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Orthodontic treatment for distalising upper first molars in children and adolescents

  1. Safa Jambi1,2,*,
  2. Badri Thiruvenkatachari3,
  3. Kevin D O'Brien3,
  4. Tanya Walsh3

Editorial Group: Cochrane Oral Health Group

Published Online: 23 OCT 2013

Assessed as up-to-date: 10 DEC 2012

DOI: 10.1002/14651858.CD008375.pub2


How to Cite

Jambi S, Thiruvenkatachari B, O'Brien KD, Walsh T. Orthodontic treatment for distalising upper first molars in children and adolescents. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD008375. DOI: 10.1002/14651858.CD008375.pub2.

Author Information

  1. 1

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

  2. 2

    Taiba University, Medina, Saudi Arabia

  3. 3

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

*Safa Jambi, safajambi@yahoo.co.uk. safa.jambi-2@postgrad.manchester.ac.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 23 OCT 2013

SEARCH

 
Characteristics of included studies [ordered by study ID]
Acar 2010

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: Baskent University, Turkey
  • Recruitment period: not stated
  • Funding source: not stated
  • Source of participants: patients attending clinic
  • Study duration: 12 weeks
  • Time points at which follow-up is reported: 1) start of treatment, 2) end of molar distalisation


Participants
  • 30 participants in total, mean age 14.6 years
  • 15 in pendulum appliance group: mean age 15 years (SD 3.4), 8 males and 7 females
  • 15 in cervical headgear group: mean age 14.2 years (SD 2.9),  5 males and 10 females


  • Inclusion criteria


  1. Dental Class II malocclusion due to mesial migration of upper first molar
  2. Minor arch length discrepancies


  • Exclusion criteria


  1. No vertical or transverse skeletal or dental problem


Interventions
  • Comparison 1: Pendulum appliance supported with K-loop buccally


  1. Hilger's pendulum appliance was used which exerted a force of 230 g when the springs were activated 90°
  2. The K-loop was made from 0.017 X 0.025 inch TMA wire and positioned between the upper first molar and first premolar
  3. Patients were recalled every 3 weeks and the K-loop activated every 6 weeks


  • Comparison 2: Headgear


  1. Cervical pull
  2. 400 g force was used
  3. Patients instructed to wear it for 16 to 20 hours a day


Outcomes
  1. Treatment time
  2. Skeletal and dental changes assessed from cephalometric radiographs
  3. Dental changes (rotation of molars and premolars) from study models


NotesErrors in reported values


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskQuote (from report): "Patients in both groups were matched according to GoGnSN angle and length of treatment"

Quote (from correspondence of main report): "patients were allocated to the two treatment groups randomly by coin tossing"

Quote (from correspondence of other report of the same study): "the patients were enrolled to the pendulum K-loop first and after completion of a predetermined number of patients (15).... additional 15 patients with dental Class II malocclusion that matched the first group by GoGnSN angle were treated with headgear"

Comment: probably not done

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "The cephalograms were traced by one investigator in a random order"

Comment: it is not mentioned whether the assessor was blinded to the type of treatment; the appliance could have been visible in the radiograph

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskTotal analysed 30 (15 in group 1 and 15 in group 2)

Selective reporting (reporting bias)Unclear riskSelective reporting of outcomes: insufficient information to permit judgement

Other biasHigh riskThere were errors in the reporting of skeletal variables in the paper

Altug-Atac 2008

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: Department of Orthodontics, Ankara University, Turkey
  • Recruitment period: not stated
  • Funding source: Ankara University Research Foundation
  • Source of participants: patients attending clinic
  • Study duration: 6.5 months
  • Time points at which follow-up is reported: 1) start of treatment, 2) end of distalisation (Class I molars)


Participants
  • 38 participants in total, age 12 to 16.58 years
  • 21 in the distalisation arch group: mean age 14.7 years (SE 1.5), 9 males and 12 females
  • 17 in the Begg system group: mean age 14.4 years (SE 1.4), 3 males and 14 females


  • Inclusion criteria


  1. Skeletal Class I and II malocclusions and dental Class II relationship on both sides
  2. Non-extraction treatment plan
  3. SN/GoGn angle less than 40°
  4. No/minimal crowding in the mandibular dental arch
  5. Erupted maxillary and mandibular second molars in occlusion


