Background
Rationale
Objectives
Methods
Protocol registration
PICOS question and eligibility criteria
Category | Inclusion criteria | Exclusion criteria |
---|---|---|
Participants | Growing patients (patients near the pubertal growth spurt as determined by the cervical vertebral maturation index) with skeletal class II malocclusion or skeletal class II or Angle class II or mandibular retrusion or mandibular hypoplasia or mandibular retrognathism | Patients with craniofacial anomalies and/or transverse discrepancies and/or skeletal asymmetries |
Intervention | Orthopedic or interceptive or early treatment using bi-maxillary skeletal anchorage or bone anchor or miniscrew or miniplate or mini-implant or bone screw or bone plate | Single jaw skeletal anchorage device |
Comparator | Either control group with no treatment or comparison with other devices | Studies with no control group |
Outcome | Primary outcome: skeletal change Secondary outcomes: dentoalveolar changes | Outcomes other than skeletal and dentoalveolar changes |
Study Design | Longitudinal (Retrospective or prospective) studies, and controlled and non-controlled clinical trials | Case reports, case series, literature reviews, systematic review, opinion articles, book chapters |
Information sources, search strategy, and study selection
Data collection
Outcome assessment
Parameter | Abbreviation and/or unit | Definition |
---|---|---|
Maxillary base position | SNA° | The angle between 3 point landmarks S, N and A point, determining the anteroposterior position of the maxilla relative to the cranial base |
Mandibular base position | SNB° | The angle between 3 point landmarks S, N and B point, determining the anteroposterior position of the mandible relative to the cranial base |
Sagittal skeletal relation | ANB° | The angle between 3 point landmarks, A point, N and B point, determining the anteroposterior relation between maxilla and the mandible relative to the cranium |
Vertical skeletal relation | MPA = SN/Go-Me* or SN/Go-Gn° | The angle between the line S–N and the mandibular plane, measuring the mandibular base tipping relative to the cranium |
Maxillary incisors inclination | U1/PP Or U1/SN° or | The angle formed between the palatal plane or SN line and the long axis of the most protruded maxillary incisor |
U1-VP mm | The linear distance between U1 and the Vertical plane | |
Mandibular incisors inclination | IMPAº | The angle formed between the mandibular plane and the long axis of the most protruded mandibular incisor |
Overjet | mm | The horizontal distance between the palatal surface of the most protruded maxillary incisor and the labial surface of the most protruded mandibular incisor |
Overbite | mm | The vertical distance between the incisal edge of the most protruded maxillary incisor and the incisal edge of the most protruded mandibular incisor |
Risk of bias
Author (year) [references] | Study design | Methodological | Data analysis | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Type of study | Consecutive cases (1 ) | Sample size (2) | Control group (2) | Selection criteria (2) | Sample size calculation (1) | Outcome measure (4) | Force magnitude (2) | Error of the method (2) | Statistical analysis (2) | Data presentation (2) | Total (24) | |
Ozbilek et al. [32] | 2 | 0 | 1 | 1 | 1 | 1 | 4 | 1 | 2 | 2 | 2 | 17 |
Al-Dumaini et al. [7] | 2 | 0 | 2 | 2 | 2 | 1 | 4 | 1 | 2 | 2 | 2 | 20 |
Manni et al. [33] | 2 | 1 | 2 | 1 | 2 | 0 | 4 | 0 | 2 | 2 | 2 | 18 |
Kochar et al. [34] | 4 | 0 | 2 | 2 | 2 | 1 | 4 | 0 | 2 | 2 | 2 | 21 |
Statistical analyses
Results
Study selection
Quality assessment
Characteristics of the participants and interventions
Author (year) [references] | Study design | Inclusion criteria | No. of patients/study/ Control /dropout | Gender (study), (Co.)/age (mean ± SD) Study/Co | Type of appliance (study)/(co.) | Skeletal maturational age | Site and number of miniscrew/ miniplate insertion | Mean of attachment (direct, indirect) study/co./ |
---|---|---|---|---|---|---|---|---|
