Final 240525 235238

CAN DIFFERENT FORMS OF
SKELETAL ANCHORAGE SYSTEMS

ENHANCE THE SKELETAL EFFECTS
OF FIXED FUNCTIONAL APPLIANCES –
A NETWORK META-ANALYSIS BASED
ON A FREQUENTIST APPROACH
LIBRARY DISSERTATION
Submitted by
DR. SELVA AROCKIAM. A
Post graduate student
2018 – 2021
MEENAKSHI ACADEMY OF HIGHER EDUCATION &RESEARCH

(Deemed to be University )
FACULTY OF DENTISTRY
DEPARTMENT OF ORTHODONTICS & DENTOFACIAL
ORTHOPAEDICS
MEENAKSHI AMMAL DENTAL COLLEGE AND HOSPITAL
CHENNAI - 600 095
Certificate
This is to certify that the Library Dissertation on “CAN
DIFFERENT FORMS OF SKELETAL ANCHORAGE
SYSTEMS ENHANCE THE SKELETAL EFFECTS OF
FIXED FUNCTIONAL APPLIANCES – A NETWORK
META-ANALYSIS BASED ON A FREQUENTIST
APPROACH” was carried out under my guidance by
Dr. Selva Arockiam. A, Post Graduate Student, Department of
Orthodontics, Meenakshi Ammal Dental College, Meenakshi
University, Chennai, in partial fulfillment of the requirement
for the Degree “Master of Dental Surgery” dur ing the period
2018-2021.
Dr.R. Devaki Vijayalakshmi, M.D.S.,

Professor and Head
Guide

(Deemed to be University)
DEPARTMENT OF ORTHODONTICS & DENTOFACIAL
ORTHOPAEDICS
CHENNAI - 600 095
Date :
Place: CHENNAI
ENDORSEMENT BY THE PRINCIPAL / HEAD OF THE
INSTITUTION
This is to certify that the library dissertation entitled
“CAN DIFFERENT FORMS OF SKELETAL
ANCHORAGE SYSTEMS ENHANCE THE SKELETAL
EFFECTS OF FIXED FUNCTIONAL APPLIANCES-A
NETWORK META-ANALYSIS BASED ON A
FREQUENTIST APPPROACH” is done by Dr. SELVA
AROCKIAM. A, under the guidance of Dr.R. DEVAKI
VIJAYALAKSHMI, Professor and Head, Department of
Orthodontics & Dentofacial Orthopaedics, Meenakshi Ammal
Dental College, and Chennai.
Dr. A. NANDAKUMAR, M.D.S., Di p.I.B (ORTHO) ,

Principal,

(Deemed to be University)
CHENNAI - 600 095
Date:
Place: CHENNAI
ACKNOWLEDGEMENT
I thank the Almighty, for His mercy and blessing
throughout my life and career.
I would like to acknowledge and extend my earnest

gratitude to Dr. NandaKumar, MDS., Dip.I.B.,(Ortho),
principal, Meenakshi Ammal dental college and hospit al,
Chennai for his support and for having provided me with all
the necessary facilities for my studies.
I am indebted to my guide and mentor , Dr.R. Devaki

Vijayalakshmi., MDS., professor and head of the department,
for her constant encouragement, excell ent guidance and
continuous support.
I express my deepest gratitude to my professors Dr. Uma

Maheshwari, Dr.Ratna Parameswaran, for their constant
encouragement and constructive suggestions.
I am profoundly grateful to Dr. Nagachandran, Dr.

Srinivasan, Dr.Priya, Dr.Shalini, Dr. Vijay, Dr. Nayeemullah
Khan, Dr. Ravanth, Dr. Karthik and Dr. Kaushik for their
support and valuable suggestions.
I express my gratitude for Professor Anna Chaimani

and Professor George Salanti , Cochrane collaboration who
taught me the algorithm to perform the network meta -analysis.
I also express my gratitude and love to my mother Mrs.
S. F. Mary for her constant support and encouragement,
without whom I could not have gotten this far.
I wish to gratefully acknowledge the v alue and help of

my seniors, Dr. Balaji Rajkumar, Dr. Janani Jayapal, Dr.Mary
Sanjana, Dr. Saloni Mehta, Dr. Sivakami, Dr. Thiagu
Chokalingam, Dr. Thilaka sre and my batchmates Dr.
Abinaya.S, Dr.Anirutha.G, Dr.Dharshini.G, Dr.Lokamithra.R,
Dr.Priyanka.V and Dr. Siva Sankari.R.S.S. and my juniors
Dr.Ahana, Dr.Aishaa, Dr.Anjali, Dr.R.Karthikesh, Dr.Krishna
Priya, Dr.Manoj, Dr. C.Praveen. My sincere thanks to netway
prints for their help and enduring work.
Dr. SELVA AROCKIAM .A

CONTENT
S NO. TITLE PAGE NO
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 4
NETWORK META-ANALYSIS VS
4. 36
PAIRED META-ANALYSIS
SEARCH STRATEGY AND STUDY
5. 41
SELECTION
6. PRISMA FLOW DIAGRAM 43
7. MATERIALS AND METHODS 44
8. RESULTS OF STUDY SELECTION 49
CHARACTERISTICS OF INCLUDED
9. 51
STUDIES
10. RISK OF BIAS WITHIN STUDIES 64

RISK OF BIAS ASSESSMENT FOR
11. RANDOMIZED CONTROLLED 66
TRIALS
RISK OF BIAS ASSESSMENT FOR
12. 67
NON-RANDOMIZED STUDIES
RESULTS OF THE META-
13. ANALYSIS, ADDITIONAL 69
ANALYSIS
PAIRED META-ANALYSIS
14. 71
SUMMARY
15. SUB-GROUP ANALYSIS 73
16. PUBLICATION BIAS 81
RESULTS OF THE NETWORK

17. 86
META-ANALYSIS
STRENGTH AND WEAKNESS OF
18. 91
THE STUDY
19. CONCLUSION OF THE STUDY 93
20. BIBLIOGRAPHY 94
21. SUPPLEMENTARY MATERIALS 105

ABSTRACT
Background:
Recent studies with skeletally anchored fixed functional
appliances have shown that different forms of skeletal
anchorage systems (mini-plates, mini-screws) when used along
with fixed functional appliances may enhance the skeletal
changes and reduce lower incisor proclination. But so far, the
controversies regarding the effectiveness of miniplate
anchored fixed functional appliances against the mini -screw
anchored fixed functional appliances and conventiona l fixed
functional appliances remains unanswered.
Objectives:
 To compare the skeletal and dento -alveolar effects of
mini-plate anchored fixed functional appliances, mini -
screw anchored fixed functional appliances and
conventional fixed functional applianc es using
frequentist network meta-analysis.
Search methods:
Unrestricted electronic search of eight databases
(pubmed, CENTRAL, scopus, embase, ovid medline, proquest,
lilacs, web of science) and manual searches were performed up
to September 2019.
Eligibility criteria:
Randomized, prospective non-randomized controlled
trials and retrospective studies comparing the use of fixed
functional appliances with skeletal anchorage (mini -screw,
mini-plates) and conventional fixed functional appliances were
included in the study.
Results:
When we take improvement of mandibular retrognathism,
mini-screw herbst produces more skeletal changes when
compared with other skeletally anchored fixed functional
appliances and conventional fixed functional appliances. But
due to the limited evidence available we were unable to do the
rank probability and SUCRA to confirm the superiority of the
skeletally anchored fixed functional appliances among
themselves.
Introduction
INTRODUCTION
Skeletal class II malocclusion is one of the most

commonly encountered malocclusions in daily orthodontic
practice. Skeletal class II deformity is characterised by
maxillary prognathism or mandibular retrusion or a
combination of both. Prevalence of skeletal class II
malocclusion is about 47 % in different ethnic groups. [ 1 , 2 , 3]
Retrognathic mandible is the most common skeletal trait in
skeletal class II malocclusion. [ 4 , 5]
Both removable and fixed functional appliances are

available for correction of skeletal class II malocclusions.
Depending on the design and duration of wear of the
functional appliance, the skeletal and dental effects produced
by these appliances vary. Altho ugh removable functional
appliances are effective in correcting skeletal class II
malocclusion due to mandibular retrognathism, they have an
inherent limitation- it requires the patient compliance for
successful correction of the malocclusion. [ 6 ]
The era of fixed functional appliances started with the

herbst appliance introduced by Emil Herbst in 1905 which was
later popularised by Pancherz in late 1970’s. [ 7 ] Thereafter
many other fixed functional appliances like the forsus fatigue
resistance device (Forsus FRD), powerscope, MARA, Jasper
jumper, easy fit jumper, mini -scope, Sabbagh universal spring
(SUS), advansync, etc. were introduced as herbst hybrids or
modified herbst analogs. These were more popularly referred
1
Introduction
as the non-compliance fixed functional appliances as they

don’t require the patient compliance for achieving the
corrections.
The fixed functional appliances can be broadly classified

under three categories: rigid fixed functional appliances,
flexible fixed functional appliances and semi -rigid (hybrid)
fixed functional appliances. [ 8 ] However, the skeletal effects
produced by these fixed functional appliances were minimal
when compared with the dental effects of these appliances.
Dental effects produced by these appliances included
mesialisation of the mandibular molars and mandibular incisor
flaring which affected the stability of the achieved skeletal
corrections.
The recent systematic review regarding the effectiveness

of fixed functional appliances by zymperdikas, et.al in 2015
concluded that effects of fixed functional appliances were
mainly dento-alveolar rather than being skeletal. [ 9] Another
systematic review by Perinetti, et.al in 2015 regarding the
effectiveness of fixed functional appliances used in
conjunction with multi-bracket fixed orthodontic appliances
concluded that fixed functional treatment was effective in
bringing about skeletal change in pubertal patients and there is
little evidence that brings about a change in post -pubertal
patients. [ 1 0]
Recently skeletally anchored f ixed functional appliances

have been introduced to minimize the dental side -effects and
2
Introduction
to enhance the skeletal effects of these fixed functional

appliances. But the effectiveness of different forms of skeletal
anchorage systems in enhancing the skeletal e ffects of fixed
functional appliances and minimizing the dental side effects
when used along with different fixed functional appliances
still remains controversial.
Therefore the aim of this current network -meta analysis

is to evaluate the effectiveness of different skeletally anchored
fixed functional appliances as compared among themselves
and also with conventional fixed functional appliances without
these skeletal anchorage systems using both direct and indirect
evidence derived from the literature.
3
Review Of Literature
REVIEW OF LITERATURE
Etiology and Development of Class II Malocclusion
The development of Class II malocclusion is a complex
process involving many factors and typically arises due to
both skeletal and dental abnormalities (Mossey 1999). These
abnormalities may result due to a genetic predisposition and/or
a wide variety of environmental influences.
The genetic component of Class II malocclusion has been

established in the literature (Harris,1963 & 1975; Nakasima et
al., 1982). Nakasima et al. (1982) conducted a study
comparing craniofacial morphologic correlations between 96
Class II patients, 104 Class III patients, and their parents.
Lateral and frontal cephalograms were obtained for the
patients and their parents. Correlation coefficients were
calculated for various cephalometric measurements. The
authors found significant differences between the Class II and
III groups, but high correlation coefficients between parents
and their offspring within each group. Therefore, they
concluded that a strong familial tendency exists for the
development of Class II malocclusion.
Various environmental and physiological factors are also

known to contribute to Class II malocclusion. Harvold et al.
(1981) studied the effects of oral respiration on craniofacial
development of primates. When nasal respiration was blocked
in primates using silicone plugs, the investigators noted that
they reverted to open mouth posture and subsequently
developed more vertical growth patterns and greater tendency
4
toward Class II malocclusion, likely due to backward rotation

of the mandible.
Similar findings were noted by Melsen et al. (1987)

when they compared mouth breathing patients to nasal
breathers. Melsen et al. (1979) studied the effects of
swallowing pattern on malocclusion. They found that children
who exhibited a swallowing pattern wit h tooth contact had a
significantly lower prevalence of vertical and sagittal
discrepancies compared to children with other swallowing
patterns. It is also known that individuals with decreased
masticatory muscle function have a tendency toward a vertical
growth pattern, Class II malocclusion, and anterior open bite
(Kiliaridis 2006).
Prolonged digit sucking has also been known to

contribute to malocclusion. Melsen et al. (1979) found that
prolonged thumb sucking results in maxillary constriction,
clockwise rotation of the mandible and subsequent Class II
malocclusion.
Finally, Solow et al. (1998) found that children who

constantly exhibit posture with head extension (raised position
of the head in relation to cervical column) are more likely to
present with vertical growth patterns and Class II
malocclusion. Therefore, environmental adaptations and
physiological functions, in addition to genetics, play an
important role in development of Class II malocclusion.
5
Several cephalometric studies have aime d to characterize

the key features of Class II malocclusion. According to
Bishara (2006), Class II division 1 malocclusion may be
characterized by the anterior position of the skeletal maxilla
and/or maxillary teeth relative to the cranium, a posterior
position of the mandible and/or mandibular teeth, an
underdeveloped mandible, or a combination of these factors.
McNamara (1981) reviewed previous studies and

investigated the frequency of occurrence of key components in
children with Angle Class II malocc lusion. He evaluated the
lateral cephalograms of 277 children aged 8 -10 with Class II
malocclusion and recorded the characteristics contributing to
the malocclusion in each patient. He found that the maxilla
exhibited a neutral position in most cases and t rue skeletal
protrusion was only present in a small percentage of the
patients. When not neutrally located, the maxilla was found to
be in a retruded position more often than a protruded position.
McNamara (1981) found that mandibular skeletal retrusion

was the single most common characteristic among the sample.
Additionally, about half of the sample exhibited excess
vertical development. From these findings, the author
suggested that treatment to alter the amount and direction of
mandibular growth may be more appropriate than those
directed at restricting maxillary development.
6
Growth in Individuals with Class II Malocclusion