Interventions
  • Comparison 1: 3-dimensional bimetric maxillary distalisation arches


  1. The distalisation arches consist of an upper arch wire with an open coil spring and Class II elastics
  2. A full-bonded lower arch was used as an anchorage unit for the Class II elastics
  3. Patients were recalled at 10-day intervals and the elastic loads were checked and adjusted at each visit


  • Comparison 2:modified Begg intraoral distalisation system


  1. Maxillary 0.018 inch Australian wire distalisation arch with bilateral double-twisted single vertical loop
  2. Full-bonded maxillary and mandibular arches
  3. Uprighting springs to activate the mandibular anchorage
  4. Class II elastics


Outcomes
  1. Primary: treatment time for distalising upper first molars for molar correction
  2. Secondary: all skeletal and dental cephalometric measurements


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The patients were randomly selected and distributed to the treatment groups"

Comment: insufficient information about the sequence generation process to permit judgement

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to permit judgement

Incomplete outcome data (attrition bias)
All outcomes
High risk
  • 50 participants randomised, 38 included in the analysis
  • 24% (12 participants) drop-out rate due to poor co-operation
  • Number of exclusion per group not stated; poor co-operation is an important outcome that could influence the results

Selective reporting (reporting bias)Unclear riskSelective reporting of outcomes: insufficient information to permit judgement

Other biasLow riskStudy appears to be free of other sources of bias

Armi 2011

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: University of Florence and University of Roma, Italy
  • Recruitment period: not stated
  • Funding source: not stated
  • Source of participants: participants enrolled in a prospective study at the department of orthodontics
  • Study duration: average 18 months
  • Time points at which follow-up is reported: 1) initial observation, 2) 18 months after initial observation


Participants
  • 60 participants in total, mean age 11.51 years
  • 17 in headgear group: mean age 11.9 years, 9 males and 8 females
  • 21 in rapid maxillary expansion/headgear group: mean age 11.1 years, 9 males and 12 female
  • 22 in the untreated control group: mean age 11.6 years, 9 males and 13 females


  • Inclusion criteria


  1. White ancestry
  2. Either unilateral or bilateral palatally displaced canines on a panoramic radiograph
  3. Dental age older than 8 years and younger than 13 years
  4. Skeletal age showing active phases of skeletal growth according to the cervical vertebral maturation method
  5. Presence of mild crowding at the maxillary arch and/or molar relation showing Class II tendency


  • Exclusion criteria


  1. Previous orthodontic treatment
  2. Craniofacial syndromes, odontomas, cysts, cleft lip and/or palate, sequelae of traumatic injuries to the face, or multiple and/or advanced caries
  3. Aplasia or severe hypoplasia of the crown of upper lateral incisors


Interventions
  • Comparison 1: Headgear group


  1. Cervical pull headgear used alone for 1 year for 12 to 14 hours a day


  • Comparison 2: Rapid maxillary expansion/headgear group


  1. Banded rapid maxillary expander with 7 mm of active expansion
  2. At the end of expansion all patients retained the expander for 6 months
  3. Followed by the use of a cervical headgear like the headgear group


  • Comparison 3: Untreated control group


Outcomes
  1. Successful or unsuccessful eruption of the palatally displaced canines
  2. Mesiodistal movement of the upper first molars


Notes
  1. The main aim of this study was to evaluate the effectiveness of the interventions on the eruption of palatally displaced canines
  2. Only 2 of the comparison groups were used in this review because of their relevance: the headgear group and the untreated control group


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "All subjects with PDCs were assigned randomly to one of the following three groups"

Comment: insufficient information about the sequence generation process to permit judgement

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to permit judgement

Incomplete outcome data (attrition bias)
All outcomes
Low risk
  • Number randomised: 64
  • Drop-outs: 4, not stated in which group
  • Reason for drop-outs: participants moved from the area or asked to be transferred to other clinicians

Selective reporting (reporting bias)High risk
  • Selective reporting of outcomes: insufficient information to permit judgement
  • Selective reporting of data: incomplete reporting of the distal movement outcome; means were presented without standard deviations

Other biasHigh riskThe control group in this study has very similar characteristics to the Baccetti 2008 study. We contacted the authors for clarification but no response was received

