DISTALIZACION EN MAXILAR PARA CORRECCIÓN CLASE II CON ANCLAJE ESQUELETICO 1-S2.0-S1761722722000778-Main

International Orthodontics 2022; 20: 100666
Websites:
www.em-consulte.com
www.sciencedirect.com
Systematic review and meta-analysis

Efficiency of maxillary total arch distalization
using temporary anchorage devices (TADs)
for treatment of Class II-malocclusions: A
systematic review and meta-analysis
Tuqa Rashad Raghis 1, Tareq Mosleh Alfrih Alsulaiman 2, Ghiath Mahmoud 1, Mohamed Youssef 1
Available online: 22 July 2022 1. Department of Orthodontics, Faculty of Dentistry, Damascus University, Damascus,
Syria
2. Ministry of Health, Damascus, Syria
Correspondence:
Tuqa Rashad Raghis, Department of Orthodontics, Faculty of Dentistry, Damascus
University, Damascus, Syria.
orthosyria@gmail.com, omar.hamadah@gmail.com
Keywords Summary
Malocclusion
Angle Class II/therapy Objectives > To evaluate the treatment effects and post-treatment stability of the maxillary total
Orthodontic appliance arch distalization using TADs during the non-extraction treatment of class II malocclusions.
design Materials and methods > Study involved an electronic search followed by hand searching for
Tooth movement randomized and non-randomized clinical studies about maxillary total arch distalization using
techniques TADs. After data extraction and risk of bias assessment, meta-analysis was performed for dental,
Modified C palatal plate skeletal and soft tissue changes using the Generic-inverse variance approach by use of the mean
Mini-screws difference and random-effect model.
Distalization Results > In total, 1788 articles were identified, 88 full texts were screened and 22 studies were
Systematic review found eligible; 17 of them were included in the quantitative analysis. The means of distalization/
Meta-analysis distal tipping of the maxillary first molar were 4 mm/3.178 in adults, 3.95 mm/1.618 in adoles-
cents after treatment with the Modified C-Palatal plate (MCPP), while they were 2.44 mm/2.918
with the inter-radicular mini-screws. Both MCPP's treatment in adults and inter-radicular mini-
screws resulted in significant intrusion of U6 (1.64 and 0.75 mm, respectively), while insignificant
extrusion of U6 was resulted in adolescents treated by MCPP. MCPP appliances resulted in palatal
inclination/extrusion of maxillary incisors U1 (6.778/2 mm in adults, 7.468/3.14 mm in adoles-
cents). In contrast, inter-radicular mini-screws resulted in less palatal less amount of palatal
inclination/insignificant intrusion of U1 (2.428/0.14 mm). MCPP treatment also resulted in signifi-
cant changes in the skeletal measurements (SNA, ANB, occlusal and mandibular planes). Insignifi-
cant differences were found between subgroups in the retraction amount of maxillary incisors, as
well as the upper and lower lips. In the follow-up of adolescents treated with MCPP, a significant
amount of mesial movement, mesial tipping, and extrusion (2.94 mm, 2.848, and 3.94 mm,
tome 20 > n83 > September 2022

https://doi.org/10.1016/j.ortho.2022.100666
© 2022 CEO. Published by Elsevier Masson SAS. All rights reserved.
T.R. Raghis, TMA. Alsulaiman, G. Mahmoud, M. Youssef

respectively) was found. However, skeletal and occlusal corrections of the Class II relationship were
maintained.
Conclusions > Maxillary total arch distalization using TADs can be an effective and stable treatment
procedure. However, RCTs or prospective cohort studies are highly recommended to establish a
clinical evidence regarding their efficiency.
Introduction adolescents. Moreover, re-implantation of mini-screws may

Class II malocclusion is considered as the most frequent problem be necessary when a large amount of distalization is required
presenting in the orthodontic practice, affecting about 20–30% [20–22].
of school children and occurring in 33% of all orthodontic Infra-zygomatic region can provide a wider range of action due
patients [1,2]. to extra-radicular placement of TADs, but flap surgery is required
Treatment options for Class II malocclusions can be categorized when placement and removal, which may cause swelling and
into extraction, non-extraction, functional and orthognathic sur- pain [17].
gery, where the tendency toward non-extraction treatment has Alternatively, mini-implantation into the palatal area has been
been increased nowadays because of the availability of effective highly recommended due to its sufficient high quality bone
and minimally invasive techniques [3]. [23,24] and lack of interference with tooth movement during
Maxillary molars distalization is the most common non-extrac- distalization [25]. Therefore, several appliances with palatally
tion treatment modality used to correct class II malocclusion by placed TADs have been reported to distalize the maxillary pos-
posterior movement of the buccal segment teeth in order to terior teeth.
achieve a class I molar relationship [4]. Recently, the modified C-palatal plate (MCPP) appliance has
For a number of years, headgear was the standard approach to been reported to effectively distalize the entire maxillary arch
distalize molars or entire maxillary arch. However, depending on in adults and adolescents [26].
patient's compliance and poor aesthetics compromised its treat- Several review articles have evaluated the using of TADs-sup-
ment effects [5,6]. ported appliances for maxillary distalization during non-extrac-
Therefore, several non-compliance depending appliances such tion treatment of class II malocclusion; systematic review of
as Herbst [7], distal jet [8,9], and pendulum appliances [8,10] Mohamed et al. concluded that mini-screw supported applian-
had been used effectively for molars distalization. Nevertheless, ces are effective in maxillary molars distalization with minimal
significant loss of anchorage was observed including forward anchorage loss [27].
movement of the premolars and incisors, as well as the relapse Levin et al., 2018 also reported in their systematic review that
of molars distalization during anterior segments retraction both of palatal and zygomatic skeletal anchorage systems are
[11,12]. In addition, a distal movement of the total maxillary effective non-extractive therapy for maxillary buccal segment
arch was almost impossible in most patients. distalization in greater than 3 mm space deficiency [28].
To reduce these shortcomings, temporary anchorage devices A meta-analysis compared molar distalization using skeletal
(TADs) have been introduced and greatly expanded the bound- versus conventional anchorage devices. It concluded that the
aries of orthodontic tooth movements. Using TADs, individual conventional and skeletal anchorage devices were not signifi-
teeth or the entire dental arch can be moved in three planes cantly different in terms of the amount of molar distalization or
with minimal loss of anchorage, which make them a proper tipping, while the anchorage loss was lower in the skeletal
choice for use in distalizing the whole maxillary arch in the non- anchorage group [29].
extraction treatment [13,14]. In addition, a recently published meta-analysis assessed the
Recently, several studies have reported the efficiency of using treatment effects of buccally or palatally placed TADs on maxil-
buccally or palatally placed TADs for total maxillary arch distal- lary first molars during distalization. It reported that inter-radic-
ization [15–19]. However, clinical evidence regarding the treat- ular TADs resulted in less distal tipping but also in less
ment effects of these mechanics is still unclear. distalization while palatal TAD-supported appliances showed
Mini-screws installed into the inter-radicular spaces are increas- the greatest amount of distal tipping [30].
ingly used for this purpose due to their simple and less invasive Although these review articles evaluated the efficacy of DAT use
placement procedures, but they are not always easy to place for distalization, they focused only on molar or buccal segment
buccally in narrow inter-radicular spaces, especially in displacement.
2

Thus, no systematic reviews have evaluated the effects of DAT EMBASE (European studies, pharmacological literature, confer-
use during distalization of the total maxillary arch or post- ence abstract), Scopus, Google scholar, and Open Grey (to iden-
treatment changes of the distalized arch. Therefore, the aim tify the grey literature).
of this meta-analysis was to investigate the available evidence The references of each relevant study were screened to discover
regarding maxillary total arch distalization using TADs during the any additional relevant publications and to improve the sensi-
non-extraction treatment of class II malocclusion in terms of tivity of the search.
dental, skeletal and soft tissue changes after distalization, as Hand searching was carried out in the following journals: Amer-
well as the stability of the treatment effects. ican Journal of Orthodontics and Dentofacial Orthopaedics, Aus-
tralian Orthodontic Journal, European Journal of Orthodontics,
Materials and methods Journal of orofacial orthopaedics, International orthodontics,
Protocol and registration Orthodontics and Craniofacial Research, Seminars in Orthodon-
Protocol registration with PROSPERO was not performed during tics, The Angle Orthodontist, The Journal of Orthodontics, and
the first stages of this review. The Korean Journal of Orthodontics.
This systematic review was written according to the Cochrane
Search strategy
Handbook for Systematic Reviews of Interventions 2nd edition
Electronic search was carried out by two independent reviewers
[31] and the Preferred Reporting Items for Systematic Reviews
using advanced searches with no restrictions on language, year,
and Meta-Analyses (PRISMA) guidelines [32].
or publication status from inception to April 2022 (last search
Eligibility criteria was conducted at 06/04/2022) using the following keywords:
#1 (mini-screw OR miniscrew OR "mini screw'' OR micro-screw
Inclusion criteria
According to the population, intervention, comparison, out- OR "micro screw'' OR mini-implant OR "mini implant'' OR
comes and study design (PICOS) framework: micro-implant OR "micro implant'' OR mini-plate OR miniplate
P (Population): adults or adolescents patients with class II OR "mini plate'' OR "modified c palatal plate'' OR MCPP OR
malocclusion; "modified palatal anchorage plate'' OR MPAP OR "skeletal
I (Intervention): non-extraction treatment with total maxillary anchorage'' OR "temporary anchorage'' OR TAD);
arch distalization using TADs; #2 (maxilla* OR upper);
C (Comparisons): between pre- and post-treatment (or #3 (total OR entire OR full OR whole OR "en masse'');
between post-treatment and post-retention) in the experi- #4 (arch OR dentition);
mental groups, beside comparisons between experimental #5 (distalization OR distal*);
groups and untreated or (treated with other methods) groups; #6 #1 AND #2 AND #3 AND #4 AND #5.
O (Outcomes): primary outcomes of the study were the The search strategy was modified for databases accordingly.
changes in (1) dental (sagittal & vertical positions and angu- Details on search strategy are found in Supplementary material
lation of U6 and U1), (2) Skeletal (SNA, ANB, occlusal plane 1.
and mandibular plane angles) and (3) soft tissues (Upper & Study selection and data extraction
Lower lip positions and nasolabial angle) measurements after Two reviewers carried out the selection of the studies indepen-
total arch distalization. While secondary outcomes were the dently and disagreements were resolved by asking a third
post-treatment changes in U6 position after follow-up period; author. Firstly, all titles were screened and the irrelevant articles
S (study design): RCTs and non-randomized prospective or
were excluded. Then, the remaining articles were evaluated to
retrospective clinical studies that contained at least pre- eliminate studies based on data obtained from abstracts. Finally,
and post-treatment measures were included. full-text of the remaining articles was checked precisely to
Exclusion criteria confirm the acceptability depending on the eligibility criteria.
The exclusion criteria are: Data were extracted independently from the included studies
case reports or case series; according to the PICOS question and arranged in fields; general
editorials, personal opinions, reviews, and technique descrip- information (author name and publication date), study design,
tion articles without reported sample; participants (size, age, sex, severity of malocclusion and the
extraction treatment, distalization without using of TADs or not main inclusion criteria), intervention (type of TADs/appliance,
involving total arch distalization. site of application and the treatment duration), outcomes (pri-
Information sources mary outcomes and methods of measurement) and study's
The search strategy included a review of electronic databases, main findings.
supplemented by a manual search. The electronic search was Assessment of methodological quality
performed in PubMed (National Library of Medicine, NCBI), Two reviewers assessed the quality of the included studies
Cochrane library (Cochrane review, Trials), Science Direct, independently and when lack of consistency, a third author
3