Growth differences in patients with Class II
malocclusion compared to Class I subjects is important to
consider. Stahl et al. (2008) compared the craniofacial growth
changes in 17 untreated subjects with Class II division 1
malocclusion to 17 subjects with normal occlusion from the
prepubertal through postpubertal stages of development.
The cervical vertebral maturation method, as described

by Baccetti et al. (2005), was used as a biological indicator of
skeletal maturity. The study showed that craniofac ial growth
in individuals with Class II malocclusion is like growth in
those with normal occlusion at most developmental stages.
The only exception being significantly smaller increases in
mandibular length during the growth spurt (cervical stage 3 -4)
in Class II subjects. As a result, when compared long -term
(cervical stage 1-6), Class II patients showed less mandibular
growth than Class I subjects.
The authors concluded that Class II skeletal disharmony

does not spontaneously self-correct with growth. It can also be
inferred from the study that the best time to attempt to
stimulate mandibular growth in Class II patients would be
during the growth spurt (cervical stage 3 -4) since this is when
mandibular growth significantly lags behind in these patients
compared to those with normal occlusion.
These conclusions had already been drawn by Buschang

and Martins (1998) in their longitudinal study of 99 Class I
7
and II subjects. They found that anteroposterior relationships

(measured as horizontal distance fr om ANS to pogonion)
usually improved during childhood but worsened during
adolescence. Differences in the horizontal growth of the
mandible was the primary reason. They also concluded that
vertical skeletal changes (vertical distance from gonion to
pogonion) increased in most of the subjects. This study also
supports the idea that Class II malocclusion does not self -
correct over time and appropriate intervention is necessary.
Current Evidence on Treatment Timing

The timing of treatment for Class II patients is critical.
Franchi et al. (2013) analyzed long -term skeletal and
dentoalveolar effects in Class II patients treated with
functional appliances either before or during puberty in order
to evaluate treatment ti ming. They cephalometrically
evaluated a group of 40 patients (22 females and 18 males)
with Class II malocclusion treated with a bionator or activator
removable functional appliances followed by fixed orthodontic
appliances and compared them to an untreat ed Class II control
group. The treated sample was divided into two groups based
on skeletal maturity (according to the method outlined by
Baccetti et al., 2005): an early treatment group of 20 subjects
(12 females and 8 males) treated before puberty and a
late treatment group of 20 subjects (10 females and 10
males) treated at puberty.
Lateral cephalograms were available at the start of

treatment, end of treatment with functional appliances, and
8
long-‐term observation (mean of 8.6 years afte r start of

treatment). The authors found that treatment during the
pubertal peak was able to produce significantly greater
increases in mandibular length (4.3 mm) and height (3.1 mm)
as well as advancement of the bony chin (3.9 mm) when
compared with earlier treatment.
Therefore, the authors concluded that treatment of Class

II malocclusions with functional appliances may be more
effective during active pubertal growth. This conclusion had
previously been drawn by several investigators based on
studies of various fixed and removable functional appliances
(Hagg et al., 1988; Hansen et al., 1991; Baccetti et al., 2000;
Faltin et al., 2003).
Current Evidence on the Efficacy of Growth

Stimulation in Class II Patients
Several treatment modalities have been developed for
Class II malocclusions. These include selective extraction
patterns, orthopedic forces delivered with headgear, functional
jaw orthopedics using functional appliances, fixed Class II
correctors, molar distalization and orthognathic surgery to
reposition one or both jaws (Pangrazio et al., 2012).
Several factors, including the etiology of the

malocclusion, the growth potential of the patient and expected
patient compliance need to be taken into consideration while
selecting the most appropriate treatment modality (Nelson et
al., 2000). This literature review will focus on functional
9
appliances in which one of the mechanisms of Class II

correction involves advancement of the mandibular teeth,
mandible, or both.
Removable or fixed functional appliances are designed to

alter the sagittal and vertical position of the jaws, resulting in
orthodontic and orthopedic changes (Pangrazio et al. 2012).
Despite their long history of use, the efficacy of these types of
appliances is a controversial topic in orthodontics. Advocates
of functional appliances cite stimulation of mandibular growth
(Hagg et al., 1988; Hansen et al., 1991; Baccetti et al., 2000;
Hagg et al., 2002; Faltin et al., 2003; Meikle et al., 2007).
Histological studies involving labora tory animals have

consistently shown the enhancement of cellular activity and
mandibular growth with the use of bite -‐ jumping appliances
(Charlier et al., 1969; Elgoygen et al., 1972; McNamara JA Jr.
et al., 1987; Rabie et al., 2001 & 2003). It has been speculated
that these changes do occur in humans as well (Moss et al.,
1969; Balthers, 1984; McNamara JA Jr. et al., 1985).
However, many investigators (Schulof et al., 1982;

Creekmore et al., 1983; Tulloch et al., 1998) believe that the
changes produced by functional appliances may be significant
in the short-‐term, but in the long term are not significantly
different from changes due to normal growth or conventional
edgewise therapy. These investigators cite that patients who
received a functional appliance phase I treatment in the mixed
dentition followed by phase II full fixed orthodontic treatment
10
in the permanent dentition, do not show any significant

differences compared to patients treated with one phase of
fixed orthodontic treatment in the perm anent dentition.
Additionally, it was shown that phase I functional appliance
treatment did not reduce the likelihood of needing extractions
or orthognathic surgery in the second phase of treatment
(Tulloch et al., 1998). It is evident that the ability to stimulate
mandibular growth with a functional appliance is still very
controversial with strong arguments for both sides.
Compliance Based Treatment Modalities

Appliances used to correct Class II malocclusion may be
classified as compliance based or non - compliance based; this
is a convenient way to divide these appliances as many
clinicians place a high importance on this distinction. In
general, removable appliances are compliance based and
dependent on patient obedience with instructions given by the
clinician. Fixed appliances, on the other hand, are non -
compliance based since the patient cannot remove the
appliance.
Removable Functional Appliances

Removable functional appliance therapy is one
compliance-based treatment modality for Class II
malocclusions. Over the last century, a wide array of
functional appliances has been developed and utilized
extensively in growing patients. Three such appliance s include
the Bionator, Twin-Block and Frankel-2.
11
The Bionator was designed and introduced by Balters in

the 1960’s (Bigliazzi et al., 2014). Bigliazzi et al. (2014)
studied the long-term dentoskeletal effects induced by
treatment with the appliance in 23 growing Class II patients (8
males, 15 females). Lateral cephalograms were analyzed at
three time points: start of treatment (mean age 10 years 2
months), end of Bionator therapy (mean age 12 years 3
months), and long-term follow-up (mean age 18 years 2
months). An untreated control sample was used for
comparison.
The authors found that the Bionator was able to produce

favourable forward and downward mandibular shape changes
while not restraining the maxilla (numerical measurements
were not provided in this study). These shape changes
contributed significantly to the correction of the Class II
malocclusions and the results were maintained in the long
term.
Similar results had been previously drawn by Malta et al.

(2010) and Franchi et al. (2013). Malta et al. (2010)
reported an average long-term increase in mandibular length
of 3.3 mm compared with untreated controls, while Franchi et
al. (2013) reported a 3.6 mm increase.
The Twin-Block appliance was developed by Clark in the

1980’s (Clark 1988). In a recent study, Giuntini et al. (2015)
studied the effects of the Twin -Block appliance and ForsusTM
Fatigue Resistant Device (FRD) in Class II patients. 28
12
growing patients treated with Twin -Block therapy followed by

fixed appliances (mean age 12.4 years pre-treatment) were
compared to 36 growing patients treated with FRD (mean age
12.3 years) in combination with fixed appliances. An untreated
sample of 27 subjects was used as a control. Mean observation
interval was 2.3 years in all groups. The Twin-Block
sample exhibited a greater increase in mandibular
length compared to the FRD and control samples (2.0 mm
more than FRD and 3.4 mm more than control). The SNB
angle also increased significantly in the Twin -Block group
(1.9° more than FRD and 1.5° more than control).
The authors concluded that the Twin -Block appliance is

able to produce significant. mandibular advancement to
correct Class II malocclusion. The results of this study
supported those found by Mahamed et al. (2012) .
These results are contrasted by those found by O’Brien et

al. (2009) in a multi-center controlled trial. O’Brien et al.
(2009) randomly divided 174 children aged 8 to 10 into two
groups: one receiving Twin-Block therapy, the other left
initially untreated. The subjects were then followed until the
end of comprehensive orthodontic treatment. The results of the
study indicated that there were no differences between
subjects who received early Twin -Block treatment and those
who received one later course o f treatment in adolescence in
terms of skeletal pattern, extraction rate and self -esteem. The
authors concluded that early treatment with the Twin -Block
13
followed by fixed appliances has no advantages compared to

fixed orthodontic treatment alone started a t a later age.
The Frankel-2 appliance (FR-2) was developed by

Rolf Frankel and introduced to orthodontics in 1966
(Perillo et al., 2011). Numerous articles have been published
in the literature with regards to this appliance. Perillo et al.
(2011) summarized the effects of the appliance in a meta -
analysis. From nine articles that were included in the analysis,
the Frankel-2, in growing patients, was associated with
enhancement of mandibular body length (0.4 mm/year), total
mandibular length (1.069 mm/year), and mandibular ramus
height (0.654 mm/year). Therefore, the authors concluded that
the Frankel-2 does have a statistically significant effect on
mandibular growth. These results are not well supported by
other systematic reviews (Cozza et al., 2006; Koretsi et al.,
2014).
Cozza et al. (2006) conducted a systematic review of

mandibular changes produced by functional appliances in
growing patients. 18 controlled clinical trials and 4
randomized control trials were included in the review . Two-
‐thirds of the studies reported a clinically significant
supplementary elongation in total mandibular length (2mm
more than control group). It was found that mandibular growth
enhancement appears to be greater if the functional appliance
is used during the pubertal growth peak assessed by skeletal
maturity. However, of the 4 RCTs included in the review, none
of them showed a significant change in mandibular length with
14
functional appliance therapy. The Herbst (a fixed functional

appliance) had the highest coefficient of efficiency of 0.28mm
per month, followed by the Twin Block (0.23mm per month),
Bionator (0.17mm per month), and Frankel -2 (0.09mm per
month).
Another systematic review regarding the treatment

effects of removable functional applianc es in growing patients
was completed by Koretsi et al. (2014). From the 17 studies
included in the review, they found that functional appliance
treatment was associated with a minimal reduction in SNA
angle (-0.28°/year) and minimal increase in SNB angle
(0.62°/year) compared to untreated controls. Removable
functional appliances produced significant dentoalveolar
changes (primarily retroclination of the maxillary incisors)
and soft tissue changes. Skeletal changes were minimal but
seemed to be more evident with the Twin-Block. These results
are only for the short-term as inadequate evidence was
available for the long-term.
Class II Elastics
Another compliance-‐based modality to correct Class II
malocclusions is using intermaxillary elastics. Class II ela stics
are used in combination with full fixed orthodontic appliances
and are typically worn from maxillary canines to mandibular
first molars. The effects of Class II elastics have been
previously investigated in several studies.
15
[11]
Nelson et al. (1999) studied the effects of Class II elastics
(Begg technique) in 18 Class II division 1 patients. The
overall reduction in overjet was 5.8 mm, with 71.1% of the
reduction being due to dental changes. The molar correction of
3.0mm in the total treatment period , was due to 63% dental
changes (1.9 mm) and 37% skeletal changes (1.1 mm). Of the
dental changes, the primary factor was forward movement of
the mandibular molars (2.0 mm). The mandibular plane angle
increased an average of 1.0°, while the lower anterior facial
height increased 5.0 mm. In summary, the Class II correction
occurred primarily through dental changes, while vertical
skeletal measurements increased.
In a later study, Nelson et al. (2000) [ 1 2] studied the long-

term effects of Class II correction with the Begg appliance and
Class II elastics compared to the Herbst appliance. Lateral
cephalograms were taken at the start of treatment, immediately
after treatment, and after long -term follow-up. Initially, more
favourable effects were seen in the Herbst group. However,
many of the changes reversed during the follow -up period and
both treatment modalities were comparable in their effects in
the long-term.
[ 13 ]
Gianelly et al. (1984) investigated the effects of
Class II elastics with both Begg and edgewise appliances.
SNA decreased in both the Begg (0.4°) and edgewise (1.5°)
groups, while SNB increased 0.3° in both groups. The
mandibular plane angle increased 1.3° in the Begg group and
0.6° in the edgewise group. Overall mandibular size increased
16
by almost 3 mm in both groups, likely due to normal growth.