Ozbilek et al. [32] | Prospective study | (1) Full Class II molar relationship, (2) minimum 5 mm overjet, (3) horizontal or normal growth pattern, (4) minimal crowding, (5) no extracted or missing permanent teeth (excluding third molars) | 15 patients/ Study 6 / Control 6 / Dropout 3 | Study (3 boys, 3 girls), Control (3 boys, 3girls) Study (12.9 ± 1.5 years), Control (12.3 ± 1.6 years) | Study: miniplates anchored Class II elastics Control: monobloc appliance | In an active growth period (peak stage of pubertal growth determined according to the methods of Bjork, and Grave and Brown) MP3cap of the middle finger | Two miniplates were placed bilaterally at the ramus of the mandible and another two miniplates were placed at the aperture piriformis area of the maxilla | Study: direct control: monobloc appliance |
Al-Dumaini et al. [7] | Prospective study | (1) 10 to 13 years; (2) ANB ≥ 5°); (3) deficient mandible; (4) NAPg ≥ 190; (5) average or vertical pattern of growth; (6) ≥ 1/2 Class II molar and canine; (7) overjet ≥ 5 mm | 54 patients /Study 28/Control 24/Dropout 2 | Study (14 boys, 14 girls), Control (11 boys, 13 girls) Study (11.83 ± 0.85 years), Control (11.75 ± 0.75 years) | Study: miniplates Control: No treatment | Before the pubertal growth spurt (according to cervical vertebrae maturational index) | Two miniplates were placed bilaterally in the posterior buccal area above the external oblique ridge and another two miniplates were placed at the aperture piriformis area of the maxilla | Study: direct control: no treatment |
Manni et al. [33] | Prospective study | (1) Class II skeletal relationships (ANB ≥ 4◦), (2) overjet ≥ 4 mm, (3) bilateral Class II molar relationships ≥ half a cusp | 26 patients / Study 13 /Control 13 / Dropout (-) | Study (10 boys, 3 girls), Control (3 boys,10 girls) Study (12.8 ± 1.5 years), Control (12.2 ± 1.3 years) | Study: skeletally anchored Herbst appliance with miniscrews Control: standard Herbst appliance without miniscrews | Patients near the pubertal growth spurt (determined by the cervical vertebral maturation [CVM] method; stage CVM 3) | In the maxillary and mandibular arch, miniscrews were placed between the mandibular first and second premolars or between the second premolars and the first molars in the attached gingiva depending on the subject's anatomy | Study: indirect control: no miniscrew |
Kochar et al. [34] | Prospective study | (1) Skeletal class II malocclusion due to mandibular retrognathism, (2) Angle class II division 1 malocclusion, (3) positive visualized treatment objective (VTO), (4) overjet greater than 6 mm, (5) average or horizontal growth pattern, (6) minimal crowding (< 3 mm) in both arches | 32 patients / Study 16 / Control 16 / Dropout (-) | Study (8 boys, 8 girls), Control (9 boys,7 girls) Study (12.37 ± 1.09 years), Control (12.06 ± 1.34 years) | Study: bimaxillary skeletal anchorage supported fixed function appliance Control: No treatment | Peak of pubertal growth spurt (determined by the cervical vertebral maturation [CVM] method; stage CVM 3) | In the maxilla, “L” shaped bone plates were placed 4–5 mm above the apices of maxillary first molar and in the mandible “T” shaped plates were positioned along the mandibular canine | Study: direct control: no treatment |
Author (year) [references] | Screw dimensions (diameter × length mm) | Force (g) | Method of assessment (2D/3D) | Measurements used | Treatment duration | Conclusion |
---|---|---|---|---|---|---|
Ozbilek et al. [32] | 2 mm diameter × 7 mm length | 500 g | 2D (lateral cephalometry) | Angular measurements: SNA, SNB, ANB, angle of convexity, SN-Go-Gn, SN-PP, SN-OP, FMA, U1-PP, IMPA, U1-L1 Linear measurements Co-A, A-VRL, A-HRL, Co-Gn, B-VRL, B-HRL, Pog-VRL, Pog-HRL, Witts, U1-VRL, L1-VRL, overjet, overbite, Ls-VRL, Li-VRL, Pog(s)- VRL | Mean duration time was 0.68 ± 0.05 years for the elastics group and 0.65 ± 0.09 years for the monobloc group | 1- Effective mandibular length was significantly greater in the miniplate-anchored group 2- Mandibular incisor retrusion was observed in the miniplate-anchored, whereas mandibular incisor protrusion was found in the monobloc group |
Al-Dumaini et al. [7] | 2 mm diameter × 6 mm length | 450 g 250 g per side for the first 3 weeks followed by 350 g per side for the next 3 weeks to reach 450 g per side for the rest of the functional treatment phase | 2D (lateral cephalometry) | Angular measurementsSNA, SNB, ANB, SNPog, NAPog, ArGoMe, SN-PP, SN-GoMe, U1-SN, L1-GoMe, U1-L1 A-Y axis, Ar-Go, Go-Me, Co-Go, Co-Pog, Pog-Y axis, B-Y axis, S-Go, N-Me, overjet, overbite | The initial alignment and leveling phase lasted for an average of 7 months followed by a functional phase for an average of 9 months | Bimaxillary miniplates-based skeletal anchorage results to increase in mandibular ramal and body lengths and counter-clockwise mandibular positioning |