Baccetti 2008

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: University of Florence and University of Roma, Italy
  • Recruitment period: not stated
  • Funding source: not stated
  • Source of participants: patients enrolled in a prospective study at the department of orthodontics
  • Study duration: average 18 months
  • Time points at which follow-up is reported: 1) initial observation, 2) 18 months after initial observation


Participants
  • 69 participants in total
  • 23 in headgear group: mean age 11.7 years, 8 males and 15 females
  • 24 in extraction/headgear group: mean age 11.9 years, 10 males and 14 females
  • 22 in the untreated control group: mean age 11.6 years, 9 males and 13 females


  • Inclusion criteria


  1. White ancestry
  2. Either unilateral or bilateral palatally displaced canines on a panoramic radiograph
  3. Dental age older than 8 years and younger than 13 years
  4. Skeletal age showing active phases of skeletal growth according to the cervical vertebral maturation method


  • Exclusion criteria


  1. Previous orthodontic treatment
  2. Craniofacial syndromes, odontomas, cysts, cleft lip and/or palate, sequelae of traumatic injuries to the face, or multiple and/or advanced caries
  3. Crowding in the upper arch, as evaluated by means of intraoral inspection
  4. Aplasia or severe hypoplasia of the crown of upper lateral incisors


Interventions3 comparisons in total

  • Comparison 1: Extraction group


  1. Extraction of the primary canine corresponding to the palatally displaced permanent canine was performed


  • Comparison 2: Extraction/headgear group


  1. Extraction of the primary canine corresponding to the palatally displaced permanent canine was followed by use of a cervical-pull headgear
  2. Patients in this group started their headgear therapy in the 3 months after extraction
  3. They were instructed to wear the headgear for 12 to 14 hours a day


  • Comparison 3: Untreated control group


Outcomes
  1. Successful or unsuccessful eruption of the palatally displaced canines
  2. Mesiodistal movement of the upper first molars


Notes
  1. The main aim of this study was to evaluate the effectiveness of the interventions on the eruption of palatally displaced canines
  2. Only 2 of the comparison groups were used in this review because of their relevance: the headgear group and the untreated control group


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "All PDC subjects were assigned randomly to one of the following three groups"

Comment: insufficient information about the sequence generation process to permit judgement

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to permit judgement

Incomplete outcome data (attrition bias)
All outcomes
Low risk
  • Number randomised: 75
  • Drop-outs: 5, not stated in which group, 1 participant not accounted for
  • Reason for drop-outs: participants moved from the area or asked to be transferred to other clinicians

Selective reporting (reporting bias)High risk
  • Selective reporting of outcomes: insufficient information to permit judgement
  • Selective reporting of data: incomplete reporting of the distal movement outcome; means were presented without standard deviations

Other biasHigh riskThe control group in this study has very similar characteristics to the Armi 2011 study. We contacted the authors for clarification but no response was received

Bondemark 2005

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: Malmo University, Sweden
  • Recruitment period: not stated
  • Funding source: Swedish Dental Society and Skane County Council, Sweden
  • Source of participants: patients attending clinic in Malmo
  • Study duration: 6.5 months
  • Time points at which follow-up is reported: 1) start of treatment, 2) end of molar correction


Participants
  • 40 participants in total, mean age 11.45 years
  • 20 in the intraoral appliance group: mean age 11.4 years (SD 1.37), 10 males and 10 females
  • 20 in the extraoral appliance group: mean age 11.5 years (SD 1.25), 8 males and 12 females


  • Inclusion criteria


  1. No orthodontic treatment before distalisation
  2. A non-extraction treatment plan
  3. Maxillary first permanent molars in occlusion and no erupted second permanent molars
  4. Class II molar relationship, defined by at least end-to-end molar relationship


Interventions
  • Comparison 1: Intraoral appliance with superelastic coils


  1. Bands on upper first molars and first and second premolars
  2. 1.1 mm tube soldered to the lingual of the molar band
  3. A Nance acrylic button was soldered to the appliance


  • Comparison 2: Headgear


  1. Cervical pull
  2. 400 g force was used for the first 2 weeks and 500 g afterwards
  3. Patient instructed to wear appliance at least 12 hours a day
  4. Patients recalled every 5 weeks