Overall, the effects of Class II elastics were consistent with
other studies and there were no significant differences
between the two groups.
[14]
Janson et al. (2013) recently completed a systematic
review on the treatment effects of Class II elastics. The review
consisted of 11 studies: 4 that tested the effects of Class II
elastics alone, and another 7 that compared the effects of
Class II elastics to another method of Class II malocclusion
correction. From the 4 studies that solely focused on the effect
of Class II elastics, the following effects were found:
Restriction of forward maxillary growth, and

insignificant movement of maxillary molars.
1. Forward growth of mandible, and 1.2mm forward

movement of mandibular first molars.
2. Proclination of mandibular incisors.
3. Overjet reduction of 5.8mm: 28.9% skeletal change and
71.1% dental change.
4. Overbite reduction of 3.0mm and molar correction of
3.0mm: 37% skeletal change and 63% dental change.
5. Increase in lower anterior facial height by an average of
5.0mm.
6. Soft tissue effects only vaguely mentioned.
7. Overall, Class II elastics are effective in correcting Class
II malocclusion, mainly via dentoalve olar effects.
17
When Class II elastics were compared with the Frankel

appliance, headgear (Gianelly et al., 1984) 1 3 , the cortical
[ 1 5]
anchorage principle (Ellen et al., 1998) , and the ForsusTM
[ 1 6]
appliance (Jones et al., 2008) , no differences were found in
the changes produced.
According to Nelson et al. (2000), the Herbst appliance

appears to produce greater skeletal change when compared to
Class II elastics in the short term (51% vs 4% skeletal overjet
correction and 66% vs 10% skeletal molar relationship
correction). However, the authors suggested that with
longer post-treatment periods (2 -3 years), natural growth
could mask the effects of the appliance and make the two
groups comparable. Overall, in terms of long -term effects, the
comparative studies showed that there are no significant
differences between Class II elastics and removable or fixed
functional appliances.
Class II elastics remain heavily utilized by orthodontists

to correct Class II malocclusions. As seen in vario us studies
(Gianelly et al., 1984; Ellen et al., 1998; Nelson et al., 2000;
Jones et al., 2008) [ 1 3 ,1 5 , 1 6] , this treatment modality does
produce several, usually unwanted, side effects including
clockwise rotation of the occlusal plane and proclination of
the mandibular incisors. The clockwise rotation of the occlusal
plane acts to exacerbate the Class II relationship and therefore
must be taken into consideration and limited whenever
possible. Significant mandibular incisor proclination is known
to be unstable and measures should be taken to prevent this.
18
Despite these side effects, Class II elastics will undoubtedly

continue to play an important role in orthodontics, as they are
easy to use, inexpensive and effective in normalizing Class II
malocclusions in compliant patients.
Non-Compliance Based Treatment Modalities

The efficacy of removable appliances and Class II
elastics in correcting Class II malocclusion is entirely
dependent upon patient compliance. The needed compliance is
out of the control of the clinician, making results
unpredictable. In order to eliminate the dependence on patient
compliance and produce more predictable results, several
fixed appliances have been developed to correct Class II
malocclusions.
Appliances such as the Herbst, Mandibular Anterior

Repositioning Appliance and AdvanSyncTM utilize rigid
inter-arch attachments in order to force the patient to
constantly posture the mandible forward. Other appliances
such as the Saif Spring, Eureka Spring, and ForsusTM Fatigue
Resistant Device rely on inter-‐ arch spring-‐force delivery
systems to correct Class II malocclusion.
The Herbst Appliance

The Herbst appliance was likely the first well -‐known
[ 7]
fixed appliance for Class II correction (Pancherz,1982) .
This appliance acts as an artificial joint between the upper and
lower jaws. Telescoping mechanisms on both sides, attached
to orthodontic bands, keeps the mandible continuously held in
19
a forward position during mandibular functions; hence it is

[ 7]
classified as a fixed functional appliance (Pancherz, 1982) .
The telescoping mechanism typically attaches at the maxillary
first molar and mandibular first premolar bands. Although it is
possible to place brackets on the anterior teeth while the
Herbst appliance is in place, it is not possible to bracket
mandibular posterior teeth due to the telescoping mechanism.
For this reason, the appliance is typically used by itself during
the initial 6 to 8 months prior to full edgewise orthodontic
treatment (Pancherz, 1997).
Several investigators have described the effects of the

[ 7]
Herbst appliance. Pancherz (1982) did a lateral
cephalometric study of 22 growing Class II, division 1 patients
(mean pre-treatment age of 12 years 1 month) treated for an
average of 6 months with the Herbst a ppliance and compared
them to a similar untreated control group. He found that all
cases treated with the Herbst appliance resulted in Class I
occlusal relationships and the improvements were due to
approximately equal skeletal and dental changes.
The average molar Class II correction was 6.7 mm (due

to 2.2 mm mandibular length increase, 2.8 mm distalization of
upper molars, and 1.0 mm mesialization of the lower molars.)
The average overjet correction was 5.2mm (due to 2.2 mm
increase in mandibular length and 1.8 mm mesial movement of
lower incisors). The author also noted a direct relationship
between the amount of initial bite jumping and mandibular
growth. Therefore, Pancherz suggested the Herbst appliance be
20
constructed with the mandible jumped anteri orly as much as

possible (in a single activation), usually to an incisal edge -to-
edge position.
Pancherz (1997) also reviewed the effects of the Herbst

appliance in the short and long term. Marked mandibular
morphological changes were evident during treatment with the
Herbst appliance. Effects on the maxillary complex were
found to be like those expected with high-pull headgear; in a
study of 45 growing patients treated with Herbst for an
average of 6 months, the upper molars were intruded in 69%
of the subjects and distalized in 96%. Pancherz (1997) noted
that without retention, effects of the applia nce are of a
temporary nature. Post-treatment, it has been shown that most
of the mandibular morphological changes revert, and in the
long term (average of 7.5 years post -treatment), there are no
differences in mandibular growth between patients treated
with the Herbst appliance and untreated controls.
Long-term stability seems to depend on obtaining a

stable cuspal interdigitation. For this reason, it is suggested
that treatment not be started in the mixed dentition due to the
propensity for relapse. Compared to removable functional
appliances, the Herbst appliance is said to have the benefits of
working 24 hours a day, not being reliant on patient
compliance and having a shorter active treatment time.
A known disadvantage of the Herbst appliance is i ts

tendency to procline the mandibular incisors.
21
Martin (2007) investigated this further by studying the

mandibular incisor changes based on the amount of bite
jumping. During Herbst treatment, intrusion, protrusion and
proclination of the lower incisors occurred in all patients. In
patients with greater bite jumping (>9.5mm), greater intrusion,
protrusion, and proclination were evident. Following treatment
with full fixed multibracket appliances, recovering tooth
movements occurred in all patients regard less of the amount of
bite jumping. Incisor position changes was unaffected by
sagittal and vertical jaw relationships, age, and growth period.
Mandibular Anterior Repositioning Appliance (MARA)

The MARA was first described by Eckhart and Toll in
1998. The MARA was introduced as an alternative to the
Herbst appliance, with its major advantage being that it treats
Class II malocclusion in combination with comprehensive
fixed appliances. The MARA uses an inclined plane as an
obstacle to be avoided during mandibular movement, thereby
inducing the lower jaw to move forward. The appliance
consists of crowns cemented on maxillary and mandibular first
molars, lower arms soldered to the crowns and upper elbow
tubes soldered to the crowns and shimmed to provide th e
desired advancement. Various modifications of the appliance
are possible to allow for expansion, distalization and other
desired movements.
[ 1 7]
Pangrazio-Kulbersh et al. (2003) studied the effects
of the MARA in 30 Class II patients (12 boys with aver age age
11.2 years and 18 girls with average age of 11.2 years) treated
22
for an average of 10.7 months. The results were compared to a

non-treated control sample and groups treated with the Frankel
and Herbst appliances from previous reports.
In the MARA group, the maxillary molars moved distally

1.1mm while in the control group they moved mesially 1.3mm.
Vertical inferior movement of the maxillary first molar was
0.1mm per year in the MARA group compared to 0.9mm per
year in the control group. The MARA g roup showed
significant mesial movement of the mandibular molars and
incisors (1.2mm and mm respectively) compared to the control
group, which showed 0.5mm mesial molar movement and
0.4mm distal incisor movement. Additionally, the MARA
group exhibited significantly greater lower incisor
proclination compared to the control group (3.9° versus 0.3°).
Vertical movements of the mandibular molars and incisors
were not significantly different between the MARA and
control groups. Skeletally, maxillary changes were not
significantly different between the MARA and control group;
therefore, the maxilla grew down and forward at the same rate.
On the other hand, mandibular skeletal changes were
significant.
In the MARA group, mandibular length increased 4.8mm

compared to 2.1mm in the control group; the chin moved
forward an average of 2.3mm versus 0.3mm in the control
group. The ANB angle decreased an average of 1.4° in the
MARA group compared to 0.1° in the controls. Additionally,
mandibular anterior face height increased 2.5mm and posterior
23
face height increased 4.0mm in the MARA patients compared

to 1.0mm and 1.3mm, respectively, in the control group.
Overall, treatment effects of the MARA appeared to be similar
to the Herbst appliance but with less headgear effect and less
lower incisor proclination.
[18]
Ghislanzoni et al. (2011) investigated the effects of
the MARA in 2011. They cephalometrically compared the
effects of the appliance in 23 growing patients (treated at pre -
‐pubertal or pubertal stages, as assess ed by the cervical
vertebral maturation method) to an untreated control group.
During the active treatment phase, there was an average

increase in mandibular length of 2.2mm and increase in lower
incisor proclination of 5.8°. Patients were followed up for an
average of 2.4 years after appliance removal. There was a
significant relapse tendency for lower incisor proclination ( -
2.1°) post-treatment. However, increases in mandibular
length (2.0mm) and headgear effects of the maxilla (SNA
decreased by an average of 1.2°) were significant in the long
term.
Another study was conducted by Pangrazio et al. (2012).

They examined the cephalometric changes induced by the
MARA in 30 growing Class II patients (treated at pre -pubertal
or pubertal stages, as assessed by the cervical vertebral
maturation method) and co mpared them to untreated controls.
The results of this study were contrasted with previous
studies. It was found that while the MARA was effective in
24
restricting maxillary growth, there was no significant

enhancement of mandibular growth with the appliance . The
Class II correction with the MARA occurred as a result of
slight maxillary molar distalization and intrusion along with
mesialization of the lower molars and proclination of the
lower incisors.
Al-Jewair (2015) completed a meta -analysis on short and

long-term effects of the MARA on mandibular dimensions in
growing patients. Overall, seven retrospective controlled
studies were used in the analysis. Short -‐term effects
revealed a significant increase in total mandibular unit length
(1.16mm per year) and ramus height (1.58mm per year) and
non-significant increases in corpus length (0.21mm per
year).When analyzing the long -term effects, treatment
with MARA showed a statistically significant advantage over
controls for all three variables, but th e effect sizes were small
and may not be clinically significant. In general, the ability of
MARA to produce clinically significant changes in mandibular
growth is controversial.
Spring Force Delivery Systems