Manni et al. [33] | 1.4 diameter mm × 8 mm length | Not reported | 2D (lateral cephalometry) | Angular measurements SNA, SNB, ANB, SN/GoGn, Is/PP, Ii/GoGn, Linear measurements Wits, A-OLp, Pg-OLp, Co-OLp, Is-OLp, Ii-OLp, Overjet, Ms-OLp, Mi-OLp | The mean treatment times were 10.0 ± 0.8 months in the treatment group and 10.8 ± 2.1 months in the control group | 1- Anchorage reinforcement using miniscrews reduced flaring of the mandibular incisor 2- The upper molars showed a slightly forward movement in HA with miniscrew anchorage |
Kochar et al. [34] | 2 mm diameter × 7 mm length | Not reported | 2D (lateral cephalometry) | Angular measurements SNA, SN-Pal Pl, NA-Pal Pl, SNB, FMA, SN-GoGn, IMPA, ANB, NA-Pog, interincisal angle Linear measurements A-VP, N-ANS (perpendicular to HP), N-PNS (perpendicular to HP), U1-VP, U1-HP, U6-VP, U6-HP, B-VP, Pog-VP, Co-Gn, Go-Pog, L1-VP, L1-GoMe, L6-VP, L6-GoMe, overjet, overbite | The mean treatment time was 7.44 ± 1.06 months | Bimaxillary skeletal anchorage supported fixed functional appliance showed significant skeletal changes. The changes in the maxilla included retrusion and restricted posterior vertical growth. Mandibular changes included significantly increased mandibular growth with negligible effect on growth pattern |
Characteristics of outcome measures
Skeletal changes: maxillary and mandibular bases
Author (year) [references] | Maxillary base position (SNA°) | Mandibular base position (SNB°) | Sagittal skeletal relation (ANB°) | Vertical skeletal relation (MPA = SN/Go− Me* or SN/Go− Gn°) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Study | Control | P value | Study | Control | P value | Study | Control | P value | Study | Control | P value | |
Ozbilek et al. [32] | − 0.083 ± 0.96 | − 0.65 ± 0.27 | 0.180 | 3.25± 0.89 | 2.40 ± 0.90 | 0.093 | − 3.18± 0.84 | − 3.20 ± 0.85 | 0.937 | 0.83 ± 1.57 | 1.21 ± 0.49 | 0.589 |
Al− Dumaini et al. [7] | − 1.40± 1.84 | 0.25 ± 0.65 | < 0.001 | 2.9 ± 1.03 | 0.55± 0.97 | < 0.001 | − 4.00± 0.80 | − 0.31 ± 1.01 | < 0.001 | − 2.25 ± 0.95* | 0.50 ± 1.00 | < 0.001 |
Manni et al. [33] | − 0.7 ± 1.6 | − 1.0 ± 2.1 | 0.62 | 2.9± 1.8 | 1.1 ± 2.8 | 0.02 | − 3.3± 1.8 | − 1.3± 1.3 | 0.01 | − 0.5 ± 2.1 | 2.2 ± 2.7 | 0.01 |
Kochar et al. [34] | − 1.29± 0.59 | 0.18 ± 0.39 | < 0.001 | 3± 0.87 | 0.29 ± 0.47 | < 0.001 | − 4.2± 0.99 | − 0.17 ± 0.64 | < 0.001 | 0.41 ± 0.51 | 0.59 ± 0.51 | 0.27 |
Dentoalveolar changes: upper and lower incisors (U1, L1)
Author (year) [references] | Maxillary incisors inclination (U1/PP Or U1/SN° or U1− VP mm) | Mandibular incisors inclination (IMPA°) | Overjet (mm) | Overbite (mm) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Study | Control | P value | Study | Control | P value | Study | Control | P value | Study | Control | P value | |
Ozbilek et al. [32] | 4.60 ± 2.40 | − 2.33 ± 1.87 | 0.002 | − 3.01± 1.66 | 5.45± 1.23 | 0.002 | − 4.80 ± 1.18 | − 3.81 ± 0.67 | 0.180 | − 2.53 ± 1.31 | − 3.55 ± 0.48 | 0.240 |
Al− Dumaini et al. [7] | − 1.15 ± 0.94 | 0.40 ± 0.97 | < 0.001 | − 1.27 ± 2.48 | 0.47 ± 1.58 | 0.002 | − 4.26 ± 0.85 | − 0.12 ± 0.44 | < 0.001 | 1.47 ± 0.73 | − 0.13 ± 0.23 | < 0.001 |
Manni et al. [33] | 5.1 ± 7.7 | 1.0 ± 9.4 | 0.33 | 1.6 ± 5.6 | 3.7 ± 4.2 | 0.40 | − 3.7 ± 2.6 | − 3.8 ± 1.9 | 0.44 | − | − | − |
Kochar et al. [34] | 0.24 ± 0.44 | 0.35 ± 0.49 | 0.33 | 3.35 ± 0.86 | 0.53 ± 0.51 | < 0.001 | − 5.44 ± 1.26 | − 0.38 ± 0.62 | < 0.001 | − 3.69 ± 0.60 | − 0.38 ± 0.50 | < 0.001 |
Occlusal parameters: overjet and overbite
Discussion
Limitations
Conclusions
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1. The most significant skeletal effect of the miniplate-based anchorage class II correctors was mandibular base protrusion with minimal effect on the maxillary arch.
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2. At the level of dentoalveolar effects, the use of fixed appliances supported by bi-maxillary anchorage did not control the proclination of the mandibular incisors.
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3. Combined maxillary and mandibular anchorage improved the occlusal parameters.