring. The evidence of the main outcomes effect on soft tissues. was summarised and rated according to a scale of KEYWORDS: malocclusion angle class II/therapy, statements. 14 SRs fulfilled the inclusion criteria. The orthodontic appliances functional, review literature appliances evaluated were as follows: Activator (2 as topic, evidence-based dentistry, adolescent, studies), Twin Block (4 studies), headgear (3 studies), growth and development Herbst (2 studies), Jasper Jumper (1 study), Bionator (1 study) and Fr€ ankel-2 (1 study). Four studies Accepted for publication 28 February 2015 Systematic Reviews (SRs) and Meta-analyses (MAs) Background are generally considered appropriate study design for Class II malocclusion is one of the most frequently offering a strong level of evidence (3), especially on encountered orthodontic issue as it occurs in about controversial topics. In addition, SRs are one of the one-third of the population (1). The efficacy of the best ways to stay up to date with current medical lit- functional orthopaedic treatments for such malocclu- erature (4) instead of reading an average of 17–20 sion is a widely debated topic, with controversial articles per day (5). A well-conducted SR aims to col- results in orthodontic literature (2). lect and synthesise all the scientific evidence on a spe- cific topic, according to strict predetermined inclusion 1 These two authors contributed equally to this work. and exclusion criteria (6). When possible, SRs might © 2015 John Wiley & Sons Ltd doi: 10.1111/joor.12295  EVIDENCE FROM SRs ON CLASS II TREATMENT 625 be integrated with MAs to statistically contrast and 2 What are the main effects reported in the SRs and combine results from different individual studies and MAs about functional orthopaedic treatment of to increase the statistical power of the analysis (7). Class II Malocclusion in growing patients and what Approaching the scientific literature using such is the evidence underlying these results? methodology might reduce the possibility of system- atic errors (bias) (8). However, the validity of the results of SRs or MAs might be influenced by different Search strategy factors; among those, the lack of methodological qual- For the current study, all the SRs and MAs concern- ity of the individual studies included in the review ing functional and orthopaedic treatment of Angle (9), and the methodological flaws in the development Class II malocclusion were analysed. The databases of the SR or MA itself must be take into consider- investigated for the systematic literature search were ation. as follows: Medline (Entrez PubMed, www.ncbi.nlm.- In 2010, it has been estimated that about 75 trials nih.gov), Latin American and Caribbean Health Sci- and 11 SRs of trials were being published every day ences (LILACS, http://lilacs.bvsalud.org), Scientific (10). Moreover, it is likely to find different SRs on Electronic Library Online (SciELO, http://www.scielo. the same topic, conducted with different aims and org) and the Cochrane Library (www.cochrane methodologies and leading to conflicting results library.com). The survey covered the period from the (11). starting of the databases (1966 for PubMED, 1997 for In this scenario, the need of overviewing and com- SciELO, 1982 for LILACS and 1993 for the Cochrane paring the results from the existent SRs in a single Library) up to September 2013. No language restric- paper takes place (12). To point out the importance of tions were set. A further hand-search of orthodontic such ‘third level’ of evidence, the Cochrane Collabo- journals (European Journal of Orthodontics, American ration has introduced the guidelines for Overview of Journal of Orthodontics and Dentofacial Orthopedics and Reviews (6), to summarise multiple Cochrane reviews The Angle Orthodontist) was performed starting from addressing the effects of two or more potential inter- the first volume available on the digital archives, to ventions for a single condition. include possible overlooked or in press papers. More- To our knowledge, currently no Systematic Review over, an exploration of the grey literature (unpub- of SRs concerning functional orthopaedic treatment of lished studies) was performed among the conference Class II malocclusion is available. Therefore, the aims abstracts of scientific congresses (European Orthodon- of the present study were tic Society and International Association of Dental 1 To evaluate the methodological quality of SRs and Research). MAs on functional orthopaedic treatment of Angle The following keywords were used and adapted Class II malocclusion in growing patients. More according to the database rules: ‘Functional Ortho- specifically, to determine the methodological qual- dontic appliance’, ‘Angle Class II’, Malocclusion, ity level of the SRs and MAs and to assess the Review, Systematic Review. The search strategies design of the primary studies included in each SR applied for each database are shown in Table 1 (see or MA. also: Table S1). 