Other methods of non-compliance Class II correction
involve the use of spring force delivery systems. A wide
variety of these appliances have been designed and have been
gaining popularity over the last couple of decades. Among the
most popular appliances are the Saif Spring, Jasper Jumper
TM, Eureka Spring, ForsusTM Fatigue Resistant Device, and
XBowTM Appliance.
25
Saif Spring
Saif Springs, introduced in the 1960’s, are long nickel -
‐titanium closed coil springs used in combination with full
fixed appliances to produce Class II intermaxillary traction.
They were introduced as a fixed alternative to Class II elastics
and the force vector and location of attachment are like
conventional Class II elastics. The springs are tied in place
with steel ligatures. There have been no longitudinal research
studies on this appliance, so its effects are not well known.
Jasper Jumper TM
The Jasper JumperTM, introduced in 1994, consists of
two vinyl coated auxillary springs fitted to fully bonded fixed
orthodontic appliances. The springs are attached to the upper
first molars posteriorly and the lower archwire anteriorly.
[ 1 9]
Cope et al. (1994) investigated the effects of the
appliance in a group of 31 growing patients (average age of
12.9 years at start of treatment and treated for 0.4 years) and
compared them to an untreated, matched control group. The
maxilla underwent significant posterior displacement as
evidenced by posterior movement of ANS and A -point by
0.91mm per year and 0.60mm per year respectively. There
was no evidence of enhanced mandibular growth in patients
treated with the Jasper JumperTM compared to controls.
Most of the Class II correction was due to dental

changes. Significant distal movement of the maxillary molars
(4.3mm per year) and incisors (4.7mm per year) was evident.
26
Additionally, mandibular molars and incisors exhibited

significant mesial movement (4.24 and 5.29mm per year
respectively). Overall the net effects of the Jasper Jumper TM
included distal maxillary skeletal and dental movements,
mesial mandibular dental movements and clock wise
mandibular rotation.
[20]
A similar study was conducted by Covell et al. (1999)
on 36 growing Class II patients (average age of 13 years 2
months at the time of appliance insertion) treated with the
Jasper Jumper TM (for average of 5 months) compared to an
untreated control group. Compared to controls, the treated
group showed significant maxillary skeletal restriction (SNA
angle decreased 1.6°), clockwise rotation of the occlusal plane
(0.6°), and proclination of the lower incisors (5.3°). The
maxillary molars were distalized and intruded, while the
mandibular molars were mesialized (2.6mm) and extruded
(0.9mm). These results are largely in agreement with those
[19]
found by Cope et al. (1994) .
Kucukkeles et al. (2007) also investigated the effects of

the Jasper JumperTM in 45 skeletal Class II growing patients
(mean age of 11.83 years pre--treatment). Their results were
similar to Cope et al. (1994). The appliance was effective in
correcting Class II malocclusion, however, 80% of the changes
were dentoalveolar. Maxillary growth was restricted and
pogonion moved slightly forward, imp roving the profile. This
forward movement of pogonion compared to the untreated
27
control group contrasts with the findings of Cope et al. (1994)

[ 1 9] [20]
and Covell et al. (1999) .
Eureka SpringTM
The Eureka SpringTM, introduced in 1997, is another
intermaxillary force delivery system. Designed for use with
full fixed edgewise appliances, the Eureka Spring utilizes an
open wound coil spring encased in a telescoping plunger. The
spring attaches to the upper molar headgear tubes and lower
archwire distal to the canines. The telescoping mechanism is
different from other appliances and allows mouth opening of
up to 60 mm.
To date, only one study has described the effects of the

Eureka Spring. Stromeyer et al. (2002) investigated the effects
of the appliance on 37 consecutively treated bilateral Class II
patients (mean age of 16 years at appliance insertion). The
average overjet correction of 2.1mm was primarily due to
dental changes (90%). The overjet correction resulted from
1.1mm distal movement of the maxillary incisors and 0.8mm
mesial movement of the mandibular incisors.
Similarly, of the average molar relationship correction of

2.7mm, 93% was due to dental changes. The maxillary molars
distalized 0.9mm, while the mandibular molars mesialized
1.6mm. The rate of molar correction was 0.7mm per month. It
is important to note that the investigators did not compare the
results to a control group. Overall, the Class II correction
occurred almost entirely by dentoalveolar movement and the
28
changes were equally distributed between the maxillary and

mandibular dentitions.
ForsusTM Fatigue Resistant Device (FRD)

The ForsusTM Fatigue Resistant Device, more simply
known as ForsusTM, incorporates a superelastic nickel -
titanium coil spring with a semirigid telescoping system. The
Forsus TM is used in combination with complete fixed
appliances and attaches at the upper first molar headgear tube
and anteriorly on the mandibular archwire by a push -‐rod
distal to the canine or first premolar bracket.
[ 2 1]
Franchi et al. (2011) described the effects of the
ForsusTM appliance in 32 consecutively treated, growing
Class II patients (mean age 12.8 years pre -‐
treatment) and compared them to a matched, untreated control
group. The mean duration of ForsusTM treatment was 5.3
months, while comprehensive treatment was 2.4 years.
The treated group showed significant restriction of

maxillary sagittal growth as the SNA angle decreased by 1.6°
compared to an increase of 0.5° in the control group. Also, the
linear length of the maxilla (measured from condylion to A
point) increased only 2.2mm in the treated group compared to
3.6mm in the control group. The effective mandibular length
(measured from condylion to gnathion) was significantly
greater in the ForsusTM group (7.5mm) compared to the
control group (5.7mm). The treated group also showed a
significantly greater decrease in the ANB angle and Wits
29
appraisal. The lower anterior facial height (measured from

anterior nasal spine to menton) increased significantly more in
the ForsusTM group (4.0mm compared to 2.7mm in the control
group).
Dentally, the treatment group showed significant

retrusion and extrusion of the maxillary incisors, while
movement of the maxillary molars did not differ from the
control group (slight extrusion and mesialization). The most
significant findings contributing to the Class II correction
were found in the mandibular dentition. The mandibular
incisors significantly proclined (6.1°) and intruded (0.5mm)
compared to controls (0.9° proclination and extrusion of
1.5mm). The mandibular first molars extruded 3.6mm
(compared to 0.9mm in controls) and moved mesially 2.4mm
(compared to 0.9mm in controls). The authors concluded that
the major skeletal effect of the ForsusTM appliance is
maxillary restriction and the effects on the mandible are
primarily dentoalveolar in nature.
Jones et al. (2008) [ 1 6] compared the effects of the

ForsusTM appliance to intermaxillary elastics in the treatment
of Class II malocclusion. 34 consecutively treated, growing
Class II patients (mean age 12.6 years pre -‐treatment) treated
with the ForsusTM appliance were compared to a matched
sample of patients treated with intermaxillary elastics (mean
age 12.2 years pre-‐treatment).
30
Average treatment duration was 2.7 years for the ForsusTM

group and 2.4 years for the intermaxillary elastics group.
Using the pitchfork analysis, in the ForsusTM group, the
maxilla moved forward 1.7mm, while the mandible moved
forward by 4.4mm. Dentally, the upper molar moved forward
1.2mm, while the lower molar moved forward 1.8mm.
The results in the intermaxillary elastic group were very

similar; the maxilla and mandible moved forward 1.5mm and
3.8mm respectively, while the upper and lower molars moved
forward 0.6mm and 0.7mm respectively. Inci sor movement
was also similar in both groups and was mainly forward
movement of the mandibular incisors. The authors concluded
that the effects of the ForsusTM appliance appeared to be
comparable to those of intermaxillary elastics and therefore
the ForsusTM appears to be a suitable non -‐compliance
alternative to Class II elastics.
Cacciatore et al. (2014) investigated the treatment and

post-treatment effects of the ForsusTM appliance in 36
consecutively treated, growing Class II patients (mean age
12.3 years pre-treatment) compared to an untreated control
group. Lateral cephalograms were taken immediately prior to
starting treatment, at the end of comprehensive treatment
(average of 2.3 years) and at a follow-up period (average of
2.3 years from end of comprehensive treatment).
At the end of comprehensive treatment, the ForsusTM

group showed significant restriction in maxillary sagittal
31
position (SNA decreased 1.7°), but no significant mandibular

skeletal changes. The maxillary incisors exhibited signi ficant
retrusion (1.6mm), while the mandibular incisors showed
significant proclination (5.6°) and protrusion (1.5mm). The
movement of both the maxillary and mandibular molars was
not significantly different than the control group.
At the end of the post-‐retention period, only the

dentoalveolar changes remained significant, while no
significant sagittal or vertical skeletal change was present.
Overall, it can be concluded that the ForsusTM appliance is
effective in correcting Class II malocclusion, but its effect is
at the dentoalveolar level.
XbowTM (Crossbow)
The XbowTM Appliance, developed by Dr. Duncan
Higgins and introduced in 2006, is another appliance that
utilizes ForsusTM springs in Class II correction. The
Crossbow consists of a maxillary Hyrax expander and
ForsusTM springs mandibular labial and lingual bows are used
for anchorage. The Crossbow does not allow for simultaneous
use of full fixed orthodontic appliances. Instead, the goal of
the appliance is to correct the sagittal and transver se
dimensions in phase I, followed by full fixed orthodontic
appliances in phase II. In theory, phase II should be shorter
since the sagittal and transverse correction has already been
addressed.
32
Flores-Mir et al. (2009) investigated the effec ts of

the XBowTM in 67 consecutively treated patients (mean
age 11 years, 11 months pre-treatment) compared to an
untreated control group. The treatment time with the appliance
was an average of 4.5 months. The results were consistent
with other studies involving the ForsusTM appliance (Jones et
al., 2008; Franchi et al., 2011; Cacciatore et al., 2014).
Skeletally, the treated group showed mild restriction of

maxillary forward growth, with no changes in mandibular
advancement or vertical dimens ion. Overjet correction was
accomplished by lower incisor protrusion. The upper molars
were distalized while the lower molars were mesialized. A
study by Chana et al. (2013) showed that the effects of the
XBowTM appliance are consistent across different fa cial
growth patterns.
AdvanSyncTM
AdvanSyncTM appliance was developed by Dr. Terry

Dischinger (2010) in conjunction with OrmcoTM as a
treatment option for skeletal Class II patients. The appliance
is described by OrmcoTM as an evolution of the Herbst
appliance designed to advance th e mandible to Class I
occlusion within 6 to 9 months, while allowing for
simultaneous use of fixed orthodontic appliances.
The advantages of the AdvanSyncTM are claimed to be

shorter overall treatment times since fixed appliances are used
simultaneously and there is constant activation with no need
33
for patient compliance. Also, 50% shorter arms compared to

traditional Herbst appliances are said to provide more patient
comfort, more discrete appearance compared to other Class II
appliances and enhanced lateral jaw movements.
The effects of the AdvanSyncTM appliance have not

been well described in the literature. To date there has only
been one published study involving the appliance. Al -Jewair et
al. (2012) [ 2 2] investigated the effects of AdvanSyncTM in 30
patients treated during their skeletal growth spurt. The
comparison groups included 40 patients treated with MARA
and an untreated Class II control group (24 subjects) from the
University of Michigan growth study. Lateral cephalometric
radiographs were taken pre-treatment (T1), post-functional
appliance treatment (T2), and at fixed orthodontic
treatment completion (T3). When looking at changes from T1
to T2, AdvanSync TM restricted maxillary growth (SNA
decreased 1.6° compared to a 0.4° increase in the control
group and 0.5° decrease in the MARA group).
Total length of the mandible (measured from condylion

to gnathion) significantly increased with the AdvanSyncTM
(4.0mm) and MARA (4.5mm) compared to the untreated
controls (2.6mm). Ramus heights and anterior and posterior
facial heights were also significantly increased in both
treatment groups.
Dentoalveolar measurements revealed significant

retroclination of the maxillary incisors in the AdvanSyncTM
34
patients (8.4°) as well as non -significant eruption and

distalization of the maxillary molars. Mandibular dental
changes were similar in both treatment groups and significant
compared to controls. Mandibular incisors proclined 5.3° with
AdvanSyncTM and 5.4° with MARATM, while mandibular
molars mesialized 2.8mm with AdvanSyncTM and 3.0mm with
MARATM.
The post-orthodontic net treatment changes (T3 -T1)

showed a significant headgear effect in the AdvanSyncTM
group (SNA decreased 3.3° compared to 0.4° increa se in
controls and 1.1° decrease in MARA). Total mandibular length
was significantly increased with MARATM (8.1mm) but not
AdvanSyncTM (5.4mm) compared to controls (5.4mm).
There were no statistically significant maxillary dental

changes in both treatment groups compared to controls, while
mandibular incisors remained significantly proclined (>5.0°)
and mandibular molars remained mesialized (>3.0mm).
Overall, both MARA and AdvanSyncTM were found be
effective in normalizing Class II malocclusions.
The authors concluded that AdvanSyncTM appears to

show more headgear effect (maxillary restriction), but less
mandibular length enhancement compared to MARA. Both
appliances produced similar dentoalveolar changes.
35
Network Meta-Anal ysis Versus Paired Meta-Anal ysis
NETWORK META-ANALYSIS VERSUS PAIRED

META-ANALYSIS
Conventional meta-analysis on the treatment effects of

interventions is conducted on the effect size based on pairwise
head-to-head direct comparison, but data from direct
comparisons are relatively limited. [ 2 3 , 2 5] In contrast, the
necessity for indirect comparisons among various treatment
interventions of the same efficacy used in clinical practice has
increased in the recent times. Accordingly, an analytic
approach called Network Meta-Analysis (NMA) was
developed to include in the meta -analysis not only direct
comparisons, but also indirect comparisons based on logical
inference; in the latter case, no comparisons are actually
performed. [ 2 3 , 2 4 , 2 5 , 2 7 ]
Statistical approaches to NMA are largely classified as