was consulted for resolution. The reviewers used the Revised provide an answer to the PICOS question, using the National
Version of Cochrane Risk-Of-Bias (ROB 2.0) tool for randomized Institutes of Health (NIH) quality assessment tool for before-
studies [33] and the Risk-Of-Bias In Non-randomized Studies of and-after studies (Pre-Post) without a control group [39]. These
Intervention (ROBINS-I) tool for non-randomized studies studies were excluded from the quantitative analysis if they
[34,35]. Risk-Of-Bias Visualization tool (robvis) was used to were considered to be of "poor quality'' after NIH assessment.
visualize the risk of bias assessment [36]. Data synthesis and analysis
ROBINS-I template provided by the tool's authors was adhered Meta-analysis was done using Review Manager Software, Ver-
to for the most parts; certain deviations from their guidelines sion 5.4.1 (Copenhagen; The Nordic Cochrane Centre, Cochrane
were made in the context of this study to generate a risk of bias Collaboration) by generic inverse-variance approach. The mean
(ROB) gradient with higher resolution [37]. difference was used as summary statistics and a random-effect
For confounding bias, "low risk'' was attributed to studies that method was used for meta-analysis. Level of significance was
performed sufficient statistical adjustment for potential con- set at 0.05. Heterogeneity was first evaluated clinically accord-
founders. "Moderate risk'' was attributed to studies that only ing to TADs location and baseline characteristics of participants.
showed baseline characteristics between treatment arms were I2 and chi-square test were performed to quantify the hetero-
similar but did not perform adjustments. Studies with weaker geneity across studies.
designs were judged at "serious'' or "critical risk'' of bias.
Since uncontrolled (one-group) before-and-after studies are Results
usually considered to be at "serious'' or "critical'' risk of bias The initial search identified 1788 records. Following the screen-
according to the ROBINS-I tool, an additional assessment was ing of the article titles, 325 potentially relevant articles were
applied to include them anyway [38], knowing that they could identified. Independent screening of the abstracts resulted in
Figure 1
Prisma flow chart of study
selection process
4

distalizion of U6
extruded in the
changes in the
Main findings
the selection of 84 publications and 4 protocols (for ongoing
The maxillary
incisors were
and skeletal
Both groups
significantly
GMD group
significant
showed
maxilla
Assessment methods
studies) for possible inclusion. The inclusion and exclusion cri-
teria were applied to the 88 full-text articles. Finally, 22 articles
that met the predefined criteria were included; 17 of them were
included in the quantitative synthesis. The PRISMA flow chart
Ceph
(figure 1) illustrates the search methodology and results. Sup-
Outcomes
plementary material 2 shows the excluded articles with reasons
tissue changes
Outcomes of
dental, soft
the study
for exclusion.
Skeletal,
MCPP vs. GMD
Comparisons
Study characteristics
Duration (months)
The included articles were published in English between
2013 and 2022. Only one from the studies was RCT study design
38.6 17.6
35.9 15.3
[21], while the remaining 21 studies were non-randomized
studies; 2 prospective and 19 retrospective.
The distalizaion groups in the study involved 773 patients, and
the main inclusion criteria were: Class II division 1 malocclusion
Placement cite
with moderate maxillary arch crowding and no tooth extraction
Intervention
of TADs
Palatal
during treatment.
–
Fourteen of the included studies, including 601 patients, applied
the modified Palatal Anchorage Plate or the Modified C shape
TADs/treatment
palatal plates (MCPPs) for total maxillary arch distalization
MCPP
GMD
[26,40–52]; six of these studies involved 152 adolescents and
eight of them involved 449 adult patients [40,42,44–49].
Six of the included studies used inter-radicular mini-screws for
130 adult patients [21,22,40,53–55], and three studies with
crowding < 5 mm
C II div 1, max
Main inclusion criteria/Severity of
42 adult patients involved the application of infra-zygomatic

mini-screws [56–58].
malocclusion
The comparative groups were either not treated (94 patients)

[22,43,50,52], or were treated with other techniques such as;
Full cusp: 10
1/4 cusp: 4
1/2 cusp: 7
1/4 cusp: 2
1/2 cusp: 8
Full cusp: 8
premolars' extraction (41 patients) [42,48], cervical pull head-
gear (43 patients) [26,47] and the Greenfield molar distalizers
(18 patients) [51].
In addition, some studies compared between two distalization
Sex M/F
9/12
6/12
Participants
groups: total arch distalization using single vs. dual mini-screws

[21], inter-dental mini-screws vs. MCPP [40], MCPP in hyper- vs.
hypodivergent groups [41], MCPP with vs. without second molar
Age (Years)
11.7 1.3
11.2 0.9
eruption [43] and MCPP with extraction vs. non-extraction treat-

ment [49].
Characteristics of the included studies.
Outcomes measurements were taken on lateral cephalographs

in most of the included studies [21,22,26,40–42,44–
Size
21
18
48,51,54,57,58], on cone beam computed tomography (CBCT)

images in five of them [43,49,50,52,56], and on 3D dental
Groups
MCPP
GMD
models in two of them [53,55]. Characteristics of the included

studies are summarized in the table I.
Retro CBA
design
Study
Authors & year
of publication
TABLE I
et al.,
Alfaifi
2021
5
TABLE I (Continued).
Authors & year Study Participants Intervention Comparisons Outcomes Main findings
of publication design
Groups Size Age (Years) Sex M/F Main inclusion criteria/Severity of TADs/treatment Placement cite Duration (months) Outcomes of Assessment methods
malocclusion of TADs the study
Alfawaz Retro CBA MCPP 25 22.5 W 7.2 10/15 3/4 cusp: 10 C II molar with MCPP Palatal 26.5 W 6.0 MCPP vs. PE Skeletal, Ceph Skeletal changes
Full cusp: 15 severe O.J dental, soft and O.J reduction
et al.,
(> 7 mm) tissue changes were similar in
2022 the MCPP and
extraction groups
PE 21 23.4 W 6.5 2/19 3/4 cusp: 9 Upper PE – 27.2 W 5.1
Full cusp: 11
Ali et al., Retro MS 17 26.4 W 10.8 6/11 Class II div 1, max One MS/side Buccaly 8.2 W 2.0 Before and 3d tooth 3d virtual Total maxillary
UCBA crowding between U5 & after movement and models arch was
2016
(2.84 W 2.79 mm), U6 distalization ach width obtained from retracted without
O.J 5 mm dental casts a change in the
vertical position
of the teeth;
however, the
second molars
were significantly
extruded
Bechtold RCT Group A 12 23.58 W 6.92 1/11 Normal or mild One MS/side Buccaly U5 & 9.08 W 4.89 Single vs. dual Displacement Ceph Group B displayed
skeletal C II, U6 mini-screws pattern of U1 significantly
et al.,
moderate C II &U6 and greater molar
2013 occlusion, and max skeletal distalization and
6
crowding 3 mm changes intrusion and

incisor retraction
than did the
group A
Group B 13 22.92 W 7.1 2/11 2 MSs/side U5 & U6, and 11.21 W 5.71
U4 & U5
Bechtold Retro MS 19 24.9 W 5.0 4/15 C II, distalization of One MS/side Buccaly T0–T1: 30.6 W 12.2 Mini-screw vs. Dental and Cephalometric Treatment
cohort U6 > 2 mm between U5 & T1–T2: 36.9 W 23.3 control skeletal resulted in
et al.,
U6 changes after 4.2 mm of U6
2020 treatment and distalization
at least 2 years without distal
after follow-up crown tipping and
3.38 of occlusal
plane steepening
Distalization
group displayed
high stability;
showed the same
amount of mesial
movement
(0.7 mm) as the
control group
Ctrl 19 25.4 W 4.9 8/11 Antero-posterior No treatment – T0-T1: 16.2 W 3.0
movement < 1 mm T1-T2: 47.4 W 11.1
C I or C II