Outcomes
  • Treatment time to achieve molar correction
  • Distal movement and tipping of maxillary first permanent molars
  • Anterior movement and inclination of maxillary central incisors, i.e. anchorage loss
  • Movement of mandibular first permanent molars
  • Movement and inclination of mandibular central incisors
  • Skeletal changes of maxilla and mandible
  • Bite opening effect


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A restricted randomisation method was used in blocks of 10"

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "the cephalograms were scored and coded by an independent person unaware of the group allocation"

Incomplete outcome data (attrition bias)
All outcomes
Low risk
  • Number randomised 40, number included in the analysis 40
  • No drop-outs

Selective reporting (reporting bias)Unclear risk
  • Selective reporting of outcomes: insufficient information to permit judgement

Other biasLow riskStudy appears to be free of other sources of bias

De Oliveira 2007

Methods
  • Trial design: 2-centre RCT (parallel-group)
  • Location: University of Sao Paulo, Brazil; Lavras Dental School, Brazil
  • Recruitment period: not stated
  • Funding source: research submitted as partial fulfilment of MSc degree
  • Source of participants: patients attending clinic at university
  • Study duration: not stated
  • Time points at which follow-up is reported: 1) start of treatment, 2) removal of fixed orthodontic appliance


Participants
  • 50 participants in total, mean age 11.45 years
  • 25 in the Jasper Jumper group: mean age 11.86 years (range, 9.45 to 14.94), 13 males and 12 females
  • 25 in the cervical headgear group: mean age 12.29 years (range, 9.95 to 15.24), 13 males and 12 females


  • Inclusion criteria


  1. Angle Class II molar relationship
  2. Class II division 1 with no subdivision malocclusion
  3. Early permanent dentition with all permanent first molars, and first and second premolars


  • Exclusion criteria


  1. No craniofacial syndrome or systemic disease
  2. No tooth agenesis or missing permanent teeth


Interventions
  • Comparison 1: Jasper Jumper


  1. Jasper Jumpers attached to the maxillary and mandibular arches, in conjunction with:
  2. Standard edgewise appliance with a 0.022 inch slot
  3. Transpalatal arch in the maxilla


  • Comparison 2: Cervical headgear


  1. Cervical headgear exerting 150 to 300 g of force on each side with an average wear of 14 to 16 hours per day
  2. Standard edgewise appliance with a 0.022 inch slot


OutcomesSkeletal and dentoalveolar measurements on initial and final cephalometric radiographs


NotesThere was also an untreated control group in the study, but it was not involved in the randomisation process


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote (from correspondence): "The randomization process was performed as follows: the patients were placed into one of the groups by the use of a coin-toss"

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to permit judgement

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll randomised patients were included in the final analysis

Selective reporting (reporting bias)Unclear risk
  • Selective reporting of outcomes: insufficient information to permit judgement
  • Selective reporting of data: the duration of treatment to distalise the molar teeth was reported as a range; this is a secondary outcome of this review

Other biasLow riskStudy appears to be free of other sources of bias

Karacay 2006

Methods
  • Trial design: RCT (parallel-group)
  • Location: Gulhane Military Medical Academy, Ankara, Turkey
  • Recruitment period: not stated
  • Funding source: not stated
  • Source of participants: patients attending clinic
  • Study duration: not stated
  • Time points at which follow-up is reported: 1) attachment of distalising appliance, 2) end of molar correction


Participants
  • 48 participants in total, mean age 13.8 years
  • 16 in the Forsus Nitinol Flat Spring group: mean age 13.6 years (SD 1.2), 9 males and 7 females
  • 16 in the Jasper Jumper group: mean age 14.0 years (SD 1.9), 10 males and 6 females
  • 16 in the control group: mean age 13.8 years (SD 1.4), gender distribution not stated


Interventions
  • Comparison 1: Forsus Nitinol Flat Spring (FNFS)


  1. Size determined by adding 12 mm to the distance between the mesial edge of the headgear tube and the distal edge of the mandibular canine bracket when the patient was in centric occlusion
  2. Attached to headgear tube of maxillary molar and auxiliary arch in mandible between canine and first premolar brackets
  3. Patients recalled every 3 weeks


  • Comparison 2: Jasper Jumper (JJ)