Frequentist and Bayesian frameworks. Because part of NMA
has indirect, multiple comparisons, Bayesian framework
seems logically more valid, and 60 -70% of NMA studies have
taken a Bayesian approach. [ 2 6] However, if the prior
probability is not established in the study hypothesis,
Bayesian analysis poses many limitations for ordinary
researchers using NMA because the problem of establishing
prior probability is rather more complex than the problem of
testing the research hypothesis, that is, the original purpose of
the meta-analysis. In 1997, Bucher et al proposed an NMA
36
approach based on the frequentist framework using random -

effects models.
Since Bucher et al proposed the concept of indirect

treatment comparison (ITC) on treatment effect in 1997, newer
modes of statistics for working out th e meta-analysis known as
the ‘Multiple Treatment Comparison’ meaning comparison of
several treatments and ‘mixed treatment comparison’ (MTC)
meaning a combination of direct and indirect comparisons
have been introduced. 2 8 However, at present, NMA is
primarily used to mean a research effort to synthesize the
results obtained by comparing several studies which examined
multiple treatments.
ISPOR defines NMA as a comparison of the

effectiveness of 2 or more treatments and categorizes the
comparison type as MTC if the network geometry shows a
closed loop and ITC if it does not.
Relevant assumptions
Meta-analysis is a statistical methodology to
synthesize the results of several studies, and overall effect
size is valid only if various priori assu mptions are satisfied.
Furthermore, NMA requires stricter methodological, logical,
and statistical assumptions about similarity, transitivity and
consistency respectively. In NMA, whether each of these is
satisfied must also be examined.
37
Similarity
To compare among the clinical trial studies extracted for
analysis, similarity in the methodology used in the studies
must be assumed. Similarity is qualitatively assessed on each
of the selected articles from a methodological point of view
and is not a hypothesis to be tested statistically. To examine
similarity, the population, intervention, comparison, and
[ 29 , 3 0 ]
outcome (PICO) technique is used .
Specifically, similarity among the studies extracted for

analysis is examined for the following 4 items: clinical
characteristics of study subjects, treatment interventions,
comparison of treatments, and outcome measures. If the
similarity assumption is not satisfied, not only are the other
two assumptions negatively affected, but there is also a need
[ 3 0]
to check for the heterogeneity error .
Transitivity
Transitivity covers the validity of the logical inference,
while similarity relates to the methodological feasibility of
comparing. Suppose if direct comparisons of 3 drugs —A, B,
and C—treating the same illness found that A was more
effective than B, and B was more effective than C, then A can
be expected to be more effective than C, even though the two
were never directly compared. Such transitivity should be
satisfied for all cases in an NMA.
If the researcher compares the outcomes of direct and

indirect comparisons according to logical inference, the
38
satisfaction of the transitivity assumption can be examined

objectively. Statistical assessment of the outcomes of direct
[23,24,25]
and indirect comparisons is called consistency . If
inconsistency is observed, non-transitivity should be suspected
[ 2 7 , 2 8]
. If non-transitivity is suspected, the presence of effect
modifiers (confounders) influencing treatment effect should
[29,30,32]
first be examined .
Consistency
Consistency, an objective measure of transitivity, means
that the comparative effect sizes obtained through direct and
indirect comparisons are consistent. Hence, consistency is
[30,31]
statistically examined transitivity , and some researchers
[32,33]
call it coherence .
Network meta-analysis in orthodontics:

So far only three network meta -analysis have been
published in orthodontics. One comparing effectiveness of
pharmacological interventions used for orthodontic pain relief,
second one comparing both pharmacologic and non -
pharmacologic interventions for orthodontic pain relief and
the third one comparing various orthopaedic interventions for
maxillary protraction in skeletal class III patients.
Objectives of the present Network Meta-analysis:

The objectives of the current network meta -analysis is to
bring to light both the direct evidence as well as the indirect
evidence pertaining to efficacy of skeletally anchored fixed
functional appliances used for treating mandibular
39
retrognathism in skeletal class II patients and also to test the

hypothesis that skeletally anchored functional appliances have
more headgear effect on the maxilla compared to conventional
fixed functional appliances and their effectiveness in
minimizing the dento-alveolar side effects of conventional
fixed functional appliances.
40
Search Strategy And Study Selection
SEARCH STRATEGY AND STUDY SELECTION
Searching the databases

The following electronic databases were surveyed for an
open-ended search until February 2019: Pubmed, Cochrane
Central Register of Controlled Trials (CENTRAL), EMBASE,
LILACS, SCOPUS, Ovid-medline, Web of science and
Proquest. Language restrictions were not applied. Manual
searching was performed in Scielo, European Journal of
Orthodontics, Clinical Implant Dentistry and R elated
Research, Clinical Oral Implant Research, Quintessence
Publishing, Journal of Orthodontics, American Journal of
Orthodontics and Dentofacial Orthopedics, The Angle
Orthodontist, and Seminars in Orthodontics. Bibliographies of
the included full text articles were scanned for relevant
studies.
All the databases were searched by only one investigator

(S.A.) who repeated the search again on 11.09.2019.
Unpublished literature was searched electronically at the

ClinicalTrials.gov (www.clinicaltrials.g ov), and the National
Research Register (www.controlled -trials.com) using the terms
‘orthodontic’, ‘fixed functional appliance’, ‘anchorage’,
‘miniscrew’, and ‘miniplate’. Authors were contacted to
identify unpublished or ongoing clinical trials and to cla rify
data as required. Assessment of studies whether to include it
in the meta-analysis was decided by investigator (S.A.)
41
Search Strategy And Study Selection
Selection criteria
To be included in the network meta -analysis, original
studies needed to fulfill the following inclusion criteri a:
1) Population: Patients with a Class II malocclusion with
mandibular retrognathism and who are still in the growth
phase (CVMI stage 3-5);
2) Intervention: Skeletal anchored fixed functional
appliance (ie.) it can be either mini -plate anchored, or
mini-screw anchored
3) Comparisons: Studies that compared the outcomes of
different intervention techniques on cephalometric
radiographs values;
4) Outcomes: Studies that evaluated cephalometric
radiograph difference values (T2 -T1) between pre-
treatment (T1) and post-treatment(T2).
5) Study designs: Randomized clinical trials or non -
randomized clinical or retrospective studies without
language restrictions.
The following literature were excluded:

1) summaries, letters, case reports, comments, meta -
analyses, reviews, and other types of research literature;
2) duplicate publications and data not included with the
standardized mean difference (MD);
3) patients with a cleft lip and palate or other cranial
symptomatic abnormalities.
42
Prisma Flow Diagram
PRISMA Flow Diagram
43
Materials And Methods
MATERIALS AND METHODS
Data items and collection

Data extraction sheets were prepared, and data were
extracted independently by the two investigators (S.A and
A.S). The collected data included: 1. study design and setting;
2. demographic data including participants‟ chronological and
skeletal age, gender, sample size, and grouping; 3. detailed
description of the interventions, treatment duration, timing of
records uptake (T1, T2, etc.), and 4. outcomes, and outcome
data of interest, including antero -posterior skeletal
measurements and dento-alveolar measurements.
Pain and long-term effects were reported whenever

possible. We contacted two authors for further information.
They responded, except for one who requested to provide
values of standard deviations of mean differences (MDs) that
were not mentioned in the published paper. The study had only
correlation coefficient we had to impute standard deviation
ourselves. Another study used for indirect effects estimation
had only z statistic which we had to convert to r coefficient
and another presented only the confidence interval of the
treatment change. The missing standard deviations were
computed using formulae according to the Cochrane
Handbook.
44
Risk of bias/quality assessment in individual studies

The Cochrane Risk of Bias Tool of the Revman software
(Version5.3) was used to analyse the risk of bias inherent in
each of the randomized clinical trials (RCTs) included, with
seven criteria for assessment: random sequence generation,
allocation concealment, blinding of participants and personnel ,
blinding of assessors, incomplete outcome data, selective
reporting of outcomes, and other potential sources of bias. An
overall assessment of risk of bias (high, unclear, low) was
made accordingly. Studies with at least one criterion for a
high/unclear risk of bias were designated as having an overall
high/unclear risk of bias.
The Down and Black tool was used for assessment of

bias in the non-RCTs modified Downs and Black checklist was
given to both the investigators to score for bias in the non -
randomized clinical trials (CCTs). Any discrepancies from this
assessment would be resolved through discussion or a third
reviewer to reach a consensus.
Summary measures and approach to synthesis for the

paired meta-analysis
Heterogeneity of the included studies was assessed on
clinical and statistical levels. Clinical heterogeneity was
gauged from the treatment protocol used —particularly
participants‟ demographic characteristics, appliances used,
treatment durations, timing of data collection, and means of
analysis. Statistical heterogeneity was assessed from graphic
45
displays of the estimated treatment effects from the included

trials together with 95% confidence intervals (CIs).
A chi-square test was used for assessment of

heterogeneity where a P value below 0.1 meant significant
heterogeneity. I2 tests were also performed to quantify the
extent of heterogeneity with values of 25 per cent, 50 per cent,
and 75 per cent, corresponding to low, moderate, and high
heterogeneity, respectively.
Accordingly, we chose a random effects model based on

REMF method that was proposed by Raudenbush 2009 as the
principal method to estimate all the pooled estimates, because
of the expected heterogeneity caused by clinical and
methodological differences between th e included studies.
A Tau2 test was also used to assess heterogeneity in the

random-effects model. All P values were two-sided with α = 5
per cent, except for the test of between -studies or between-
subgroups heterogeneity (α = 10 per cent). In order to pool
data from the included studies that used cone beam computed
tomography (CBCT) as an analysis tool, standardized mean
differences (SMDs) and their corresponding 95% CIs were
used instead of the MDs as recommended by the Cochrane
Handbook.
46
Data analysis for the network meta-analysis

Transitivity was assessed using a network plot, which
described direct and indirect comparisons of multiple
interventions. Inconsistency between direct and indirect
sources of evidence was statistically assessed by node -
splitting analysis. If the p-value of the node-splitting analysis
was greater than 0.05, a consistency model was chosen. The
node-splitting models could not be performed when the
outcome lacked a direct or indirect comparison.
Thus, we used the analysis of heterogeneity to quantify

the degree of heterogeneity by I2 calculation. The values of I2
> 50% were considered to show heterogeneity across the trials.
To confirm the robustness of the results, sensitivity analysis
was performed to explore whether any factors might affect the
overall effect by excluding heterogeneous studies one at a
time, followed by recalculation of the overall effect.
Additionally, we used Surface Under the Cumulative

Ranking curve (SUCRA) to rank the different treatments and
define the best interventional strategy, and the larger value of
SUCRA implied a higher hierarchy. Publication bias was
assessed visually using the comparison -adjusted funnel. The
comparison-adjusted funnel plot was drawn using the
“netfunnel” command in Stata software (Version 16;
StataCorp, College Station, Texas).
47
Risk of bias across studies

If more than 8 studies were included in the meta -
analysis, funnel plots were presented to identify publication
bias. The overall quality of evidence (confidence in effect
estimates) for each of the main outcomes was rated by the
Grades of Recommendation, Assessment, Development, and
Evaluation (GRADE) approach. The GRADE profiler was used
to evaluate the methodological quality of the studies, the
directness of evidence, the inconsistency, the precision of
effect estimates, and the risk of publication bias. The GRADE
quality was interpreted as follows: „high quality‟ —further
research is very unlikely to change the confidence in the
estimate of effect; „moderate quality ‟—further research is
likely to have an important impact on the confidence in the
estimate of effect and may change the estimate; „low
quality‟— further research is very likely to have an important
impact on the confidence in the estimate of effect and is likely
to change the estimate; and „very low quality‟ —very uncertain
about the estimate.
Additional analyses
Sub-group analyses based on study design, anchorage
type and appliance type were planned to be presented along
with the paired meta-analysis. Meta-analyses were undertaken
using the STATA software (IC version 16; (StataCorp, College
Station, Texas).
48
Results Of Study Selection
RESULTS OF STUDY SELECTION
STUDY SELECTION AND CHARACTERISTICS

One thousand four hundred and sixty articles were
initially identified through electronic search, and five articles
were obtained through manual searching (Figure 1). After
reviewing titles and abstracts, 21 articles initially met the
inclusion criteria. After retrieval of the full text articles, three
studies were found to be case reports and thus were excluded.
One study included Herbst appliances with different forms of
anchorage as splints and bands only.
One study investigated the miniplate anchored Forsus

Fatigue Resistant Device (FFRD; 3M Unitek, Monrovia, CA)
without comparison to a control group. Thus, fifteen articles
were finally included in the qualitative analysis. All were
prospective clinical trials and retrospective studies. Six
[ 4 0 , 4 2 - 4 6]
studies were described as RCTs , five were CCTs
[ 4 7 , 4 8 , 5 2 ,5 4 , 5 5] [ 4 9 , 50 , 5 3]
, three were retrospective studies , one was
[51]
a preliminary study with no statistical analysis .
51
The preliminary study was excluded from the
[41]
quantitative analysis, together with one of the RCTs , which
analysed the overall acceptance of, and pain experienced by,
patients treated with the miniscrew anchored FFRD. It was the
only article reporting this outcome and thus could not b e
included in a meta-analysis.
49
Results Of Study Selection
[ 40 , 4 2 , 4 3 , 4 4 , 4 5 , 4 6 , 47 , 4 8 , 5 2 ,5 4 , 5 5 ]
Eleven studies were therefore
included in the quantitative analysis. The characteristics of the
[44,46]
included studies are presented in Table 1. Two studies
included an untreated control group in addition to the
skeletally anchored FFA and the conventional FFA. The data
from the untreated control groups are not included in this
review.
50
Characteristics Of Included Studies
CHARACTERISTICS OF INCLUDED STUDIES
MANNI ET.AL LUZI ET AL.