Beyling Retro MS 23 29.6 W 11.5 3/20 C II > half cusp 2 MSs/side Between U5 & 10.5 W 4.5 (min. 5.2, Changes at T0, Predictability of Plaster models 97% of the
ITS (13.6–50.9) Treatment with a U6 (one max. 19.8) T1, T2, T3 time class II canine & Intraoral planned canine
et al.,
CCLA and mini- palataly and points relationship photographs relationship and
2021 screws one buccaly Compare T0–T3 and overjet overjet correction
placed) changes with correction. was achieved
the treatment (mean 3.6 and
plan/set-up 3.1 respectively)
(TxP) The presented
technique allows
for a predictable
correction of Class
II malocclusion
Chou Retro MCPP 20 12.9 W 1.0 8/12 Age 11–14, dental C MCPP Palatal T0-T1: 13.9 W 2.3 months Changes at Long-term CBCT images at Improved sagittal
cohort II > 1/4 cusp, and time points skeletodental T0, T1, T2. skeletal and
et al.,
max T1–T2: 5.9 W 2.7 years. within MCPP effects, volume dental
2021 crowding 5 mm group of maxillary relationships
tuberosity and were maintained
MCPP vs. ctrl airway space. in the long-term
(airway and evaluation
tuberosity There was no
comparison) negative long-
term effect on
7
airway space
Ctrl 20 19.3 W 1.6 11/9 Dental C II, no No treatment – – CBCT at one

previous treatment time point
Jo et al., Retro CBA MCPP 20 22.4 W 6.3 4/16 C II relationship, MCPP Palatal 25.8 W 10.8 MCPP vs. PE Skeletal, dental Ceph MCPP is an
crowding < 5 mm and soft tissue effective
2018
and overjet > 4 mm changes. distalizing
appliance of
maxillary arch
PE produced
greater U1
retraction
PE 20 24.6 W 7.6 1/19 Four PE 28.3 W 7.3
Jung et al., Retro CBA Hyperdivergent 20 12.1 W 1.1 Total 18/22 FMA 28 Skeletal C II MCPP Palatal 15.4 W 1.3 Hyper- vs. Skeletal and Ceph Hypo-divergent
(ANB > 4), max Hypo-divergent dental changes group displayed
2021
crowding < 4 mm groups. greater
distalization and
tipping of U6
FMA increased
3 in hypo-
divergent, while
it maintained in
hyper-divergent
group
Hypodivergent 20 12.3 W 1.5 FMA 22 14.9 W 1.5

Kook Retro MCPP 20 22.9 7/13 1/4 cusp: 15 Age > 17 years, MPAP Palatal 12.5 Before and Skeletal and Cephalographs The MPAP
UCBA (Range: 17.4–33) 1/2 cusp: 12 dental C II after treatment dental changes obtained from appliance is
et al.,
3/4 cusp: 7 relationship CBCT images. effective in
2014 Full cusp: 6 sides minimizing distal
tipping and
preventing molar
extrusion during
distalization
Lee et al., Retro CBA MCPP 22 21.9 W 6.6. NR C II div I, normal MCPP Palatal NR MCPP vs. MS Dental, skeletal Ceph Greater
growth pattern, max groups and soft tissue distalization and
2018
crowding 5 mm changes intrusion with
minimal distal
tipping in MCPP
group
Only MCPP group
showed
significant upper
lip retraction
MS 18 24.2 W 6.8. NR One MS/side Buccaly NR

between U5 &
U6
8
Lee et al., Retro CBA MCPP 20 (33 U8) 12.5 W 1.2 6/14 11 to 14 years, uni- MCOO Palatal 14.4 W 6.35 MCPP vs. Ctrl Changes in the CBCT images First, second, and
or bilateral groups. position of U8 third molars
2019
unerupted U8, moved downward
dental C II > 1/4 and forward in
cusp, and max the control group,
crowding 5 mm while they
moved backward
and upward in
the MCPP group
Ctrl 20 (35 U8) 12.7 W 1.1 12/8 No treatment – 12.9 W 4.04
Park et al., Retro MCPP 284 NR NR C II malocclusions MCPP Palatal NR Actual vs. The differences AI model It is possible to
UCBA aged > 18 years and predicted between actual based on predict the
2021
treated with MCPP changes for and predicted convolutional skeletal, dental,
each landmark cephalometric neural and soft tissue
changes networks changes resulting
(CNN) from
architecture nonextraction
treatment with
MCPP


Park et al., Retro MCPP G1 15 13.2 W 1.32 5/10 Ages 11–14 years, MCPP Palatal T0-T1: T2: after 5.2 years G1 vs. G2 3D changes in CBCT at T0, T1 Less distal tipping
cohort dental C II > 1/4 18.1 W 13.12 molars at time and T2 of U6 and U7 in
2021
study cusp, max points G1, but shorter
crowding < 5 mm treatment time in
and uni-or bilateral G2
developing U8 In the long term,
U7 were fully
erupted after
distalization in G2
U8 showed a
favorable position
in both MCPP
groups
MCPP G2 12 12.0 W 1.24 5/7 T0-T1:
13.1 W 7.04
Ctrl 1 20 12.65 W 1.14 12/8 Same criteria as G1 No treatment – T0-T1: Ctrl1 vs. G1 and G2 Changes after CBCT at T0 and
and G2 12.9 W 4.04 distalization T1
Ctrl 2 15 19.4 W 1.69 4/11 Ctrl2 vs. G1 and G2 Changes after CBCT at one
retention time
Park et al., Retro CBA MCPP 22 24.7 W 7.7 6/16 1/4: 5 C II div 1, max MCPP Palatal 29.9 W 11.9 MCPP vs. HG Dental and Ceph MCPP showed
1/2: 4 crowding < 5 mm, skeletal greater
9
2017
3/4: 9 man changes distalization of U6
Full: 4 crowding < 3 mm with less distal
tipping and
intrusion
No significant
differences in
skeletal or soft
tissue changes
HG 22 23.0 W 7.7 6/16 1/4: 4 HG – 24.1 W 9.1
1/2: 2
3/4: 13
Full: 3
Park et al., Retro CBA NE 17 21.5 6/27 1/4: 18 C II dv I MCPP Palatal NR NE vs. EX Changes in the CBCT MCPP resulted in
1/2: 9 position of the significant total
2018
3/4: 1 maxillary arch distalization
Full: 6 dentition and without
the airway significant
space displacement of
the teeth in the
transverse
dimension
EX 16 22.9 1/4: 21 NR
1/2: 6
3/4: 0
Full: 5

Sa'aed Retro CBA MCPP 24 12.42 W 1.69 6/18 1/4: 8 C II div 1, normal MPAP Palatal 28.0 W 8.2 MCPP vs. HG Skeletal effects Ceph MPAP showed
1/2: 6 diverged and max and amount of significant
et al.,
3/4: 8 crowding < 5 distalization skeletal changes
2015 Full: 2 on the maxilla.
However, this
was not
significantly
different from the
headgear group
HG 21 12.05 W 1.40 11/10 1/4: 4 HG – 28.9 W 10.5
1/2: 8
3/4: 8
Full: 1
Shoaib Retro UC MCPP 23 20.1 9/14 Dental C II div I, MCPP Palatal T0–T1: Changes at Skeletal, dental Ceph MCPP showed
Follow-up distalization using 12.2 months time points and soft tissue minimal changes
et al.,
MCPP T1–T2: 3.5 years (range, changes after 3 years of
2019 2.0–7.2) treatment. The
relapse was 12%
of the
distalization and
35% of the
10
intrusion
Shahani Pro CBA PSL 6 > 18 NR C II div I with MS+ PSL IZC NR PSLB vs. CA Dental, skeletal Ceph Both appliances
pleasing profile, and and soft tissue were effective in
et al.,
good compliance changes total maxillary
2019 arch distalisation.
First molar's
tipping and
intrusion, and
incisor extrusion
were greater in
PSL compared to
CA groups
Clear aligners 6 NR MS + CA IZC NR
Shaikh Pro UCBA IZ 10 15–30 NR C II div I, gummy IZ implants + inter- IZC between NR Before and Amount of Ceph Mean of 4.6 mm
smile, deep over radicular MS 1st & 2nd after treatment distalization of maxillary
et al.,
bite, and good molars + MS and reduction distalization, 3.8
2021 patient compliance U2&U3 of gummy of anterior
smile intrusion and
4 mm of overbite
correction were
achieved
Song Retro UC MS 39 (28 U) 25.5 (range: 18.3–32.3) 8/31 Intact permanent MS Upper: T0-T1: (range: 6–22) Changes at Vertical and Ceph & dental Total arch
Follow-up dentition without 48: U5 & U6/ time points horizontal casts distalization can
et al.,
extraction, 28:U6 & U7/ T1-T2: 29.3 W 12.8 movement of be used in
2022 crowding < 4 mm, 2: mid-palatal. (range: 14–52) teeth, changes patients with a
and followed at in arch width moderate amount
least 1 year for and molar of arch length
post-retention. rotation discrepancy


effectively with
stable retention
Wu et al., Retro IZ 20 23 W 5 4/16 Bilateral cusp-to- MS IZC 8 months Before and 3D CBCT Mini-screws
UCBA cusp class II after treatment measurements implanted in the
2017
malocclusion, of dental IZ crest is an
overjet 8 changes efficient device
for maxillary
dentition
distalization
Retro: retrospective; Pro: prospective; CBA: controlled before-after study; UCBA: uncontrolled before-after study; ITS: interrupted time series; MCPP: modified c palatal plate; GMD: Greenfield molar distalizer; PE: premolar extraction; M:
male; F: female, ceph: cephalometric images; MS: mini-screws; OJ: over jet; max: maxillary; ctrl: control group; NE: non-extraction; HG: head gear; PSL: passive self-ligating; CA: clear aligner; IZC: infra-zygomatic crest.
11


Quality assessment Bias due to confounding was the most problematic domain, it
Using ROBINS-I tool, only one of the included non-randomized was graded as "critical'' for two studies and "serious'' for nine
studies was judged to be at "low'' risk of bias, while nine studies studies, because important confounding domains (severity of
were at "moderate'', seven studies at "serious'' and four studies malocclusion and growth pattern) were not measured at base-
at "critical'' overall risk of bias. figures 2 and 3 show the line, the pre-intervention measures were insufficient, or the
summary and graph of risk of bias (RoBvis) for non-randomized measures were significantly different between the groups.
studies included.
Figure 2
Risk of bias summary for non-randomized studies included
12