  1. Size determined by adding 12 mm to the distance between the mesial edge of the headgear tube and the distal edge of the mandibular canine bracket when the patient was in centric occlusion
  2. Attached to headgear tube of maxillary molar and auxiliary arch in mandible between canine and first premolar brackets
  3. Patients recalled every 3 weeks


  • Comparison 3: Untreated control


Outcomes
  • Skeletal and dentoalveolar measurements on initial and final cephalometric radiographs
  • Inter-molar and inter-canine widths on study models


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The patients were randomly divided into three groups"

Comment: insufficient information about the sequence generation process to permit judgement

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to permit judgement

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk
  • 48 patients were included in the analysis
  • Number of drop-outs not addressed

Selective reporting (reporting bias)High riskSelective reporting of outcome data: no estimate of variability for change by group

Other biasLow riskStudy appears to be free of other sources of bias

Papadopoulos 2010

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: Department of Orthodontics, Aristotle University of Thessaloniki, Greece
  • Recruitment period: not stated
  • Funding source: none
  • Source of participants: patients attending clinic
  • Study duration: 6.5 months
  • Time points at which follow-up is reported: 1) start of distalisation, 2) end of distalisation


Participants
  • 26 participants in total, age 7.1 to 11.9 years
  • 15 in the First Class appliance group: mean age 9.2 years (range: 7.6 to 10.8), 8 males and 7 females
  • 11 in the 'no treatment' group: mean age 9.7 years (range: 7.1 to 11.9), 5 males and 6 females


  • Inclusion criteria


  1. Bilateral Class II molar relationship (quarter to 1 molar cusp)


  • Exclusion criteria


  1. Past orthodontic treatment
  2. Crossbites
  3. Severe carious lesions
  4. Poor oral hygiene
  5. Mobility of the maxillary deciduous molars
  6. Flat palate
  7. Ectopic maxillary canines
  8. Anterior open bites
  9. Vertical growth pattern
  10. Tongue habits


Interventions
  • Comparison 1: First Class appliance


  1. Banded first molars and second premolars or second primary molars
  2. 2 buccally positioned activation screws
  3. 2 palatally positioned open nickel-titanium coil springs
  4. Buccal and palatal tubes
  5. Large modified Nance button


  • Comparison 2: Untreated control


OutcomesCephalometric and dental cast variables


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "They were randomized into 2 groups"

Comment: insufficient information about the sequence generation process to permit judgement

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to permit judgement

Incomplete outcome data (attrition bias)
All outcomes
Low risk27 randomised, 1 dropped out because of broken appliance

Selective reporting (reporting bias)Unclear riskSelective reporting of outcomes: insufficient information to permit judgement

Other biasLow riskStudy appears to be free of other sources of bias

Paul 2002

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: University Dental Hospital, Manchester
  • Recruitment period: not stated
  • Funding source: none
  • Source of participants: patients referred for treatment
  • Study duration: 6 months
  • Time points at which follow-up is reported: 1) start of distalisation, 2) end of distalisation


Participants
  • 23 participants in total, age 10 to 16 years
  • 12 in the removable appliance group: mean age 13.5 years (SD 1.58)
  • 11 in the Begg system group: mean age 14.75 years (SD 1.75)


  • Inclusion criteria


  1. Patient 10 to 16 years old at start of treatment
  2. Upper second premolars present and erupted (required for the Jones Jig)


Interventions
  • Comparison 1: Upper removable appliance


  1. Adam's cribs on upper first premolars
  2. Southend clasp on the upper central incisor
  3. Occlusal stops on the upper canine
  4. Palatal finger springs to distalise the molars


  • Comparison 2: Jones Jig


  1. Bands on the upper second premolars
  2. Nance palatal arch
  3. The jig main frame attached to headgear slot on molar bands
  4. Niti coil spring


OutcomesPrimary outcomes

  1. Changes in the position of upper first molar in terms of


  • distal movement
  • distal tipping
  • disto-palatal rotation (molar straightening)


Secondary outcomes

  1. Mesial movement of the upper first premolars (loss of anchorage)
  2. Reported discomfort


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A restricted randomisation method was used in blocks of 12"

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "the examiner measuring the models was blind until all the data were recorded"

Incomplete outcome data (attrition bias)
All outcomes
Low risk
  • Number randomised: 27, number evaluated: 23
  • 15% drop-out rate:


  1. URA (2) (reasons: repeated breakage and did not attend after fit)
  2. Jones Jig (2) (reasons: treatment plan changed and patient did not want treatment)

Selective reporting (reporting bias)High risk
  • Selective reporting of outcomes: insufficient information to permit judgement
  • Selective reporting of data: there were no data on loss of anterior anchorage; this is an important outcome that is expected to be reported

Other biasLow riskStudy appears to be free of other sources of bias

Toy 2011

Methods
  • Trial design: single-centre RCT (parallel-group)
  • Location: Hacettepe University, Turkey
  • Recruitment period: not stated
  • Funding source: not stated
  • Source of participants: patients referred to orthodontic clinic
  • Study duration: 6.4 months
  • Time points at which follow-up is reported: 1) start of treatment, 2) end of molar distalisation or in the case of the headgear group, after 4.96 +/- 0.35 months


Participants
  • 30 participants in total, mean age 11.59
  • 15 in the intraoral pendulum appliance group: mean age 11.45 years (SD 1.54), 6 males and 9 females
  • 15 in the cervical headgear group: mean age 11.72 years (SD 1.24), 5 males and 10 females


  • Inclusion criteria


  1. Skeletal Class I malocclusion with bilateral Class II molars
  2. Radiographic confirmation that at least one-third of the roots of the unerupted maxillary second molars had developed
  3. A non-extraction treatment plan
  4. Good oral hygiene
  5. No or minimal crowding in the mandibular dental arch
  6. No signs of temporomandibular joint disorder


Interventions
  • Comparison 1: Intraoral pendulum appliance with a midline expansion screw


  1. Palatal acrylic button anchored to the maxillary first and second premolars with bonded occlusal rests
  2. A midline screw and bilateral 0.032 inch TMA cantilever springs were inserted into lingual sheaths on the first molar bands
  3. Springs were initially activated 90°
  4. Participants were monitored at 3-week intervals
  5. Participants were instructed to turn the expansion screw a quarter turn once a week


  • Comparison 2: Headgear group


  1. Cervical pull headgear
  2. Activated to deliver a force of 500 g
  3. Participants were instructed to wear the appliance for 12 to 14 hours per day
  4. Participants were monitored at 3-week intervals


Outcomes
  1. Mesiodistal movement of the upper first molars
  2. Anterior movement of upper incisor
  3. Overjet
  4. Other cephalometric variables


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The subjects were randomly allocated to ..."

Comment: insufficient information about the sequence generation process to permit judgement

Allocation concealment (selection bias)Unclear riskMethod of concealment is not described

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to permit judgement

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk
  • 30 patients were included in the analysis
  • Number of drop-outs not addressed

Selective reporting (reporting bias)Unclear risk
  • Selective reporting of outcomes: insufficient information to permit judgement

Other biasLow riskStudy appears to be free of other sources of bias

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Abed 2010Did not involve treatment with a distalising appliance; outcomes are not relevant; retrospective study

Angelieri 2008Retrospective study

Cetinsahin 2010Not a randomised trial; patient allocation depended on anchorage need. Did not involve treatment with a distalising appliance

Erverdi 1997Not a randomised trial

Gelgor 2007Not a randomised trial

Kaya 2009Did not involve treatment with a distalising appliance

Kinzinger 2003Not relevant; participants in this study were grouped according to dental maturation stage

Kinzinger 2004Not relevant; participants in this study were grouped according to second and third molar maturation stage

Kinzinger 2005Not relevant; participants in this study were grouped according to the tooth used for anchorage

Kinzinger 2006Not relevant; participants in this study were grouped according to dental maturation stage

Kinzinger 2010No comparison intervention

Kucukkeles 2007Not a randomised trial

Liu 2009Did not involve treatment with a distalising appliance; all patients over 16 years of age

Mossaz 2007Not a randomised trial, patients chose their intervention

Oncag 2007Not a randomised trial

Sari 2003Not a randomised trial

Schutze 2007Not a randomised trial

Silvola 2009The comparative intervention was not relevant to this review

Taner 2003Not a randomised trial

Ucem 1998Not a randomised trial

Uzel 2007Correspondence with author confirmed it was not randomised

 
Comparison 1. Appliance versus untreated control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Movement of upper first molars2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 First Class appliance versus untreated controls
126Mean Difference (IV, Fixed, 95% CI)-4.04 [-5.49, -2.59]