Study
2012 [ 4 4 ] 2013 [ 5 1 ]
Design and CCT/a private
RCT/not reported
setting practice in ROME
Only Lower
Skeletal Pancherz , incisors inclination
Outcomes
dento-alveolar and
ANB changes
2 failed mini
Failure of mini- No failure of mini- screws in 2
screws/miniplates screws different patients
(2/10)
T2 after the herbst T2 after fixed appl.
T2
cephalograms Ttt/ cephalograms
T1 before Herbst
T1 before Herbst
Time of T1 appliance/
cephalograms
cephalograms
Treatment
Test gp:7.6 Control Herbst phase: 9
duration
gp : 7.5 months
(months)
Skeletal
maturational Not reported Not reported
stage
Gender/age 27 males and 23 Both genders 11 to
(years) females 11.8±1.7 15
A metallic or elastic Connected
Means of
ligature (1000 g) to the hooks
attachment to
linked the mini- on Herbst
mini-
screws to metallic appliance with
screws/mini-
buttons bonded to the a 0.12-mm ss
plates
lower canines ligature
Site of mini- Between lower
screws/mini- Between lower 5 &6 4&5 or between
plates lower 5&6
Torque added to
No No
the lower wire
10;
50; Test Gp (25) and
No.of subjects Test gp (5):
Control gp (25)
Control gp (5)
51
Test gp: Test:

Herbst with Modified
reduced mandibular Herbst &
acrylic splint & mini miniscrew
Interventions
screws) Control gp: Control:
(Herbst with conventional
mandibular cast
acrylic splint). Herbst
- Bilateral
- Class II division
Angle Class II
1 - Increased
div. 1 ≥ 1/2 unit. -
overjet (5 to 12
Permanent or late
mm). - Absence of
Patients and mixed dentition
mild/severe
characterisistics - Absence of tooth
crowding of the
agenesis, second
lower arch
molars, transverse or
requiring
vertical
extractions
discrepancies
Only lower incisors Skeletal,

Outcomes
changes dento-alveolar
5 failed mini
screws but Failure of
Failue of mini-
their datasets mini screws
screws/mini
were excluded bilaterally in 2
plates
from the trial’s patients (4/32)
analyses.
T1 at the end
(T2) after
of fixed appliance
T2 Class I molar/
treatment/
cephalograms
cephalograms
T0 before active (T1) Just before
Time of T1 treatment/ insertion of
cephalograms FRD/ cephalograms
Test gp 1:
Herbst age: 6.5 ±} 1.97
Treatment test gp: Test gp 2:
duration 4.6 ±} 0.4 5.5 ±} 1.80
(months) Control gp: Control
4.7 ±} 0.8 Observation
5.6 ±} 2.19
52
Bremen et al. 2011

Study [48] Aslan et al. 2014 [47]
Design and CCT/ Private office CCT/Gazi university,
setting Germany Turkey
Skeletal
maturationl CVMI (CS 4-6) Hand wrist radiographs
stage
22 Males 26
MI gp (9 males, 3 females
females) / 12.0 ±} Test gp 1
Gender/age 1.6, control gp 13.68 ±} 1.09
(years) (5 males, 7 Test gp 2:
females) / 14.64 ±} 1.56
12.9 ±} 2.2 Control
14.13 •} 1.50
Active laceback
Indirect
(0.012”
anchorage
Means of ss ligature
0.018 X
attachment plus separating
0.025-ss wire
to mini- elastic)
between vertical
screws/mini- between the
slot of the
plates MI and the
L3 bracket &
lower Herbst
miniscrew slot
axle
Site of mini-
screws/mini- Between lower 5&6 Between lower 3 & 4
plates
Torque added to
the lower No No
wire
48;
26 Cl II div 1
24; (13 test gp 1 &
Test gp (12) 13 test gp 2)
No.of subjects
& Control gp 7 Cl II div. 2 (3
(12) test gp 1, 4 test
gp 2)
15 control
53
Test gp 1:
FFRD on
Test gp:
reaching
Easy-Fit
0.016X0.022
Jumper
ss with mini-screws Test
(modified
gp 2:
Herbst appliance)
FFRD on
Interventions with
reaching
mini screws
0.016X0.022
Control gp:
ss
Easy-Fit
Control gp:
Jumper (historical
no treatment
control)
(historical
control)
- Patients with - At least 1/2
only minor unit Class II
crowding or molar relation,
well aligned - horizontal or
arches - normal growth
Bilateral pattern,
Patients and
Class II molar minimum (up
characterisis
occlusion of at to 3 mm) or no
tics
least 1/2 cusp. crowding,
Absence no extracted or
of extractions, missing permanent
excess or teeth
lack of - Active growth
space period.
Study Elkordy et al.

2016 [ 4 2 ]
Design and RCT/University,Cairo,Egypt
setting
Outcomes Skeletal, dento-alveolar
Failue of mini- 3 mini screws(3/30)
screws/miniplates
T2 (T2) after edge to edge incisors / CBCT
images
Time of T1 (T1) Just before insertion
of FRD/ CBCT images
54
Treatment Test gp 1:
duration 5.34 ±} 1.29
(months) Test gp 2:
4.86 ±} 1.32
Control gp:
6.25 ±} 1.06
Skeletal MP3 method (MP3 G or H)
maturational
stage
Gender/age Females
(years) Test gp 1:
13.25 ±} 1.12
Test gp 2:
13.07 ±} 1.41
Control:
12.71 ±} 1.44
Means of .019X .025 ss
attachment to wire between
mini- miniscrew
screws/mini- head and
plates bonded to
labial surface
of L3s
Site of mini- Between lower 3& 4
screws/mini-
plates
Torque added to No
the lower wire
No.of subjects 43;
Test gp 1 (15)
Test gp 2 (16)
Control (12)
Interventions Test gp 1: FFRD on reaching
0.019X0.025 ss with mini screws
Test gp 2: FFRD on reaching
0.019X0.025 ss Control gp: no treatment
55
Patients and Females11–14 y of age

characterisistics - Skeletal Class II division 1 with a
deficient mandible (SNB <76)
- Horizontal or neutral growth
(MMP < 30) - Increased overjet with
Class II canine relationship (minimum of
Mandibular arch crowding less than 3 mm
- severe proclination of lower incisors
Study Elkordy et al. 2016 a [41]

Design and
RCT/ University,Cairo,Egypt
setting
Patient acceptance
Outcomes and pain
Failue of mini-
Not reported
screws/miniplates
T2 ---
Lateral cephalograms,
Time of T1
T1, T2 were not reported
Treatment
duration Test gp: 5.08 ±} 1.11 Control gp: 4.96 ±} 1.47
(months)
Skeletal
maturational Not reported
stage
Gender/age Females Test gp 1: 13.45 ±} 1.12
(years) Control gp: 13.07 ±} 1.41
Means of
attachment to
.019X .025 ss wire between
mini-
miniscrew head and bonded to labial surface of L3s
screws/mini-
plates
Site of mini-
screws/mini- Between lower 3 &4
plates
Torque added to
No
the lower wire
56
No.of subjects 32; Test gp (16) Control gp (16)

Test gp 1: FFRD on reaching
Interventions 0.019X0.025 ss with miniscrews
Control gp: FFRD on reaching 0.019X0.025 ss
Females 11–14 y of age
- Skeletal Class II division
1 with a deficient mandible (SNB
Patients and <76) - Horizontal or neutral growth
characterisistics - Minimum overjet of 5 mm with Class II
canine relationshipMandibular arch crowding less
than 3 mm
Study Manni et al 2016 a [ 5 3 ]

Design and setting RCT/ University,Cairo,Egypt
Patient acceptance
Outcomes
and pain
Failue of mini-
Not reported
screws/miniplates
T2 ---
Lateral cephalograms,
Time of T1
T1, T2 were no reported
Treatment duration Test gp: 5.08 ±} 1.11
(months) Control gp: 4.96 ±} 1.47
Skeletal maturational stage Not reported
Females Test gp 1:
Gender/age (years) 13.45 ±} 1.12 Control gp:
13.07 ±} 1.41
.019X .025 ss wire between
Means of attachment to
miniscrew head and bonded to
mini-screws/mini-plates
labial surface of L3s
Site of mini-screws/mini-
Between lower 3 &4
plates
Torque added to the lower
No
wire
32; Test gp (16) Control gp
No.of subjects
(16)
57
Test gp 1: FFRD on
reaching 0.019X0.025 ss with
Interventions miniscrews
Control gp: FFRD on reaching
0.019X0.025 ss
Females 11–14 y of age -
Skeletal
Class II division 1 with a
deficient mandible (SNB <76)
Patients and
- Horizontal or neutral growth
characterisistics
- Minimum
overjet of 5 mm with Class II
canine relationshipMandibular
arch crowding less than 3 mm
MANNI ET.AL EISSA ET AL.

Study
2016 [ 5 4 ] 2013 [ 4 0 ]
Design and
RCT/not reported CCT
setting
Only Lower
Skeletal Pancherz ,
Outcomes incisors inclination
dento-alveolar
and ANB changes
2 failed mini
screws in 2
Failure of mini- No failure of mini-
different
screws/miniplates screws
patients
(2/10)
T2 after fixed
T2 after the herbst
T2 appl. Ttt/
cephalograms
cephalograms
T1
T1 before Herbst before Herbst
Time of T1
cephalograms appliance/
cephalograms
Treatment
Test gp:7.6 Control Herbst phase:
duration
gp : 7.5 9 months
(months)
58
Skeletal
stage
Gender/age 27 males and 23 Both genders

(years) females 11.8±1.7 11 to 15
A metallic or
Connected
Means of elastic ligature
to the hooks
attachment to (1000 g) linked the
on Herbst
mini- mini-screws to
appliance with
screws/mini- metallic buttons
a 0.12-mm ss
plates bonded to the lower
ligature
canines
Site of mini- Between lower 4&5
Between lower 5
screws/mini- or between lower
&6
plates 5&6
Torque added to
No No
the lower wire
10;
50; Test Gp (25)
No.of subjects Test gp (5):
and Control gp (25)
Control gp (5)
Test gp:
Herbst with Test:
reduced mandibular Modified
acrylic splint & Herbst &
Interventions
mini screws) miniscrew Control:
Control gp: (Herbst conventional
with mandibular cast Herbst
acrylic splint).
59
- Bilateral
Angle Class II
- Class II division
div. 1 ≥ 1/2 unit.
1 - Increased
- Permanent
overjet (5 to 12
or late mixed
Patients and mm). - Absence of
dentition - Absence
characterisistics mild/severe
of tooth agenesis,
crowding of the
second molars,
lower arch requiring
transverse or
extractions
vertical
discrepancies
Turkkahraman
[43]
Study Elkordy 2019 Et.al
2016 [ 5 5 ]
Design and setting RCT/Egypt CCT
Only Lower
Skeletal , dento- incisors inclination
Outcomes
alveolar and
ANB changes
2 failed mini
screws in 2
Failure of mini- No failure of mini-
different
screws/miniplates screws
patients
(2/10)
T2 after fixed
T2 after the herbst
T2 appl. Ttt/
cephalograms
cephalograms
T1
T1 before Herbst before Herbst
Time of T1
cephalograms appliance/
cephalograms
Treatment Test gp:7.6 Herbst phase:
duration (months) Control gp : 7.5 9 months
Skeletal
stage
Gender/ 27 males and 23 Both genders
age (years) females 11.8±1.7 11 to 15
60
Connected
A metallic or
Means of to the hooks
elastic ligature
attachment to on Herbst
(1000 g) linked the
mini-screws/mini- appliance with
mini-screws to
plates a 0.12-mm ss
metallic butttons
ligature
Between lower 4&5
Site of mini- Between lower 5
or between lower
screws/mini-plates &6
5&6
Torque added to
No No
the lower wire
50; Test Gp (25) 10;
No.of subjects and Control gp Test gp (5):
(25) Control gp (5)
Test gp:
Herbst with Test:
reduced Modified
mandibular Herbst &
acrylic miniscrew
Interventions
splint & mini Control:
screws) Control conventional
gp: (Herbst with cast
mandibular acrylic Herbst
splint).
- Bilateral
- Class II division
Angle Class II
1 - Increased
div. 1 ≥ 1/2 unit.
overjet (5 to 12
- Permanent or late
mm). - Absence of
Patients and mixed dentition -
mild/severe
characterisistics Absence of tooth
crowding of the
agenesis, second
lower arch
molars, transverse
requiring
or vertical
extractions
discrepancies
61
Aboulazm et al.
Study
2009 [ 4 5 ]
CCT/university , Minia and