Figure 3
Risk of bias graph for non-randomized studies included
Figure 4
Risk of bias summary for the randomized controlled study included
In addition, the role of normal growth may cause a time varying Further rating was applied for ten studies to assess the quality of
confounding, which gives a "serious'' risk of bias for uncon- before-after treatment comparisons within distalization groups
trolled (one-group) studies with growing patients. using NIH tool, (one of the studies was at critical risk of bias
Selection bias was less problematic domain; all retrospective according to ROBINS I and was not further rated because it was a
studies selected participants based on well-defined eligibility comparative study with two distalization groups and the small
criteria, which increases the representatively of the selected sample size was too small to be included; 6 patients for each
samples [59]. In addition, outcomes were measured from col- group). Two studies were rated by NIH tool as "poor quality'', and
lected records (radiographic images or cast models) that were then were excluded.
obtained retrospectively before and immediately after treat- ROB 2.0 tool assessed the quality of Bechtold et al., 2013 study
ment or retention; i.e., start of intervention and follow-up were to be at "some concerns'' (figure 4), due to lack of information
coincided for participants in most of the studies. On the other about blinding of outcome assessors and absence of pre-speci-
hand, the two prospective studies were at "critical'' risk of fied protocol. Details on risk of bias assessment for each study
selection bias because the sample size of each study was too are described in Supplementary material 3.
small to be representative.
Bias due to classification of intervention or missing data was
assessed as "low risk'' for all studies. However, for retrospective
studies, these domains are considered less significant [59]. Results of the individual studies (quantitative
Bias due to deviation of intended intervention was considered analysis)
as "serious'' in three studies; one because patients' compliance Means and standard deviations of each outcome were extracted
was not considered, and two studies due to applying of TADs at directly from the studies included in the quantitative analysis
different sites that requires different biomechanics and forces. and arranged in table II.
Only two studies applied blinding to the outcome assessors, According to the available data, three themes of comparisons
while it was unclear for the remaining studies. could be made:
pre/post-treatment (T0–T1) comparisons within distalization
None of the studies had a pre-specified protocol; however,
selective reporting of outcomes was considered to be at "low groups;
post-treatment and post-retention (T1–T2) comparisons within
risk'' because outcome measures were objective and all
reported results correspond to all intended outcomes. distalization groups.;
13
TABLE II
Data extracted from studies included in the quantitative analysis; the means of T0–T1 or T1–T2 changes and (SD), (positive values refer to the decreased measures after treatment or
after retention, while negative values refer to the increased measures after treatment or after retention). A-P: anterior-posterior position; Ver: vertical position; MP: mandibular
plane; Occp: occlusal plane; UL: upper lip; LL: lower lip.
Study Group U6 A-P U6 Ver U6 axis U1 A-P U1 Ver U1 axis SNA ANB MP OccP UL LL Nasolabial angle
MCPP with adult Alfawaz et al., MCPP 5.4 (1.1) 1.3 (1.8) 3.3 (1.4) 6.1 (2.6) 1.0 (2.5) 14.1 (6.3) 1.0 (0.4) 0.9 (0.5) 1.5 (1.8) 0.9 (2.7) 1.8 (1.2) 0.6 (1.8) 7.5 (4.0)
2021
participants
Jo et al., 2018 MCPP 3.97 0.67 1.31 1.33 2.93 (1.90) 3.35 1.49 S1.03 W .02 7.25 W 2.68 0.66 (0.62) 0.29 (0.74) 0.55 0.54 2.08 1.37 1.09 0.38 0.86 0.48 5.52 3.40
[32]
Kook et al., 3.30 (1.80) 1.75 (1.35) 3.42 (5.79) 2.99 (2.73) S1.09 (3.51) 6.21 (7.64) 0.76 (1.95) 1.01 (1.46) 0.55 (2.58) 2.81 (3.37) 1.18 (1.99) 1.54 (2.33) 3.26 (4.87)
2014 [28]
Lee et al., MCPP 4.22 1.25 1.64 (2.06) 1.98 (4.20) 2.89 (2.93) 0.76 (2.85) 0.54 (1.24) 0.82 (1.16) 0.32 (1.39) 0.30 (1.47) 4.07 (3.91) 1.18 (0.99) 0.67 (2.09) 5.72 (8.27)
2018
Park et al., MCPP 4.22 2.00 2.53 1.40 3.85 (3.11) 3.18 3.19 S1.59 W 2.21 8.02 W 8.12 1.12 (1.28) 0.81 (1.08) 3.84 3.03 1.14 0.75 1.24 1.15 5.07 4.95
2017 [30]
Park et al., MCPP (NE) 3.24 (1.79) 1.41 (2.07) 3.07 (6.77) 1.41 (2.23) 0.59 (1.05) 4.44 (7.19)
2018 [33]
Shoaib et al., T0–T1 3.44 1.08 1.42 1.12 2.35 (6.74) 1.74 (1.21) 1.36 (1.51) 0.57 (1.69) –6.36 4.10 2.30 0.99 0.70 2.95 –9.36 6.04
2019 [24]
T1–T2 –0.41 0.25 –0.50 0.46 0.92 2.46 –0.48 (0.48) –0.32 (0.79) –0.23 (0.94) –0.22 2.16 –0.28 0.41 –0.02 0.88 1.55 1.54
Mcpp with Alfaifi et al., MCPP 3.96 1.46 1.60 1.45 1.86 1.94 3.77 1.46 S3.15 W 0.47 7.13 W 2.90 2.19 W 0.84 2.10 0.91 0.38 1.62 2.26 1.19 0.44 0.35 1.42 0.94 0.38 1.81
2020 [35]
adolescent
14
participants
Chou et al., MCPP T0–T1 4.66 2.23 0.25 3.48 1.48 6.68 3.62 4.70 S1.99 W 4.09 8.55 W 9.01 1.23 W 0.98 1.61 0.95 S1.32 W 2.86 3.77 4.30 1.68 1.15 0.96 2.70 2.91 7.16
2020 [37]
MCPP T1–T2 2.93 2.20 3.67 3.47 3.62 5.40 1.28 3.26 S1.88 W 3.34 S0.92 W 5.64 S1.38 W 1.53 0.22 0.68 0.05 2.69 0.67 2.98 0.08 0.96 0.17 1.58 0.89 10.74
Jung et al., hyperdivergent 2.69 (1.76) 0.57 (1.90) 0.28 (3.24) 1.63 (3.12) 2.82 (1.84) 7.97 7.36 0.51 (1.10) 0.13 (1.11) 0.26 (1.08)
2021 [38]
hypodivergent 4.26 (1.68) 0.15 (1.76) 2.18 (2.82) 2.33 (2.80) 3.71 (2.45) 8.20 6.89 0.82 (1.26) 0.71 (0.67) 3.05 (1.13)
Lee et al., Mcpp 1.65 (3.74) 0.35 (2.13) 0.39 (8.26)

2019
Park et al., G1 T0–T1 4.36 (4.26) 0.04 (2.54) 0.94 (6.59) 0.18 (0.47) 0.69 (0.50) 2.43 2.51
2021 a
G2 T0–T1 3.18 (3.33) 0.95 (2.55) 4.36 (8.54) S0.04 (0.39) 1.04 (0.60) 0.02 3.76
G1 T1–T2 2.67 (3.04) 2.77 (2.50) 0.37 9.25
G2 T1–T2 3.56 (3.92) 6.41 (4.52) 3.54 (7.73)
S3.17 (0.52)
Sa'aed et al., MCPP 3.06 (0.54) 1.66 (0.55) 1.53 (0.98) 3.32 (0.79) 7.66 (1.80) 1.96 (0.47) 1.53 (0.24) 1.24 (0.48) 2.15 (0.82) 1.25 (0.33) 0.65 (0.46) 2.67 (1.81)
2014 [21]
Inter-radicular Ali et al., 2016 2.04 1.41 0.11 1.39 1.78 1.21 0.17 1.67
[29]
mini-screws
Bechtold et al., Group A 1.29 (0.66) 0.84 (1.09) 3.19 (4.61) 1.83 (1.23) 0.49 (0.88) 1.72 (2.22) 0.09 (0.29) 0.87 (0.91)
2013 [19]
Group B 2.91 (0.96) 1.4 (0.99) 1.55 (1.32) 2.41 (1.8) 1.56 (1.19) 2.41 (7.4) 0.74 (0.96) 0.43 (0.88)


Nasolabial angle
4.52 (6.60)
comparisons of the treatment effects between groups.
MCPP appliance
The means of U6 distalization achieved through MCPP applian-
0.04 1.07
0.97 (1.96)
0.85 (2.08)
ces ranged from 1.65 mm [40] to 5.4 mm [42]. Distal tipping
LL
ranged from 0.288 [41] (hypodivergent group of Jung et al.,

study) to 4.368 [43] (G2 of the 2021 study by Park et al.).
0.16 0.89
0.90 (1.20)
0.89 (1.19)
In the vertical direction, U6 was intruded in most of studies with

UL
a range from 0.15 mm (hypodivergent group in the study by

Jung et al.) [41] to 2.53 mm [47]. On the other hand, some of
2.58 (3.91)
1.06 (2.24)
S3.3 W 4.3
0.41 (1.62)
0.3 2.1
the studies reported extrusion, which ranged from 0.04 mm (G1

OccP
of the 2021 study by Park et al.) [43] to 1.66 mm [26]. Ten

studies evaluated the changes in incisors: U1 was retracted from
0.36 (1.14)
0.01 (1.61)
0.23 (2.03)
0.5 0.8
0.5 W 4.3
1.41 mm [40] to 6.1 mm [42], and extruded from 0.59 mm [40]

MP
to 3.71 mm hypodivergent group in the study by Jung et al. [41].

