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

Wei Miao
Wei Miao
, 
Dan Zhou
Dan Zhou
, 
Chunjie Li
Chunjie Li
, 
Lichun Chen
Lichun Chen
, 
Min Guan
Min Guan
, 
Yiran Peng
Yiran Peng
 and 
Li Mei
Li Mei
   | Jul 13, 2021
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Article Category: research-article
Published Online: Jul 13, 2021
Page range: 37 - 49
DOI: https://doi.org/10.21307/aoj-2021-004
© 2021 Wei Miao et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Figure 1.

Flow Diagram.
Flow Diagram.

Figure 2.

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

Figure 3.

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

Figure 4.

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

Figure 5.

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

Figure 6.

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

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

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

Characteristics of the included studies.

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

Search strategy used for PubMed.

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

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

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