Design and setting
Alexandria and Egypt
Skeletal,
Outcomes
dento-alveolar
Failure of mini-
No failures
screws/miniplates
(T2)
T2 3 months after removal of
TFBC/ lateral cephalograms
(T1) Just before TFBC
Time of T1 insertion/ latera;
cephalograms
Treatment duration Test gp: mean 14 months
(months) Control gp: mean 16 months
Skeletal maturational
Not reported
stage
Both Test gp: 14 years
Gender/
2 months Control gp:
age (years)
13 years 10 months
Direct anchorage
Means of attachment to
of TFBC
mini-screws/mini-plates
on miniplates
Site of mini-screws/mini-
Miniplates at lower 3,4 region
plates
Torque added to the lower

No
wire
19; Test gp (9) Control gp

No.of subjects
(10)
62
Test gp: TFBC & mandibular

miniplates. Control gp:
Interventions TFBC on Upper and lower
archwires 19; Test gp (9)
Control gp (10)
Skeletal Class II Convex
skeletal profile due to
mandibular retrusion;
Minimum overjet 4 mm - No
Patients and
previous orthodontic
characterisistics
or growth modification
treatment - No signs of
TMD - No skeletal/ dental
asymmetry
63
Risk Of Bias Within Studies
RISK OF BIAS WITHIN STUDIES
The Cochrane Risk of Bias Tool was applied for

[ 4 0 , 4 2 , 4 3 , 4 4 , 4 5 , 47 ]
assessment of the six included RCTs .Of the
seven criteria, low risk of bias was given for the generation of
the random sequence, allocation concealment, completeness of
data reporting, and blinding of the assessors in the six studies.
Blinding of the clinicians and/or patients was not repo rted in
[ 4 4 , 4 5]
two studies and was judged as unclear risk of bias.
However, blinding of clinician and/or patients was considered
unlikely because of the nature of the clinical trial.
In addition, the outcomes that were investigated in the

trials were not likely to be influenced by the lack of blinding.
Selective reporting was suspected in the study by Manni et al
[ 5 2]
, which was judged to have an unclear risk of bias, because
the analysis that was used (Pancherz cephalometric analysis)
failed to include results for a key outcome (mandibular length
change) that would be expected to have been reported from
such a study.
[52]
For the same study , the sample comprised 50
patients, including 27 males and 23 females. The inclusion of
males and females in studies of Class II correction in subjects
with a circumpubertal age (11.8+/ -1.7 years) is considered of
questionable validity due to the already proven variations in
growth timing, pattern, and rate between males and females.
64
Risk Of Bias Within Studies
Accordingly, it was judged as h aving unclear risk of ‘other

[29]
sources of bias’. A study by Elkordy et al was judged as
having unclear risk of ‘other sources of bias’ because the
study did not report a baseline table of the participants.
In the present meta-analysis, the remaining included

[ 4 8 , 4 7 , 5 2 , 5 4 , 5 5]
studies were non-randomized CCTs . The modified
down and black criteria was used to evaluate the quality of
these studies. All studies were found to be of moderate
quality.
65
Risk Of Bias Assessment For Randomised Clinical Trials
RISK OF BIAS ASSESSMENT FOR RANDOMISED

CLINICAL TRIALS
66
Risk Of Bias Assessment Of The Included Non-Randomized Trials
RISK OF BIAS ASSESSMENT OF THE INCLUDED NON -

RANDOMIZED STUDIES USING THE DOWNS AND
BLACK CHECKLIST
Bre Man
Celkikogl
Aboulaz Aslan et. al, men ni et
u et.al
m, 2009 2011 et.al al
[ 4 5] [ 4 7] 2016
2014 [ 5 0] 2014
[ 4 8] [ 5 2]
Q1: Aim
clearly Yes Yes Yes Yes yes
described?
Q2:
Outcomes
Yes Yes Yes Yes Yes
clearly
described?
Q3: Patients
characteristi
cs clearly Yes Yes Yes Yes Yes
described?
Q4:
Intervention
s clearly Yes Yes Yes Yes Yes
described?
Q5:
Principal
confounders
Yes Partially Yes No Yes
clearly
described?
67
Risk Of Bias Assessment Of The Included Non-Randomized Trials
Q6: Main findings

Yes Yes Yes Yes Yes
clearly described?
Q7: Random
variability for main Yes No No No No
outcome provided?
Q8: Adverse events
Yes Yes Yes Yes Yes
reported?
Q9: Loss-to-follow
Yes Yes Yes No No
up reported?
Q10: Actual p-value

Yes Yes Yes Yes Yes
reported?
Q11: Sample asked

to participate
Yes Yes Yes Yes Yes
representative of
the population?
Q12: Sample agreed
to participate
Yes Yes Yes Yes Yes
representative of
the population?
Q13: Staff
participating
representative of Yes Yes Yes Yes Yes
the patients’
environment?
Q14: Attempt to
No No No No No
blind participants?
Q15: Attempt to No
No No No No
blind assessors?
Q16: Data dredging

results stated
No No No No No
clearly?
68
Results Of Meta-Analysis, And additional Anal yses
RESULTS OF META-ANALYSIS, AND

ADDITIONAL ANALYSES
SKELETAL EFFECTS
Skeletal effects were reported in nine of the studies
[ 4 0 , 42 , 4 3 , 4 5 , 4 7 , 49 , 5 0, 5 4 , 5 5 ] .
included in the quantitative analysis A
total of 83 patients were studied (40 were from the
intervention group receiving FFA and skeletal anchors, and 33
received FFA alone). Results of the meta -analysis revealed no
statistically significant difference regarding t he mandibular
length between the skeletal and conventional anchorage
groups, where the overall effect P value = 0.09 [SMD = 1.98
(95% CI −0.11 to 4.07)].
The SNB angle (which shows the relation between the

mandible and the cranial base) was only assessed in the afore
mentioned three studies . [ 2 6 , 2 9 , 3 1]
Results from meta-analysis
showed no significant difference between the studied groups
in the changes in the SNB angle [SMD = 0.47 (95% CI −0.06
to 1.00)].
The heterogeneity was too high for thi s variable (I2 =

79.80 per cent). Regarding maxillary skeletal effects, no
significant differences between the studied groups [SMD = 0
(95% CI −0.23 to 0.23)]. This variable had a heterogeneity of
0 percent.
69
Results Of Meta-Analysis, And additional Anal yses
DENTO-ALVEOLAR CHANGES
Dento-alveolar changes that reported inclination changes
[ 4 0 , 4 2 , 4 3 , 44 , 4 5 , 4 7, 4 8 , 4 9 , 5 2 , 5 3 , 5 4 , 5 5]
in the lower incisors were taken
into consideration. As far as the dento -alveolar changes are
concerned, for the lower incisors inclination changes 375
patients were studied (194 for the skeletal anchorage and 181
for conventional FFA).
A statistically significant reduction of the lower incisor

proclination [SMD = −1.74, (95% CI −2.49 to −0.99)] was
resulted from the addition of skeletal anchors to FFA with
heterogeneity 89%. The upper incisor inclination was shown to
be significantly more reduced with the use of skeletal anchors
[SMD = −1.04 (95% CI −1.57 to −0.51)]. This outcome had
the advantage of acceptable heterogeneity after pooling of the
subgroups’ data (I2 = 20 per cent).
The results of the included studies varied considerably

and various factors influenced the treatment results. Details of
the subgroups analyses on the basis of the type of skeletal
anchorage, FFA used and the study design are represented in
the respective tables, and the anchorage type seemed to
account for the heterogeneity of most of the results; where the
use of miniplates anchorage yielded more skeletal mandibular
effects than the use of miniscrews with FFA. Only one study
[ 4 2]
used CBCT for analysis of the treatment effects. All the
results remained the same after exclusion of the study using
CBCT from the meta-analysis.
70
Paired Meta-Anal ysis Summary
PAIRED META-ANALYSIS SUMMARY
71
Paired Meta-Anal ysis Summary
72
Sub-Group Anal ysis
SUB-GROUP ANALYSIS
a) SNB CHANGES
1) BASED ON STUDY DESIGN:
73
Sub-Group Anal ysis
2) BASED ON ANCHORAGE:
3) BASED ON APPLIANCE TYPE:
74
Sub-Group Anal ysis
B) MANDIBULAR LENGTH CHANGES:
1) STUDY DESIGN:
75
Sub-Group Anal ysis
2) TYPE OF ANCHORAGE:
76
Sub-Group Anal ysis
3) BASED ON APPLIANCE TYPE:
77
Sub-Group Anal ysis
C) MANDIBULAR INCISOR PROCLINATION:
78
Sub-Group Anal ysis
2) BASED ON ANCHORAGE TYPE:
79
Sub-Group Anal ysis
C) TYPE OF APPLIANCE:
80
Publication Bias
PUBLICATION BIAS
FUNNEL PLOT FOR SNB CHANGES:
81
Publication Bias
FUNNEL PLOT FOR MANDIBULAR LENGTH

CHANGES:
82
Publication Bias
FUNNEL PLOT FOR MANDIBULAR INCISOR

PROCLINATION:
83
Publication Bias
PUBLICATION BIAS
A funnel plot is used to visually explore “small -study

effects”. The term small-study effects (Sterne, Gavaghan, and
Egger 2000) is used in meta-analysis to describe the cases
when the results of smaller studies differ systematically from
the results of larger studies. For instance, smaller studies
often report larger effect sizes than the larger studies. One of
the reasons for the presence of small -study effects is
publication bias, also referred to as reporting bias.
The funnel plot (Light and Pillemer 1984) is a scatterplot

of the study-specific effect sizes against measures of study
precision. This plot is commonly used to explore publication
bias. In the absence of publication bias, the shape of the
scatterplot should resemble a symmetric (inverted) funnel.
Here we have used contour enhanced funnel plots to

check for publication bias. Peters et al. (2008) (also see
Palmer et al. [2016]) suggest that contour lines of statistical
significance (or significance contours) be added to the funnel
plot. These “contour-enhanced” funnel plots are useful for
determining whether the funnel -plot asymmetry is potentially
caused by publication bias or is perhaps due to other reaso ns.
The contour lines that correspond to certain significance
levels (P = 0.01, 0.05, 0.1, etc.) of tests of zero effect sizes
are overlaid on the funnel plot. Publication bias is suspect if
there are studies, especially smaller studies, that are missing
84
Publication Bias
in the nonsignificant regions. Otherwise, other reasons may

explain the presence of the funnel -plot asymmetry.
PUBLICATION BIAS IN THE CURRENT META -

ANALYSIS
When we consider the SNB changes, most of the studies
with precise, larger effect sizes fall withi n the darkest grey
region in the contour enhanced funnel plot (P value greater
than 15%). So most of the studies are of lesser statistical
significance. Whereas the studies which good levels of
statistical significance don’t have larger effect sizes (P val ue
between 1-5%).
When we consider the effect of skeletally anchored fixed

functional appliances on mandibular incisor inclination most
of the studies with larger effect sizes had good levels
statistical significance (P value between 1 -5%).
When we take effects on mandibular length, most of the

studies had good effect sizes but were within the darkest grey
region which signifies lack of statistical significance ( P value
greater than 15%).None of the funnel plots were symmetrical
so it signifies that the studies have widely varying effect sizes
with highly varying levels of statistical significance indicating
publication bias
85
Results of network meta-Anal ysis
NETWORK MAP - SNB CHANGES
86
CONTRIBUTION PLOT – SNB CHANGES
87
PREDICTIVE INTERVAL PLOT – SNB CHANGES
88
NET FUNNEL PLOT – SNB CHANGES
89
RESULTS OF NETWORK META -ANALYSIS (SNB