Regarding skeletal effects: SNA angle reduction ranged from
0.02 (1.20)
0.16 (0.95)
0.09 (0.54)
0.6 W 1.2
0.1 0.5
0.048 (G2 of the 2021 study by Park et al.) [43] to 2.198 [51].
ANB
ANB angle reduction ranged from 0.18 [43] to 2.10 [51].
When evaluating soft tissue changes: the upper and lower lips
0.06 (1.46)
0.49 (0.81)
0.29 (1.65)
0.6 W 2.4
0.1 0.6
were retracted with a range from 0.44 mm [51] to 2.3 mm [45]

SNA
for the upper lip, and a range from 0.67 mm [40] to 1.54 mm
[46] for the lower lip.
S0.1 W 1.7
1.08 3.55
1.13 (1.85)
3.86 (4.28)
3.9 W 5.1
U1 axis
Inter-radicular mini-screws
Five studies involved the application of inter-radicular mini-
screws for total arch distalization and one have compared the
0.32 (2.13)
0.26 (2.57)
S0.4 W 1.2
S0.1 W 1.7
0.28 (1.40)
3.9 1.1
U1 Ver
treatment effects of inter-radicular mini-screws with MCPP

appliances [40].
The amount of distal movement of the maxillary first molars
0.43 (1.15)
S0.2 W 0.6
2.48 (2.72)
2.68 (2.19)
3.4 W 3.5
4.6 2.0
U1 A-P
ranged from 1.29 mm (group A of the 2013 study by Bechtold

et al.) [21] to 4.2 mm (2020 study by Bechtold et al.) [22]. U6
was also intruded by about 0.11 mm [53] to 1.4 mm (group B of
S0.6 W 1.4
0.71 2.44
7.21 (5.22)
2.66 (3.97)
0.6 W 3.8
U6 axis
the 2013 study by Bechtold et al.) [21], and distally tipped by

0.68 [22] to 7.218 [40].
The upper central incisors were retracted by about 1.78 mm [53]
0.35 (0.55)
S0.9 W 0.7
0.13 (1.88)
0.92 (1.16)
0.8 W 2.6
2.0 1.3
U6 Ver
to 3.4 mm [22], and lingually tipped by 1.138 [40] to 3.98 [22]. In

the vertical direction, U1 were extruded (about 0.1 mm to
0.76 mm) except in group B of the 2013 study by Bechtold
0.52 (0.99)
S0.7 W 0.6
2.00 (1.26)
2.46 (1.97)
4.2 W 2.0
3.3 1.5
U6 A-P
et al. [21], which showed about 1.56 mm of intrusion, and in the

2022 study by Song et al, which reported 0.28 mm of non-
significant intrusion [54].
Mini-screws
Right side
Group
T0–T1
T0–T1
T1–T2
T1–T2
Infra-zygomatic mini-screws
Wu et al. (2017) reported that the mesial buccal cusp of the
Wu et al., 2017
Bechtold et al.,
maxillary first molars showed an average of 3.5 mm of distal

Song et al.,
Lee et al.,
2020 [36]
Study
2018
2022
movement with 2.1 mm of intrusion. The crowns of U1 were

TABLE II (Continued).
retracted by about 4.3 mm with extrusion of 3.8 mm [56].
Meta-analysis
Infra-zygomatic
The included studies were pooled into three subgroups: MCPP

mini-screws
adults, MCPP adolescents and inter-radicular mini-screws. table

III and forest plots (figures 5–23) provide the aggregated data for
each outcome.
15
TABLE III
Meta-analysis results for pre/post-treatment, post-treatment–post-retention, MCPP vs. HG and MCPP vs. PE comparisons.
Pre/post-treatment (T0–T1) comparisons
Outcome Subgroup Statistical method Total T0 Total T1 Effect estimate Test of overall effect Heterogeneity
U6 distalization MCPP adults Mean Difference (IV, Random, 95% CI) 149 149 4.00 [3.42, 4.58] Z = 13.49 (P < 0.00001) Chi2 = 52.44, df = 6 (P < 0.00001) I2 = 89%
MCPP adolescents Mean Difference (IV, Random, 95% CI) 152 152 3.54 [2.91, 4.17] Z = 10.95 (P < 0.00001) Chi2 = 21.78, df = 7 (P = 0.003) I2 = 68%
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 107 107 2.44 [1.68, 3.19] Z = 6.33 (P < 0.00001) Chi2 = 49.55, df = 5 (P < 0.00001) I2 = 90%
Test for subgroup differences: Chi2 = 10.42, df = 2 (P = 0.005), I2 = 80.8%
U6 distal tipping MCPP adults Mean Difference (IV, Random, 95% CI) 149 149 3.17 [2.77, 3.58] Z = 15.32 (P < 0.00001) Chi2 = 3.74, df = 6 (P = 0.71) I20%
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 79 79 2.91 [1.06, 4.76] Z = 3.09 (P = 0.002) Chi2 = 23.64, df = 4 (P < 0.0001) I2 = 83%
Test for subgroup differences: Chi2 = 19.74, df = 2 (P < 0.0001), I2 = 89.9%
U6 vertical changes MCPP adults Mean Difference (IV, Random, 95% CI) 149 149 1.64 [1.29, 1.99] Z = 9.14 (P < 0.00001) Chi2 = 12.27, df = 6 (P = 0.06) I2 = 51%
MCPP adolescents Mean Difference (IV, Random, 95% CI) 152 152 0.22 [ 0.97, 0.53] Z = 0.58 (P = 0.56) Chi2 = 33.20, df = 7 (P < 0.0001) I2 = 79%
Inter-radicular miniscrews Mean Difference (IV, Random, 95% CI) 107 107 0.75 [0.35, 1.16] Z = 3.63 (P = 0.0003) Chi2 = 11.56, df = 5 (P = 0.04) I2 = 57%
U1 retraction MCPP adults Mean Difference (IV, Random, 95% CI) 126 126 3.33 [2.11, 4.55] Z = 5.35 (P < 0.00001) Chi2 = 41.74, df = 5 (P < 0.00001) I2 = 88%
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 107 107 2.23 [1.81, 2.65] Z = 10.48 (P < 0.00001) Chi2 = 7.12, df = 5 (P = 0.21) I2 = 30%
16
U1 palatal tipping MCPP adults Mean Difference (IV, Random, 95% CI) 126 126 6.77 [3.21, 10.33] Z = 3.72 (P = 0.0002) Chi2 = 66.21, df = 5 (P < 0.00001) I2 = 92%
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 90 90 2.42 [1.16, 3.68] Z = 3.77 (P = 0.0002) Chi2 = 12.05, df = 4 (P = 0.02) I2 = 67%
U1 vertical changes MCPP adults Mean Difference (IV, Random, 95% CI) 126 126 2.00 [ 2.73, 1.28] Z = 5.41 (P < 0.00001) Chi2 = 25.23, df = 5 (P = 0.0001) I2 = 80%
MCPP adolescents Mean Difference (IV, Random, 95% CI) 105 105 3.14 [ 3.32, -2.95] Z = 32.94 (P < 0.00001) Chi2 = 3.28, df = 4 (P = 0.51) I2 = 0%
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 107 107 0.14 [ 0.49, 0.77] Z = 0.44 (P = 0.66) Chi2 = 26.75, df = 5 (P < 0.0001) I2 = 81%
Skeletal changes
SNA angle MCPP adults Mean Difference (IV, Random, 95% CI) 132 132 1.00 [0.73, 1.28] Z = 7.17 (P < 0.00001) Chi2 = 15.42, df = 5 (P = 0.009) I2 = 68%
2
MCPP adolescents Mean Difference (IV, Random, 95% CI) 132 132 0.95 [0.28, 1.61] Z = 2.80 (P = 0.005) Chi = 137.00, df = 6 (P < 0.00001) I2 = 96%
2 2
Test for subgroup differences: Chi = 7.31, df = 2 (P = 0.03), I = 72.6%
ANB angle MCPP adults Mean Difference (IV, Random, 95% CI) 132 132 0.75 [0.44, 1.06] Z = 4.78 (P < 0.00001) Chi2 = 16.54, df = 5 (P = 0.005) I2 = 70%
MCPP adolescents Mean Difference (IV, Random, 95% CI) 112 112 1.11 [0.66, 1.56] Z = 4.85 (P < 0.00001) Chi2 = 65.70, df = 6 (P < 0.00001) I2 = 91%
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 65 65 0.23 [ 0.08, 0.55] Z = 1.44 (P = 0.15) Chi2 = 2.74, df = 2 (P = 0.25) I2 = 27%
Occlusal plane angle MCPP adults Mean Difference (IV, Random, 95% CI) 132 132 3.24 [ 4.57, 1.90] Z = 4.75 (P < 0.00001) Chi2 = 38.99, df = 5 (P < 0.00001) I2 = 87%
MCPP adolescents Mean Difference (IV, Random, 95% CI) 65 65 2.41 [ 3.06, 1.76] Z = 7.29 (P < 0.00001) Chi2 = 2.36, df = 2 (P = 0.31) I2 = 15%
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 90 90 1.17 [ 1.85, 0.50] Z = 3.40 (P = 0.0007) Chi2 = 12.89, df = 4 (P = 0.01) I2 = 69%