    1.2 Distalising appliance (Forsus and Jasper Jumper) versus untreated control
148Mean Difference (IV, Fixed, 95% CI)-1.6 [-2.20, 1.00]

 2 Movement of upper incisor teeth2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 First Class appliance versus untreated controls
126Mean Difference (IV, Fixed, 95% CI)1.32 [-1.14, 3.78]

    2.2 Distalising appliance (Forsus and Jasper Jumper) versus untreated control
148Mean Difference (IV, Fixed, 95% CI)-1.4 [-2.38, -0.42]

 3 Loss of anchorage (overjet mm)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 First Class appliance versus untreated controls
126Mean Difference (IV, Fixed, 95% CI)1.18 [0.26, 2.10]

    3.2 Distalising appliance (Forsus and Jasper Jumper) versus untreated control
148Mean Difference (IV, Fixed, 95% CI)-3.55 [-4.53, -2.57]

 
Comparison 2. Intraoral appliance versus headgear

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Movement of upper first molar4150Mean Difference (IV, Random, 95% CI)-1.45 [-2.74, -0.15]

 2 Movement of upper incisor teeth4150Mean Difference (IV, Random, 95% CI)1.82 [1.39, 2.24]

 3 Change in overjet270Mean Difference (IV, Fixed, 95% CI)1.64 [1.26, 2.02]

 
Comparison 3. Intraoral appliance versus other intraoral appliance

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Movement of upper first molars3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 Three-dimensional bimetric distalising arch versus modified Begg intraoral distalising system
138Mean Difference (IV, Fixed, 95% CI)-0.28 [-0.63, 0.07]

    1.2 Jasper Jumper versus Forsus Nitinol Flat Spring
132Mean Difference (IV, Fixed, 95% CI)0.80 [0.12, 1.48]

    1.3 Upper removable appliance with finger springs versus Jones Jig appliance
123Mean Difference (IV, Fixed, 95% CI)-0.13 [-1.50, 1.24]

 2 Movement of upper incisor teeth2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 Three-dimensional bimetric distalising arch versus modified Begg intraoral distalising system
138Mean Difference (IV, Fixed, 95% CI)-0.39 [-1.43, 0.65]

    2.2 Jasper Jumper versus Forsus Nitinol Flat Spring
132Mean Difference (IV, Fixed, 95% CI)0.0 [-0.80, 0.80]

 3 Loss of anchorage (overjet)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 Three-dimensional dimetric distalising arch versus modified Begg intraoral distalising system
138Mean Difference (IV, Fixed, 95% CI)-0.43 [-0.74, -0.12]

    3.2 Jasper Jumper versus Forsus Nitinol Flat Spring
132Mean Difference (IV, Fixed, 95% CI)0.5 [-0.04, 1.04]

 4 Duration of treatment2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    4.1 Three-dimensional bimetric distalising arch versus modified Begg intraoral distalising system
138Mean Difference (IV, Fixed, 95% CI)-3.1 [-3.49, -2.71]

    4.2 Jasper Jumper versus Forsus Nitinol Flat Spring
132Mean Difference (IV, Fixed, 95% CI)-0.05 [-0.87, 0.77]

 
Summary of findings for the main comparison. Orthodontic appliance compared to untreated control for distalising first molars

Orthodontic appliance compared to untreated control for distalising first molars

Patient or population: children and adolescents undergoing orthodontic treatment
Settings: university or private orthodontic clinic
Intervention: orthodontic appliance
Comparison: untreated control

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Untreated controlOrthodontic appliance

Movement of upper first molars (mm)Not estimatedNot estimatedMeta-analysis not appropriate74
(2 studies)
⊕⊕⊝⊝
low1,2
No pooled estimate due to different types of appliances (First Class and distalising) used in the studies

Movement of upper incisor teeth (mm)Not estimatedNot estimatedMeta-analysis not appropriate74
(2 studies)
⊕⊕⊝⊝
low1,2
No pooled estimate due to different types of appliances (First Class and distalising) used in the studies