2 To provide an overview of the reported effects of The search was later updated, applying same strate- the treatments and to rate the evidence on which gies but customising the publication date range from these results are based. September 2013 to June 2014. Materials and methods Studies selection and data collection The questions to be answered in the present SR are as Inclusion criteria: follows: 1 To be a Systematic Review or a Meta-Analysis; 1 What is the methodological quality level of the SRs 2 Studies on the effects of functional orthopaedic and MAs addressing the effects of functional ortho- appliances on Class II skeletal malocclusion; paedic treatment of Class II malocclusion? 3 Studies on growing patients. © 2015 John Wiley & Sons Ltd 626
et al. V. D’ANTO Table 1. Search strategy for each database and relative results Database Search strategy Results PubMed ((‘Activator Appliances’ [Mesh]) OR ‘Orthodontic Appliances, 94 Functional’ [Mesh] OR ‘Orthodontic Appliances, Removable’ [Mesh]) AND (‘Malocclusion, Angle Class II’ [Mesh])) AND (Review* OR Meta-Analys*) Cochrane Library Malocclusion Angle Class II; Filter: Review 2 SciELO Angle Class II Malocclusion AND (Review OR Meta-Analysis) 4 LILACS (tw:(Angle Class II Malocclusion)) AND (tw:(Review)) 23 Exclusion criteria: Table 2. Interpretation of the LRD scores. The scores are based on the type of studies included in the SR 1 Dual publication; 2 Systematic Review of SRs; LRD score Studies included 3 SR updated in a later publication; I Systematic Review of RCT 4 Treatment protocol not involving functional ortho- II Randomised clinical trial paedics. III Study without randomisation, such as a Two investigators (V.D. and R.B.) independently cohort study, case–control study IV A non-controlled study, such as read all titles and abstracts. Two of four databases cross-sectional study, case series, (LILACS and SciELO) were analysed by only one case reports investigator, due to language limitations. Subse- V Narrative review or expert opinion quently, full-texts of the references that seemed to fulfil the inclusion criteria were acquired and analy- answer’, when the item is relevant, but not described sed thoroughly. Finally, only the papers that com- by the authors. Each ‘Yes’ answer is scored 1 point, pletely satisfied all the inclusion criteria were selected. while the other answers are scored 0 point. According Disagreements between the two examiners were dis- to the number of criteria met, the quality of the cussed and resolved to reach a unanimous consensus. included paper was rated as ‘Low’ (AMSTAR ≤3); In addition, the reference lists of the included SRs ‘Medium’ (AMSTAR 4–7); ‘High’ (AMSTAR ≥8) (14, were analysed to identify any further relevant missing 15). papers. Moreover, to assess the design of the primary stud- From the included papers data about Authors, Year ies included in each SR the LRD (Level of Research of Publication, Study Design, Diagnosis, Number of Design scoring) was used (16, 17). The interpretation Patients, Intervention, Control, Outcome, Quality of of such score, which is base on the hierarchy of evi- the included studies, Results, Author’s Conclusions dence, is shown in Table 2. and Author’s Comments on Quality of Studies were For each included study, both investigators (V.D. independently extracted by two authors (V.D. and and R.B.) independently assessed the methodological R.B), and the consensus was reached through discus- quality. There was no blinding for the authors during sion. both quality assessment and data extraction. The inte- rexaminer reliability for the AMSTAR scores was calculated by means of Cohen’s k coefficient. Quality assessment of the included systematic reviews Nonetheless, disagreements and discrepancies on the For each included SR, the methodological quality was AMSTAR items were discussed and solved to reach a assessed using the AMSTAR (Assessment of Multiple unanimous score. Systematic Reviews) (13). AMSTAR is composed by 11 items, each one can be answered ‘Yes’, when Synthesis of the results and rating of the evidence clearly done, ‘No’, when clearly not done, ‘Not Appli- cable’, when the item is not relevant, such as when a The main results of the included SRs were summar- MA was not attempted by the authors, ‘Can’t ised according to the appliances examined in the © 2015 John Wiley & Sons Ltd  EVIDENCE FROM SRs ON CLASS II TREATMENT 627 study. Afterwards, the evidence on which such results The 14 SRs included and the data extracted from are based was rated according to a modified predeter- each SR are shown in Table 4 (18–31). One-third of mined scale of statements (14, 15). The statements the included SRs (5 of 14) were integrated with MA applied took into account: the way the data were (18, 20, 28, 30, 31). The number of patients included pooled (MA or narrative synthesis), the statistical sig- ranged from 59 to 1763. The diagnosis reported in nificance of the result and the number of studies/par- most of the paper was generally ‘Angle Class II mal- ticipants on which the result was based. A full occlusion’; six SRs (19, 23–26, 31) more specifically explanation of the statements adopted is reported in evaluated Class II Division 1 malocclusion and only Table 3. Moreover, a downgrade of the rating was in one study (27) vertical facial growth was taken performed (i.e. from sufficient evidence to some evi- into account as inclusion criterion (Class II hyperdi- dence) whenever the quality of most of the individual vergent patients). Six SRs (18, 19, 21, 22, 27, 30) studies addressing a specific outcome was low. The included only papers with a comparable Class II quality of the individual studies was not re-assessed, untreated group. The appliances studied in the but reported as assessed by the authors of the included SRs were as follows: Activator (18, 26); reviews. Twin Block (18, 22, 25, 29); headgear (18, 20, 27); Herbst (19, 23); Jasper Jumper (24); Bionator (26); Fr€ankel-2 (30). Four papers evaluated several func- Results tional orthopaedic appliances, as a group (20, 21, 28, 31). The primary outcome of most of the articles (7 Papers selection SRs) was the effect of treatment on the mandible, The updated electronic search of all databases measured through different cephalometric methods resulted in 123 references. One article was retrieved and reference points. from sources other than database, and it was an ‘in press’ paper provided by the authors. After duplicates Quality of the included systematic reviews were removed, 115 references were left. Eighty-six references were excluded because the topic was not The Cohen’s k coefficient for the AMSTAR items was pertinent or because they were not SRs. The remain- 0
91, thus indicating very good interexaminer agree- ing eligible 29 articles were entirely read, and 15 of ment. them were excluded (Fig. 1; Table S2). The most The AMSTAR score ranged from a minimum of 2 common exclusion criterion was the absence of a to a maximum of 10; the mean score was 6. The systematic search strategy, especially among the old- single AMSTAR items for each paper and the total est papers. AMSTAR scores are shown in Table 5. Three papers Table 3. Scale of Statements adopted to rate the evidence of the outcomes retrieved from each SR Sufficient evidence Meta-analysis: statistically significant pooled result that is based on a large number of included studies/ participants or Narrative synthesis: large number of studies and/or study participants showing a statistical significance When these conditions are applied to a non-significant result, the interpretation is ‘evidence of no effect’ (ineffectiveness). Some evidence Meta-analysis: statistically significant pooled result that is based on a small number of included studies/ participants or Narrative synthesis: small number of studies and/or study participants showing a statistical significance. Insufficient evidence Underpowering of the included studies to be able to detect an effect of the intervention (small number of to support studies/participant supporting significant or non-significant results) Not to be interpreted as the first statement. This is about ‘no evidence of effect or no evidence of no effect’. Insufficient evidence Gap in the evidence (controversial results) to determine © 2015 John Wiley & Sons Ltd 628
et al. V. D’ANTO Fig. 1. PRISMA Flow Diagram of the included and excluded records. were rated as ‘low quality’, 8 papers were rated as decrease the OVJ [ 3
88 mm (19) to 4
17 mm ‘medium quality’, and 3 papers were rated as ‘high (31)], with higher results for the Twin Block when quality’. assessed individually [ 6
45 mm (19); 3
3 to Six papers included only Clinical Controlled Studies 6
9 mm (22)]. (CCTs), three papers included only Randomised There is insufficient evidence to support a significant Controlled Studies (RCTs), four papers included both reduction of the OVJ ( 4
6 to 5
6 mm) with Splint- CCTs and RCTs, and one paper included also book Type Herbst appliance (23). chapter and expert opinions. The LRD scores are There is insufficient evidence to determine an effect of shown in Table 6. the headgear on the OVJ as controversial results are reported: no significant effect was found by Antonara- kis and Kiliaridis (18) while a small significant reduc- Main outcomes and rating of the evidence tion was reported by Thiruvenkatachari et al. (31) For this purpose, the papers showing low quality (20, ( 1
07 mm). 27, 29) (AMSTAR