TABLE III (Continued).
Skeletal changes
Mandibular plane MCPP adults Mean Difference (IV, Random, 95% CI) 110 110 S0.66 [S1.02, Z = 3.63 (P = 0.0003) Chi2 = 7.35, df = 4 (P = 0.12) I2 = 46%
S0.30]
MCPP adolescents Mean Difference (IV, Random, 95% CI) 132 132 S1.29 [S2.38, Z = 2.31 (P = 0.02) Chi2 = 77.48, df = 6 (P < 0.00001) I2 = 92%
S0.20]
Inter-radicular mini-screws Mean Difference (IV, Random, 95% CI) 90 90 0.13 [S0.21, 0.47] Z = 0.73 (P = 0.47) Chi2 = 9.04, df = 4 (P = 0.06) I2 = 56%
Soft tissue changes
Upper lip to the vertical line MCPP adults Mean Difference (IV, Random, 95% CI) 132 132 1.45 [1.05, 1.84] Z = 7.17 (P < 0.00001) Chi2 = 35.24, df = 5 (P < 0.00001) I2 = 86%
MCPP adolescents Mean Difference (IV, Random, 95% CI) 65 65 1.10 [0.22, 1.97] Z = 2.45 (P = 0.01) Chi2 = 25.82, df = 2 (P < 0.00001) I2 = 92%
Inter-radicular miniscrews Mean Difference (IV, Random, 95% CI) 46 46 0.89 [0.55, 1.24] Z = 5.08 (P < 0.00001) Chi2 = 0.00, df = 1 (P = 0.98) I2 = 0%
Lower lip to the vertical line MCPP adults Mean Difference (IV, Random, 95% CI) 132 132 0.73 [0.22, 1.24] Z = 2.79 (P = 0.005) Chi2 = 20.69, df = 5 (P = 0.0009) I2 = 76%
Test for subgroup differences: Chi2 = 1.66, df = 2 (P = 0.44), I2 = 0%
Nasolabial angle MCPP adults Mean Difference (IV, Random, 95% CI) 132 132 6.05875 Z = 7.42 (P < 0.00001) Chi2 = 18.14, df = 5 (P = 0.003); I2 = 72%
MCPP adolescents Mean Difference (IV, Random, 95% CI) 65 65 1.37705 Z = 1.48 (P = 0.14) Chi2 = 3.70, df = 2 (P = 0.16) I2 = 46%
Post-treatment and post-retention (T1–T2) comparisons
Outcome Statistical method Total T1 Total T2 Effect estimate Test of overall effect Heterogeneity
17
Changes in U6 for MCPP adolescents' subgroup Mesial movement Mean Difference (IV, Random, 95% CI) 47 47 2.94 [ 3.71, 2.18] Z = 7.53 (P < 0.00001) Chi2 = 0.42, df = 2 (P = 0.81) I2 = 0%
2 2
Extrusion Mean Difference (IV, Random, 95% CI) 47 47 3.97 [ 5.71, 2.23] Z = 4.48 (P < 0.00001) Chi = 6.29, df = 2 (P = 0.04) I = 68%
Mesial tipping Mean Difference (IV, Random, 95% CI) 47 47 2.84 [ 4.98, 0.70] Z = 2.60 (P = 0.009) Chi2 = 2.31, df = 2 (P = 0.31) I2 = 13%
Changes in U6 for inter-radicular mini-screws' subgroup Mesial movement Mean Difference (IV, Random, 95% CI) 47 47 0.64 [ 0.85, 0.42] Z = 5.77 (P < 0.00001) Chi2 = 0.60, df = 1 (P = 0.44) I2 = 0%
Extrusion Mean Difference (IV, Random, 95% CI) 47 47 0.61 [ 1.15, 0.07] Z = 2.23 (P = 0.03) Chi2 = 8.31, df = 1 (P = 0.004) I2 = 88%
Mesial tipping Mean Difference (IV, Random, 95% CI) 47 47 0.64 [ 1.15, 0.12] Z = 2.41 (P = 0.02) Chi2 = 0.04, df = 1 (P = 0.84) I2 = 0%
MCPP vs. HG
Outcome Type of data Statistical method Total MCPP Total HG/PE Effect estimate Test of overall effect Heterogeneity
2
U6 distalization CON Mean Difference (IV, Random, 95% CI) 46 43 1.78 [1.01, 2.54] Z = 4.56 (P < 0.00001) Chi = 0.54, df = 1 (P = 0.46) I2 = 0%
SNA CON Mean Difference (IV, Random, 95% CI) 46 43 0.60 [0.06, 1.13] Z = 2.20 (P = 0.03) Chi2 = 0.77, df = 1 (P = 0.38) I2 = 0%
2 2
ANB CON Mean Difference (IV, Random, 95% CI) 46 43 0.03 [ 1.44, 1.38] Z = 0.04 (P = 0.97) Chi = 11.16, df = 1 (P = 0.0008) I = 91%
Occlusal plane CON Mean Difference (IV, Random, 95% CI) 46 43 1.45 [ 0.26, 3.15] Z = 1.66 (P = 0.10) Chi2 = 0.31, df = 1 (P = 0.58) I2 = 0%
MCPP vs. PE
Changes in U1
A-P position CON Mean Difference (IV, Random, 95% CI) 45 41 1.93 [ 2.70, 1.16] Z = 4.92 (P < 0.00001) Chi2 = 0.09, df = 1 (P = 0.77) I2 = 0%
Vertical position CON Mean Difference (IV, Random, 95% CI) 45 41 0.25 [ 0.31, 0.81] Z = 0.87 (P = 0.39) Chi2 = 0.71, df = 1 (P = 0.40) I2 = 0%
Changes in axis CON Mean Difference (IV, Random, 95% CI) 45 41 5.57 [ 9.88, 1.26] Z = 2.53 (P = 0.01) Chi2 = 3.17, df = 1 (P = 0.07) I2 = 68%
Soft tissue changes
Upper lip CON Mean Difference (IV, Random, 95% CI) 45 41 0.82 [ 1.24, 0.41] Z = 3.90 (P < 0.0001) Chi2 = 1.27, df = 1 (P = 0.26) I2 = 21%
2
Lower lip CON Mean Difference (IV, Random, 95% CI) 45 41 0.45 [ 0.79, 0.11] Z = 2.57 (P = 0.01) Chi = 0.45, df = 1 (P = 0.50) I2 = 0%
Nasolabial angle CON Mean Difference (IV, Random, 95% CI) 45 41 2.87 [ 5.13, 0.62] Z = 2.50 (P = 0.01) Chi2 = 0.87, df = 1 (P = 0.35) I2 = 0%


Pre/post-treatment (T0–T1) comparisons Chi2 test revealed to significant differences between subgroups
Dental changes in the maxillary first molar's distal movement, distal tipping and
figures 5–7 provide graphical representations of maxillary first vertical displacement.
molar distalization, distal tipping and vertical displacement. Retraction of U1 achieved by MCPP was 3.33 mm for adults
MCPP in adults resulted in a significant distal movement of U6 (95% CI [2.11, 4.55]; P < 0.00001; I2 = 88%; figure 8.1) and
with mean of 4.00 mm (95% CI [3.42, 4.58]; P < 0.0001; 2.95 mm for adolescents (95% CI [2.05, 3.86]; P = 0.003;
I2 = 89%; figure 5.1) with 3.178 of distal tipping (95% CI I2 = 61%; figure 8.2), and it was 2.23 mm with inter-radicular
[2.77, 3.58]; P < 0.00001; I2 = 0; figure 6.1) and 1.64 mm of mini-screws (95% CI [1.81, 2.65]; P < 0.00001; I2 = 30%; fig-
intrusion (95% CI [1.29, 1.99]; P < 0.00001; I2 = 51%; ure 8.3). No significant differences were found between the
figure 7.1). subgroups in U1 retraction (P = 0.1).
MCPP in adolescents, also resulted in a significant distalization of Palatal tipping of U1 was 6.778 in adults (95% CI [3.21, 10.33];
3.54 mm (95% CI [2.91, 4.17]; P < 0.00001; I2 = 68%; figure 5.2) P < 0.00001; I2 = 92%; figure 9.1) and 7.468 in adolescents
along with distal tipping of 1.618 (95% CI [1.05, 2.17]; (95% CI [6.46, 8.46]; P < 0.00001; I2 = 0; figure 9.2) after treat-
P < 0.00001; I2 = 0; figure 6.2). However, in the vertical direc- ment with MCPP, while it was 2.428 for mini-screws group (95%
tion, 0.22 mm of non-significant extrusion was resulted (95% CI [1.16, 3.68]; P = 0.0002; I2 = 67; figure 9.3). The differences
CI [ 0.97, 0.53]; P = 0.56; I2 = 79%; figure 7.2). between subgroups in palatal tipping of U1 were significant
Distal movement of U6 produced by inter-radicular mini-screws (P < 0.00001).
was 2.44 mm (95% CI [1.68, 3.19]; P < 0.00001; I2 = 90%; fig- Vertically, extrusion of U1 was resulted after treatment with
ure 5.3). U6 was also tipped distally by 2.918 (95% CI [1.06, MCPP; 2.00 mm in adults (95% CI [ 2.73, 1.28];
4.76]; P = 0.002; I2 = 83%; figure 6.3) and intruded by 0.75 mm P < 0.00001; I2 = 80%; figure 10.1), and 3.14 mm in adoles-
(95% CI [0.35, 1.16]; P = 0.0003; I2 = 57%; figure 7.3). cents (95% CI [ 3.32, 2.95]; P < 0.00001; I2 = 0; figure 10.2).
Figure 5
Forest plots of U6 distalization in (1) Modified C-Palatal plate (MCPP) adults, (2) MCPP adolescents and (3) inter-radicular mini-screws
subgroups
18

Figure 6
Forest plots of U6 distal tipping in (1) Modified C-Palatal plate (MCPP) adults, (2) MCPP adolescents and (3) inter-radicular mini-
screws subgroups
19

Figure 7
Forest plots of U6 vertical displacement in (1) Modified C-Palatal plate (MCPP) adults, (2) MCPP adolescents and (3) inter-radicular
mini-screws subgroups
20

Figure 8
Forest plots of U1 retraction in (1) Modified C-Palatal plate (MCPP) adults, (2) MCPP adolescents and (3) inter-radicular mini-screws
subgroups
21

Figure 9
Forest plots of U1 palatal tipping in (1) Modified C-Palatal plate (MCPP) adults, (2) MCPP adolescents and (3) inter-radicular mini-
screws subgroups
22

Figure 10
Forest plots of U1 vertical displacement in (1) Modified C-Palatal plate (MCPP) adults, (2) MCPP adolescents and (3) inter-radicular
mini-screws subgroups
23

On the other hand; mini-screws resulted in 0.14 mm of insig- The differences between subgroups in the reduction of SNA and
nificant intrusion (95% CI [ 0.49, 0.77]; P = 0.66; I2 = 88%; ANB angles were significant (P = 0.03 and P = 0.004,
figure 10.3). The differences between subgroups in the vertical respectively).
displacement of U1 were significant (P < 0.00001). Vertically, the occlusal plane angle was significantly increased by
3.248 (95% CI [ 4.57, 1.90]; P < 0.00001; I2 = 87%; fig-
Skeletal changes
ure 13.1) in adults treated by MCPP, 2.418 (95% CI [ 3.06,
Significant decrease in SNA angle was resulted by MCPP treat-
1.76]; P < 0.00001; I2 = 15%; figure 13.2) for MCPP adoles-
ment in adults and adolescents with means of 1.008 (95% CI
cents subgroup, and 1.178 (95% CI [ 1.85, 0.50];
[0.73, 1.28]; P < 0.00001; I2 = 68%; figure 11.1) and 0.95 (95%

P = 0.0007; I2 = 69%; figure 13.3) for mini-screws treated

CI [0.28, 1.61]; P = 0.005; I2 = 96%; figure 11.2), respectively.
subgroup.
ANB angle also decreased by 0.758 (95% CI [0.44, 1.06];
The differences between subgroups were significant
P < 0.00001; I2 = 70%; figure 12.1) in adults and 1.118 (95%
(P = 0.005).
CI [0.66, 1.56]; P < 0.00001; I2 = 91%; figure 12.2) in
Downward rotation of the mandibular plane was also resulted
adolescents.
after treatment with MCPP; as the MP angle slightly increased by
Less reduction of SNA was noticed after distalization with inter-
0.668 (95% CI [ 1.02, 0.30]; P = 0.0003; I2 = 46%; fig-
radicular mini-screws; MD = 0.458 (95% CI [0.14, 0.75];
ure 14.1) in adults, while in adolescents, a larger increase of
P = 0.004; I2 = 0; figure 11.3), and the reduction of ANB angle
1.298 (95% CI [ 2.38, 0.20]; P = 0.02; I2 = 92%; figure 14.2)
was insignificant; MD = 0.238 (95% CI [ 0.08, 0.55]; P = 0.15;
was noticed. On the other hand, in the mini-screws treated
I2 = 27%; figure 12.3).
Figure 11
Forest plots of changes in SNA angle after treatment
24