Change in overjet (mm)Not estimatedNot estimatedMeta-analysis not appropriate74
(2 studies)
⊕⊕⊝⊝
low1,2
No pooled estimate due to different types of appliances (First Class and distalising) used in the studies

*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% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval

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

 1One study at high risk of bias; one study at unclear risk of bias
2Evidence based on two studies with a low number of participants
 
Summary of findings 2. Intraoral appliance compared to headgear for distalising first molars

Intraoral appliance compared to headgear for distalising first molars

Patient or population: children and adolescents undergoing orthodontic treatment
Settings: university or private orthodontic clinic
Intervention: intraoral appliance
Comparison: headgear

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed risk1Corresponding risk

HeadgearIntraoral appliance

Movement of upper first molars (mm)The mean movement of upper first molars (mm) in the headgear group was -1.04 mm (distal movement)The mean movement of upper first molars (mm) in a distal direction for the intraoral appliance group was 1.45 mm more (-2.74 to -0.15)150
(4 studies)
⊕⊝⊝⊝
very low2,3
Movement of the upper first molars in a distal direction is the desired type of tooth movement. This result indicates that the intraoral appliance is superior to headgear for this outcome

Movement of upper incisor teeth (mm)The mean movement of upper incisor teeth (mm) in the headgear group was -1.09 mm (distal movement)The mean movement of upper incisor teeth (mm) in a mesial direction for the intraoral appliance group was 1.82 mm more (1.39 to 2.24)150
(4 studies)
⊕⊕⊝⊝
low2,4
Movement of the upper incisor teeth in a mesial direction is an unwanted tooth movement and indicates that the intraoral appliance is inferior to headgear for this outcome

Change in overjet (mm)The mean loss of anchorage (mm) in the headgear group was -0.86 mm (reduction in overjet)The mean change (increase) in overjet (mm) in the intraoral appliance group was 1.64 mm more (1.26 to 2.02)70
(2 studies)
⊕⊕⊝⊝
low5
An increase in overjet is unwanted and indicates that the intraoral appliance is inferior to headgear for this outcome

*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% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval

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

 1The basis for the assumed risk was the mean of the control groups across studies
2 Three studies at unclear risk of bias; one study at high risk of bias
3 Evidence based on the results of four small studies with equivocal results
4 Evidence based on the results of four studies with a low number of participants
5 Evidence based on the results of two studies with a low number of participants, at unclear risk of bias
 
Summary of findings 3. Intraoral appliance compared to other intraoral appliance for children and adolescents

Intraoral appliance compared to other intraoral appliance for children and adolescents

Patient or population: children and adolescents undergoing orthodontic treatment
Settings: university or private orthodontic clinic
Intervention: intraoral appliance
Comparison: other intraoral appliance

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Other intraoral applianceIntraoral appliance

Movement of upper first molars (mm) Not estimatedNot estimatedMeta-analysis not appropriate93
(3 studies)
⊕⊝⊝⊝
very low1,2
No pooled estimate due to different types of appliances used in the studies

Movement of upper incisor teeth (mm) Not estimatedNot estimatedMeta-analysis not appropriate70
(2 studies)
⊕⊝⊝⊝
very low3,4
No pooled estimate due to different types of appliances used in the studies

Change in overjet (mm) Not estimatedNot estimatedMeta-analysis not appropriate70
(2 studies)
⊕⊝⊝⊝
very low3,4
No pooled estimate due to different types of appliances used in the studies

*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% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval

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

 1Three studies at high risk of bias
2 Evidence based on the results of three small studies with a low number of participants and equivocal results
3 Two studies at high risk of bias
4 Evidence based on the results of two studies with a low number of participants
 
Table 1. Reported outcomes in included studies which are relevant to this review

Study IDMovement of molar teethAnterior movement of incisor teethOverjetDuration of treatmentNumber of attendancesAdverse effects

Acar 2010YesYesNoNoNoNo

Altug-Atac 2008YesYesYesYesNoNo

Armi 2011YesNoNoNoNoNo

Baccetti 2008YesNoNoNoNoNo

Bondemark 2005YesYesYesYesNoNo

De Oliveira 2007YesYesNoYesNoNo

Karacay 2006YesYesYesYesNoNo

Papadopoulos 2010YesYesYesNoNoNo

Paul 2002YesNoNoYesNoNo

Toy 2011YesYesYesYesNoNo