CHANGES)
Three indirect linkages were detected in the network plot

for SNB changes in between forsus FRD vs mini -screw herbst,
mini-screw herbst vs mini-plate forsus and mini-screw forsus
vs mini-plate forsus. In the net funnel plot 5 stud ies had
moderate standard error of 0-0.5 and 4 studies have standard
error less than 0.5. In the contribution plot among the indirect
effect’s comparison most of the effect sizes were contributed
by comparison between mini-plate forsus and mini-screw
forsus.
From the contribution interval plot we were able to infer

that mini-screw herbst vs forsus comparison had overall effect
sizes greater than other interventions. So mini -screw herbst
produced more pronounced changes in SNB when compared
with other interventions (-0.53, CI = -1.84,0.79).
90
Strengths And Limitations
STRENGTHS AND LIMITATIONS
The current review search strategy had no language

restrictions, included multiple electronic database searches,
and involved a detailed manual searching process. We
carefully followed specific guidelines at every stage as far as
possible. However, the evidence retrieved from this systematic
review has to be taken with caution where data were retrieved
from RCTs (only six were included, one of which reported
only the primary outcome of the review), and nonrandomized
prospective CCTs.
Lack of randomization of patients to different

interventions in clinical trials is believed to add a high risk of
selection bias. However, we believe that the prospective CCTs
represent more realistic scenarios in the context of day -to-day
clinical practice, which could possibly strengthen the
applicability of the outcomes.
A random-effects model was used for data synthesis,

since the included studies were RCTs and CCTs. The goal of
the random-effects model is to estimate the mean effect across
the included studies without having the overall estimate overly
influenced by any of them. Further studies are needed that
should include a benefit‒risk ratio analysis for surgical
intervention vs skeletal anchorage in circumpubertal patients
for the correction of skeletal Class II ma locclusion.
91
Strengths And Limitations
A limitation of the meta-analyses reported in this review

is that results were represented as SMD. The SMD was used in
accordance with the recommendations of the Cochrane
Handbook, to be able to combine the data from studies using
CBCT with those using lateral cephalograms. No data are
currently available rejecting the reliability of combining both
data sets. On the contrary, data combination was supported by
the reported finding that measurements from CBCT
cephalograms were not significantly different from those from
conventional two-dimensional radiographic images.
An important limitation of the included studies was the

variable timing of the records obtained. Some studies had T2
records obtained after the end of fixed appliance therapy and
[43]
not immediately after FFA treatment, and one study had T2
records taken three months after the FFA phase. This could
threaten the validity of the results, because the fixed appliance
phase, which was not standardized in the incl uded studies,
could have an effect on the magnitude of change in the
[ 4 3]
outcomes of interest .
Another important limitation in the included studies is

that most of them did not define the skeletal maturational
stage of the included subjects. As the chronological age was
previously proven to be inaccurate, the skeletal age should
have been used instead. Lack of gender specification is
another drawback in the included studies, since the genders
have different growth rates and maturation timings.
92
Conclusion Of The Study
CONCLUSIONS
According to existing evidence, the following

conclusions can be drawn regarding the effectiveness of the
use of skeletal anchors in conjunction with fixed functional
appliances:
1. The present evidence was inadequate to propose a
conclusion regarding the effects of the use of different
types of skeletal anchorage systems in conjunction with
fixed functional appliances and difficult to extrapolate
the pronounced effects in correcting mandibular
retrognathism.
2. The magnitude of the skeletal corrections achieved by
FFA in conjunction with SAS was marginal when
compared to conventional FFA in skeletal Class II
malocclusion.
3. Combined use of FFA and SAS reduced the anchorage
loss in the mandibular arch by preventing the lower
incisor proclination.
4. Pain and discomfort experienced by the patients with
the use of FFA & SAS could not be assessed properly
due to lack of literature at present.
5. No evidence is available to assess the lo ng-term effects
of the use of skeletal anchorage in conjunction with
FFA.
93
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Supplementary Materials
SUPPLEMENTARY MATERIALS
PRISMA CHECKLIST FOR CONDUCTING A
SYSTEMATIC REVIEW INVOLVING A NETWORK
META-ANALYSIS (2015)
PRISMA NMA Checklist of Items to Include When Reporting A Systematic

Review Involving a Network Meta-analysis
Section/Topic Item Checklist Item

#
TITLE
Title 1 Identify the report as a systematic review incorporating a
network meta-analysis (or related form of meta-analysis).
ABSTRACT
Structured 2 Provide a structured summary including, as applicable:
summary Background: main objectives
Methods: data sources; study eligibility criteria, participants,
and interventions; study appraisal; and synthesis methods, such
as network meta-analysis.
Results: number of studies and participants identified;
summary estimates with corresponding confidence/credible
intervals; treatment rankings may also be discussed. Authors
may choose to summarize pairwise comparisons against a
chosen treatment included in their analyses for brevity.
Discussion/Conclusions: limitations; conclusions and
implications of findings.
Other: primary source of funding; systematic review
registration number with registry name.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is
already known, including mention of why a network meta-
analysis has been conducted.
Objectives 4 Provide an explicit statement of questions being addressed, with
reference to participants, interventions, comparisons, outcomes,
and study design (PICOS).
METHODS
Protocol and 5 Indicate whether a review protocol exists and if and where it can
registration be accessed (e.g., Web address); and, if available, provide
registration information, including registration number.
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up)
and report characteristics (e.g., years considered, language,
publication status) used as criteria for eligibility, giving rationale.
Clearly describe eligible treatments included in the treatment
105
network, and note whether any have been clustered or merged

into the same node (with justification).
Information sources 7 Describe all information sources (e.g., databases with dates of
coverage, contact with study authors to identify additional
studies) in the search and date last searched.
Search 8 Present full electronic search strategy for at least one database,
including any limits used, such that it could be repeated.
Study selection 9 State the process for selecting studies (i.e., screening, eligibility,
included in systematic review, and, if applicable, included in the
meta-analysis).
Data collection 10 Describe method of data extraction from reports (e.g., piloted
process forms, independently, in duplicate) and any processes for
obtaining and confirming data from investigators.
Data items 11 List and define all variables for which data were sought (e.g.,
PICOS, funding sources) and any assumptions and
simplifications made.
Geometry of the S1 Describe methods used to explore the geometry of the treatment
network network under study and potential biases related to it. This
should include how the evidence base has been graphically
summarized for presentation, and what characteristics were
compiled and used to describe the evidence base to readers.
Risk of bias within 12 Describe methods used for assessing risk of bias of individual
individual studies studies (including specification of whether this was done at the
study or outcome level), and how this information is to be used
in any data synthesis.
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference
in means). Also describe the use of additional summary measures
assessed, such as treatment rankings and surface under the
cumulative ranking curve (SUCRA) values, as well as modified
approaches used to present summary findings from meta-
analyses.
Planned methods of 14 Describe the methods of handling data and combining results of
analysis studies for each network meta-analysis. This should include, but
not be limited to:
 Handling of multi-arm trials;
 Selection of variance structure;
 Selection of prior distributions in Bayesian analyses;
and
 Assessment of model fit.
Assessment of S2 Describe the statistical methods used to evaluate the agreement
Inconsistency of direct and indirect evidence in the treatment network(s)
studied. Describe efforts taken to address its presence when
found.
Risk of bias across 15 Specify any assessment of risk of bias that may affect the
studies cumulative evidence (e.g., publication bias, selective reporting
within studies).
Additional analyses 16 Describe methods of additional analyses if done, indicating
which were pre-specified. This may include, but not be limited
to, the following:
 Sensitivity or subgroup analyses;
 Meta-regression analyses;
 Alternative formulations of the treatment network; and
 Use of alternative prior distributions for Bayesian
analyses (if applicable).
106
RESULTS†
Study selection 17 Give numbers of studies screened, assessed for eligibility, and
included in the review, with reasons for exclusions at each stage,
ideally with a flow diagram.
Presentation of S3 Provide a network graph of the included studies to enable
network structure visualization of the geometry of the treatment network.
Summary of S4 Provide a brief overview of characteristics of the treatment
network geometry network. This may include commentary on the abundance of
trials and randomized patients for the different interventions and
pairwise comparisons in the network, gaps of evidence in the
treatment network, and potential biases reflected by the network
structure.
Study 18 For each study, present characteristics for which data were
characteristics extracted (e.g., study size, PICOS, follow-up period) and provide
the citations.
Risk of bias within 19 Present data on risk of bias of each study and, if available, any
studies outcome level assessment.
Results of 20 For all outcomes considered (benefits or harms), present, for
individual studies each study: 1) simple summary data for each intervention group,
and 2) effect estimates and confidence intervals. Modified
approaches may be needed to deal with information from larger
networks.
Synthesis of results 21 Present results of each meta-analysis done, including
confidence/credible intervals. In larger networks, authors may
focus on comparisons versus a particular comparator (e.g.
placebo or standard care), with full findings presented in an
appendix. League tables and forest plots may be considered to
summarize pairwise comparisons. If additional summary
measures were explored (such as treatment rankings), these
should also be presented.
Exploration for S5 Describe results from investigations of inconsistency. This may
inconsistency include such information as measures of model fit to compare
consistency and inconsistency models, P values from statistical
tests, or summary of inconsistency estimates from different parts
of the treatment network.
Risk of bias across 22 Present results of any assessment of risk of bias across studies for
studies the evidence base being studied.
Results of 23 Give results of additional analyses, if done (e.g., sensitivity or
additional analyses subgroup analyses, meta-regression analyses, alternative network
geometries studied, alternative choice of prior distributions for
Bayesian analyses, and so forth).
DISCUSSION
107
Summary of 24 Summarize the main findings, including the strength of evidence

evidence for each main outcome; consider their relevance to key groups
(e.g., healthcare providers, users, and policy-makers).
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias),
and at review level (e.g., incomplete retrieval of identified
research, reporting bias). Comment on the validity of the
assumptions, such as transitivity and consistency. Comment on
any concerns regarding network geometry (e.g., avoidance of
certain comparisons).
Conclusions 26 Provide a general interpretation of the results in the context of
other evidence, and implications for future research.
FUNDING
Funding 27 Describe sources of funding for the systematic review and other
support (e.g., supply of data); role of funders for the systematic
review. This should also include information regarding whether
funding has been received from manufacturers of treatments in
the network and/or whether some of the authors are content
experts with professional conflicts of interest that could affect
use of treatments in the network.
PICOS = population, intervention, comparators, outcomes, study design.
* Text in italics indicates wording specific to reporting of network meta-analyses that has
been added to guidance from the PRISMA statement.
108

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CAN DIFFERENT FORMS OF

SKELETAL ANCHORAGE SYSTEMS

MEENAKSHI ACADEMY OF HIGHER EDUCATION &RESEARCH

Dr.R. Devaki Vijayalakshmi, M.D.S.,

MEENAKSHI ACADEMY OF HIGHER EDUCATION &RESEARCH

Dr. A. NANDAKUMAR, M.D.S., Di p.I.B (ORTHO) ,

MEENAKSHI ACADEMY OF HIGHER EDUCATION &RESEARCH

I would like to acknowledge and extend my earnest

I am indebted to my guide and mentor , Dr.R. Devaki

I express my deepest gratitude to my professors Dr. Uma

I am profoundly grateful to Dr. Nagachandran, Dr.

I express my gratitude for Professor Anna Chaimani

I wish to gratefully acknowledge the v alue and help of

Dr. SELVA AROCKIAM .A

S NO. TITLE PAGE NO

6. PRISMA FLOW DIAGRAM 43

7. MATERIALS AND METHODS 44

8. RESULTS OF STUDY SELECTION 49

10. RISK OF BIAS WITHIN STUDIES 64

15. SUB-GROUP ANALYSIS 73

16. PUBLICATION BIAS 81

RESULTS OF THE NETWORK

19. CONCLUSION OF THE STUDY 93

21. SUPPLEMENTARY MATERIALS 105

Skeletal class II malocclusion is one of the most

Both removable and fixed functional appliances are

The era of fixed functional appliances started with the

as the non-compliance fixed functional appliances as they

The fixed functional appliances can be broadly classified

The recent systematic review regarding the effectiveness

Recently skeletally anchored f ixed functional appliances

to enhance the skeletal effects of these fixed functional

Therefore the aim of this current network -meta analysis

The genetic component of Class II malocclusion has been

Various environmental and physiological factors are also

toward Class II malocclusion, likely due to backward rotation

Similar findings were noted by Melsen et al. (1987)

Prolonged digit sucking has also been known to

Finally, Solow et al. (1998) found that children who

Several cephalometric studies have aime d to characterize

McNamara (1981) reviewed previous studies and

McNamara (1981) found that mandibular skeletal retrusion

Growth in Individuals with Class II Malocclusion

The cervical vertebral maturation method, as described

The authors concluded that Class II skeletal disharmony

These conclusions had already been drawn by Buschang

and II subjects. They found that anteroposterior relationships

Current Evidence on Treatment Timing

Lateral cephalograms were available at the start of

long-­‐term observation (mean of 8.6 years afte r start of

Therefore, the authors concluded that treatment of Class

Current Evidence on the Efficacy of Growth

Several factors, including the etiology of the

appliances in which one of the mechanisms of Class II

Removable or fixed functional appliances are designed to

Histological studies involving labora tory animals have

However, many investigators (Schulof et al., 1982;

in the permanent dentition, do not show any significant

Compliance Based Treatment Modalities

Removable Functional Appliances

The Bionator was designed and introduced by Balters in

The authors found that the Bionator was able to produce

Similar results had been previously drawn by Malta et al.

long-‐term observation (mean of 8.6 years afte r start of