Figure 12
Forest plots of changes in ANB angle after treatment
Figure 13
Forest plots of changes in the occlusal plane angle
25

Figure 14
Forest plots of changes in the mandibular plane angle
subgroup, the estimated effect revealed to insignificant Lower lip was also retracted after treatment with MCPP;
decrease of MP angle by 0.138 (95% CI [ 0.21, 0.47]; 0.73 mm in adults (95% CI [0.22, 1.24]; P = 0.005; I2 = 76%;
P = 0.47; I2 = 56%; figure 14.3). figure 16.1), 1.18 mm in adolescents (95% CI [0.71, 1.66];
Subgroups differences in MP angle were also significant P < 0.00001; I2 = 23%; figure 16.2), also it was retracted in
(P = 0.001). mini-screws subgroup by 0.90 mm (95% CI [0.31, 1.49];
P = 0.003; I2 = 0%; figure 16.3).
Soft tissue changes The differences between subgroups in retraction of upper and
Significant retraction of upper lip was resulted with means of lower lips were insignificant (P = 0.12, P = 0.44 respectively).
1.45 mm (95% CI [1.05, 1.84]; P < 0.0001; I2 = 86%; figure 15.1) The nasolabial angle increased significantly by 6.068 (95% CI
in adults and 1.10 mm (95% CI [0.22, 1.97]; P < 0.0001; [ 7.66, 4.46]; P < 0.00001; I2 = 72%; figure 17.1) after treat-
I2 = 92%; figure 15.2) in adolescents treated by MCPP. While ment with MCPP in adults, but this increase was insignificant in
it was 0.89 mm in mini-screws subgroup, (95% CI [0.55, 1.24]; adolescents; MD = 1.388 (95% CI [ 3.20, 0.45]; P = 0.14;
P < 0.0001; I2 = 0%; figure 15.3). I2 = 46%; figure 17.2).
26

Figure 15
Forest plots of changes in upper lip position
Figure 16
Forest plots of changes in lower lip position
27

Figure 17
Forest plots of changes in the nasolabial angle
The differences between two subgroups were significant 0.41 mm and extruded 0.50 mm. While during follow-up in
(P = 0.0002). adolescents, U6 showed a significant mesial movement of
2.94 mm (95% CI [ 3.71, 2.18]; P < 0.00001; I2 = 0%; fig-
Post-treatment – post-retention (T1–T2) comparisons
ure 18.1) with extrusion of 3.97 mm (95% CI [ 5.71, 2.23];
Shoaib et al. [45] evaluated the changes in U6 position during
P < 0.00001; I2 = 68%; figure 18.2), and mesial tipping of 2.848
follow-up after treatment with MCPP in adults; the authors
(95% CI [ 4.98, 0.70]; P = 0.009; I2 = 13%; figure 18.3).
reported that the maxillary first molars moved mesially about
Figure 18
Forest plots of U6 changes during follow-up after distalization with Modified C-Palatal plate (MCPP) in adolescents
28

Figure 19
Forest plots of U6 changes during follow-up after distalization with inter-radicular mini-screws
Regarding the stability of distalization with inter-radicular mini- Distal tipping of U6 in adults was significantly larger in HG group
screws, mesial movement of 0.64 mm (95% CI [ 0.85, (8.578) comparing with (3.858) in MCPP group, while there was
0.42]; P < 0.00001; I2 = 0%; figure 19.1), U6 also extruded no significant difference in distal tipping of U6 between the two
by 0.61 mm (95% CI 0.61 [ 1.15, 0.07]; P = 0.03; groups in adolescents.
I2 = 88%; figure 19.2), and mesially tipped by 0.648 (95% Skeletally, SNA angle was more decreased by MCPP treatment
CI [ 1.15, 0.12]; P = 0.02; I2 = 0%; figure 19.3). (P = 0.03); while the differences between the two group in ANB
and occlusal plane angles were insignificant (figure 21).
Comparisons with other techniques Treatment effects of MCPP versus premolars extraction (PE)
Treatment effects with MCPP have been compared to those with were also compared.
headgear (HG). Retraction and palatal tipping of U1 were significantly larger in
The distal movement of U6 accomplished by MCPP appliance the extraction groups, but no significant differences were found
was significantly larger (MD = 1.78; 95% CI [1.01, 2.54]; in the vertical extrusion of U1 between the two groups (P = 0.39;
P < 0.0001; I2 = 0%; figure 20). figure 22).
According to the vertical displacement of U6 in adults, MCPP Comparison of the soft tissues changes caused by MCPP vs.
groups showed about 2.5 mm of intrusion, while 0.4 mm of PE treatment also showed that the retraction of upper and
insignificant extrusion was resulted by HG. For adolescents, U6 lower lips, as well as increasing in the nasolabial angle were
showed slight extrusion (1.66 mm) in MCPP groups, while significantly larger in the premolar extraction groups
extrusion was significant (2.58 mm) in HG groups. (figure 23).
Figure 20
Forest plot of U6 distal movement achieved by Modified C-Palatal plate (MCPP) vs. HG
29

Figure 21
Forest plots of skeletal changes after treatment with Modified C-Palatal plate (MCPP) vs. HG
Figure 22
Forest plots of U1 changes after treatment with Modified C-Palatal plate (MCPP) vs. PE
30

Figure 23
Forest plots of soft-tissue changes after treatment with Modified C-Palatal plate (MCPP) vs. PE
Discussion Treatment effects

Recently, temporary anchorage devices (TADs) have been Both MCPP and inter-radicular mini-screws were resulted in a
increasingly used in orthodontics to reduce the need for extrac- significant distal movement of the maxillary first molars. How-
tion and surgical treatments [60]. This is due to the provision of ever, there were significant differences in the treatment effects
absolute and skeletal anchorage for dental movements [61,62], between subgroups.
making it a suitable choice for use in distalizing the entire upper MCPP appliances showed 4 mm of distalization in adults and
arch during non-extraction treatment [63]. Previously, 2-stages 3.54 mm in adolescents, while mini-screws showed 2.4 mm of
method with mini-screws was the frequently used technique to distalization.
distalize the maxillary dental arch to prevent the interference of This may be similar to a recently published meta-analysis, which
inter-radicular mini-screws with the distal movement of adja- reported that 2.75 mm of maxillary first molars' distalization
cent teeth [64,65]. In the first stage, the maxillary molars moved was produced by buccal inter-radicular TADs, but it was 4.07 mm
distally, but loss of anchorage often occurred during molar with palatal TADs [30].
distalization, which is characterized by mesial movement of Greater distalization associated with MCPP as compared to
the premolars and flaring of the anterior teeth. Later, in the buccal miniscrews was also reported previously by finite ele-
second stage, the premolars and the anterior teeth were ment and clinical studies [40,66,67]. This could be due to the fact
retracted against the molars that were distalized in the first that MCPP appliances are located in the palatal area, which
stage. However, TADs are able to retract the whole maxillary provides a larger field of action without interference with the
arch en-masse without dividing the procedure to two stages and proximal roots.
eliminate mesial tipping of the premolars and protrusion of the The distal tipping of U6 produced by MCPP was 3.178 in adults
anterior segment [47]. and 1.618 in adolescents, while it was 2.918 in the miniscrew
In the last few years, en-masse distalization of the entire subgroup. Although previous studies reported that distalization
maxillary arch has been one of the most successful therapeutic with palatal plate would result in less tipping than buccal mini-
methods to correct class II relationship. screws [40,66], our analysis suggested that MCPP in adults
This systematic review was conducted to evaluate the effec- produced larger amount of distal tipping.
tiveness of using TADs for total maxillary arch distalization This seems to be in agreement with the results of the 2021 study
during the non-extraction treatment of class II malocclusion. by Bayome et al. who found that buccal inter-radicular DATs
31

were associated with a low distal first molar tipping (1.708) [30]. Regarding skeletal effects, MCPP appliance resulted in signifi-
However, MCPP produced much less tipping than palatally skel- cant decreases of SNA and ANB angles in addition to a clockwise
etal anchored distalizing appliances, which produced about 8.48 rotation of the occlusal plane. The MP angle slightly increased in
of distal tipping according to Soheilifar et al. [29]. adults. However, this increase was larger in adolescents and this
This reduction in tipping could be attributed to the design of the may be attributed to the growth effects.
MCPP device, which by engaging elastics (or coil springs) at the Inter-radicular mini-screws showed less amount of decrease in
plate notch allows the force vector to be controlled; this method SNA and insignificant decrease in ANB angles. The occlusal plane
is most appropriate for producing bodily movement [67]. showed less rotation and the MP angle was insignificantly
Vertically, significant intrusion of U6 was resulted by the appli- reduced; this could be due to the intrusion movement of maxil-
cation of MCPP in adults (1.64), while non-significant extrusion lary arch when dual mini-screws were applied.
was resulted in MCPP adolescents' group; this might be because The upper and lower lips were retracted significantly by MCPP
the intrusion in growing patients was camouflaged with the appliances and the nasolabial angle was significantly increased.
downward growth of the maxilla, which resulted in extrusion of Inter-radicular mini-screws showed less retraction of upper and
the maxillary posterior teeth [67]. lower lips. However, differences between subgroups were
In addition, the amount of intrusion can be determined by insignificant.
selecting the notch to which the elastomeric chains are In the comparison with other distalization methods, MCPP
attached. So that when the most apical indentation on the showed greater distalization of the maxillary first molars in
MCPP was used, the force vector passed close to CR of the first adult patients compared with that produced when using head-
molar, resulting in a minimal amount of distal tipping combined gear, with less distal tipping accompanied by intrusion [47]. That
with a larger amount of distalization and intrusion of molars [66– may be due to the non-depending on the patient compliance in
68]. the MCPP appliances, also the age factor becomes less dominant
Our analysis showed that a smaller amount of U6 intrusion was compared to its effects in headgear therapy.
associated with buccal mini-screws (0.75 mm). In adolescent patients, the MCPP and headgear appliances
Similar intrusion of U6 was reported in the 2021 meta-analysis produced similar skeletal changes [26] such as the reduction
by Bayome et al. [30]. However, Yu et al. reported that distal- of ANB. Vertically, the MCPP group showed slight extrusion of
ization with mini-implants on the buccal side would cause the maxillary first molars, while the headgear group demonstrated
first molar to be distally tipped and extruded [66]. significant extrusion. This may be due to the limited control that
This discrepancy in vertical displacement with mini-screws seem cervical headgear has over the downward growth of the maxilla
to be partially due to the vertical position of the mini-screws, [26].
and/or the level of the hooks attached to the archwire [53]. Kang et al. [70], in their finite element study, reported that
Applying force from a retraction hook at a higher level resulted headgear resulted in distal tipping and extrusion of first molar,
in initial lingual root movement of the anterior segment, and while palatal plate resulted in intrusion of the first molar accom-
extrusive distal translation of the posterior segment [69]. panied by more distalization at the root level than at the crown
Both MCPP and inter-radicular mini-screws showed a significant level. These findings were in agreement with most of findings of
retraction and palatal inclination of upper incisors; U1 retraction our analysis; however, distal tipping was also observed in MCPP
was greatest in the adult MCPP subgroup, followed by the groups, probably because of differences in the clinical situations
adolescent and mini-screw subgroups. However, the differences and finite element models.
between subgroups were not significant. Both MCPP and Greenfield Molar Distalizer (GMD) produced
In the vertical direction, significant extrusion of U1 was observed significant skeletal changes in the maxilla, but the differences
after treatment with MCPP and it was larger with adolescents were limited between them. Both the MCPP and GMD resulted
than with adults. in a significant distalization of the maxillary first molars and
The vertical changes of U1 produced by mini-screws were retraction of anterior teeth [51].
diverse. Anterior extrusion was found in two of the included When comparing with premolar extraction each of retraction,
studies and in group A of the 2013 Bechtold et al. study. palatal tipping of U1 and as a result retraction of upper and lower
While Song et al. in 2022 reported an intrusion of approxi- lips were larger in the extraction groups.
mately 0.28 mm, group B of the Bechtold et al. study [21]
had a significant intrusion of 1.56 mm. These differences
between studies are likely due to the fact that the position Stability of treatment effects
and number of mini-screws may be determining factors for Shoaib et al. [45] evaluated the stability of treatment effects
selective vertical control, as when using dual mini-screws, three years after distalization with MCPP in adults. The authors
the force system could induce intrusive translation of the observed approximately 0.41 mm of mesial movement and
whole arch [68,69]. 0.5 mm of extrusion of maxillary first molars during the post-
32

treatment period, suggesting that approximately 88% of the the MCPP appliance when applied in adults produced the
distal movement and 65% of the intrusion were maintained. greatest distalization combined with intrusion of the maxillary
The high stability of the distal movement could be attributed to first molars, while distalization with insignificant extrusion
the reduction of distal tipping during distalization with MCPPs were observed in adolescents;
[67], and the longer distalization time (about 12.2 months) the inter-radicular mini-screws were associated with less
could also play a role in improving post-treatment stability. amount of first molar distal tipping. However, they also
In adolescents, the maxillary first molars showed 2.94 mm of resulted in the smallest amount of distalization;
mesial movement, 2.848 of mesial tipping and 3.97 mm of maxillary incisors were also more retracted, palatally inclined
extrusion during follow-up period. and extruded with MCPP appliances. However, intrusion of the
However, this did not indicate a relapse of the Class I molar entire maxillary arch was possible when dual mini-screws
relationship obtained post-treatment. Similar to the results of a were applied bilaterally;
long-term study on adolescents wearing pendulum appliances MCPP appliances resulted in greater decrease of SNA and ANB
[71], Chou et al. in 2021 demonstrated that despite residual angles when compared with mini-screws. In addition, a clock-
skeletal growth detected after the end of treatment with a wise rotation of the occlusal plane and a slight increase in the
significant increase in SNA and SNB between T2 and T3, the mandibular plane angle were resulted by MCPP and they were
sagittal skeletal and dental relationships were maintained dur- greater than those resulted by mini-screws;
ing the retention period. This indicates that a favourable growth MCPP appliances, when compared with headgear, showed a
pattern (skeletal) and correct intercuspation (dentoalveolar) greater distalization combined with intrusion of U6. In ado-
could be favourable factors in growing patients [72,73]. lescents, it showed greater distalization with less extrusion of
According to inter-radicular mini screws; 0.64 mm of mesial U6 and non-significant differences in the skeletal changes;
movement, 0.648 of mesial tipping and 0.61 mm of extru- less amounts of retraction/palatal inclination and a non-sig-
sion of U6 were observed during retention period. The sagittal nificant difference in the vertical extrusion of the anterior
stability of U6 throughout the post-treatment retention period teeth were observed in MCPP groups as compared to the
could be attributed to its movement pattern, as it showed a premolars' extraction groups;
minimal distal tipping. both MCPP and inter-radicular mini-screws can provide a high
Akgül and Toygar reported a similar or more marked extrusion degree of stability of the treatment effects during the follow-
tendency in adults without orthodontic treatment in a long-term up periods.
observational study (0.63 mm) [74]. Randomized controlled trials or prospective long-term cohort
studies are highly recommended to establish a clinical evidence
Limitations regarding the efficiency of maxillary total arch distalization
The lack of randomised clinical trials or prospective cohort using various designs of TADS during non-extraction treatment
studies was the main limitation of this systematic review. To of class II malocclusion.
provide a better understanding of the effects of TAD use during
total arch distalization, retrospective controlled and uncontrolled Funding sources: this research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit sectors.
pre/post-studies were also included.
However, meta-analyses of single-arm studies may be ques- Author contributions: Tuqa Rashad Raghis and Tareq Mosleh Alfrih
tioned due to potential bias, so the results should be interpreted Alsulaiman accomplished electronic and hand searching, data extraction,
methodological quality, meta-analysis and writing the manuscript.
with caution. Ghiath Mahmoud performed data extraction and methodological quality.
In addition, the studies pooled in this analysis included patients Mohamed Youssef performed methodological quality of the included studies
and writing the final manuscript.
with heterogeneous malocclusion severity. This may be a con- All authors mentioned above have written the report, reviewed successive
founding factor in the results. versions, shared in their revisions and approved the final version.
The methods of assessment in the included studies were also
Disclosure of interest: the authors declare that they have no competing
variable; measurements were taken on lateral cephalograms in interest.
most studies, but also on CBCT images and on 3D dental models.
It should be noted, however, that all of these methods were
validated and reported to be accurate for assessing treatment
effects.
Supplementary data
Supplementary data associated with this article
Conclusions
can be found, in the online version, at https://
It could be concluded that the maxillary total arch distalization doi.org/10.1016/j.ortho.2022.100666.
using TADs is an effective and stable non-extraction treatment
procedure of class II malocclusion:
33

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36

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International Orthodontics 2022; 20: 100666

Systematic review and meta-analysis

tome 20 > n83 > September 2022

Systematic review and meta-analysis

Introduction adolescents. Moreover, re-implantation of mini-screws may

tome 20 > n83 > September 2022

Systematic review and meta-analysis

between post-treatment and post-retention) in the experi-  #4 (arch OR dentition);

mental groups, beside comparisons between experimental  #5 (distalization OR distal*);

tome 20 > n83 > September 2022

Systematic review and meta-analysis

tome 20 > n83 > September 2022

Systematic review and meta-analysis

42 adult patients involved the application of infra-zygomatic

The comparative groups were either not treated (94 patients)

groups: total arch distalization using single vs. dual mini-screws

eruption [43] and MCPP with extraction vs. non-extraction treat-

Outcomes measurements were taken on lateral cephalographs

48,51,54,57,58], on cone beam computed tomography (CBCT)

models in two of them [53,55]. Characteristics of the included

tome 20 > n83 > September 2022

crowding  3 mm changes intrusion and

Systematic review and meta-analysis

International Orthodontics 2022; 20: 100666

Ctrl 20 19.3 W 1.6 11/9 Dental C II, no No treatment – – CBCT at one

PE 20 24.6 W 7.6 1/19 Four PE 28.3 W 7.3

Hypodivergent 20 12.3 W 1.5 FMA  22 14.9 W 1.5

Systematic review and meta-analysis

MS 18 24.2 W 6.8. NR One MS/side Buccaly NR

Ctrl 20 (35 U8) 12.7 W 1.1 12/8 No treatment – 12.9 W 4.04

Systematic review and meta-analysis

International Orthodontics 2022; 20: 100666

Systematic review and meta-analysis

Systematic review and meta-analysis

International Orthodontics 2022; 20: 100666

Systematic review and meta-analysis

Systematic review and meta-analysis

tome 20 > n83 > September 2022

Systematic review and meta-analysis

tome 20 > n83 > September 2022

Lee et al., Mcpp 1.65 (3.74) 0.35 (2.13) 0.39 (8.26)

G1 T1–T2 2.67 (3.04) 2.77 (2.50) 0.37 9.25

G2 T1–T2 3.56 (3.92) 6.41 (4.52) 3.54 (7.73)

Systematic review and meta-analysis

Systematic review and meta-analysis

ranged from 0.288 [41] (hypodivergent group of Jung et al.,

In the vertical direction, U6 was intruded in most of studies with

a range from 0.15 mm (hypodivergent group in the study by

the studies reported extrusion, which ranged from 0.04 mm (G1

of the 2021 study by Park et al.) [43] to 1.66 mm [26]. Ten

1.41 mm [40] to 6.1 mm [42], and extruded from 0.59 mm [40]

to 3.71 mm hypodivergent group in the study by Jung et al. [41].

ANB angle reduction ranged from 0.18 [43] to 2.10 [51].

were retracted with a range from 0.44 mm [51] to 2.3 mm [45]

treatment effects of inter-radicular mini-screws with MCPP

ranged from 1.29 mm (group A of the 2013 study by Bechtold

the 2013 study by Bechtold et al.) [21], and distally tipped by

to 3.4 mm [22], and lingually tipped by 1.138 [40] to 3.98 [22]. In

between post-treatment and post-retention) in the experi- #4 (arch OR dentition);

mental groups, beside comparisons between experimental #5 (distalization OR distal*);

crowding 3 mm changes intrusion and

Hypodivergent 20 12.3 W 1.5 FMA 22 14.9 W 1.5

ANB angle reduction ranged from 0.18 [43] to 2.10 [51].