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A Systematic Review and Meta-Analysis
A Systematic Review and Meta-Analysis
A Systematic Review and Meta-Analysis
Scientific Section
Journal of Orthodontics
Abstract
Introduction: The purpose of this study was to seek and summarise the Bolton overall index (OI) and anterior index
(AI) regarding normal occlusion and Angle’s malocclusion according to gender, and to assess if these indices support
Bolton’s standards as general references.
Methods: PubMed, LILACS, Embase, CENTRAL and Google Scholar databases were searched up to June 2019
(CRD42018088438). Non-randomised clinical studies, published in English and assessing Bolton’s OI and/or AI in normal
occlusion and Angle’s malocclusion groups, were included. OI and AI means, sample size and SDs were collected. The
National Heart, Lung, and Blood Institute’s Quality Assessment Tool for Observational Cohort and Cross-Sectional
Studies was used to assess the risk of bias. Pairwise random-effects and multilevel Bayesian network meta-analyses were
used to synthesise available data.
Results: Fifty-three observational studies were included (11,411 participants; 3746 men, 4430 women; 15 studies lacked
gender information). For normal occlusion, pooled estimates for OI and AI means were 91.78% (95% confidence interval
[CI] = 91.42–92.14; I2 = 92.87%) and 78.25% (95% CI = 77.87–78.62; I2 = 90.67%), respectively. We could identify in
Angle’s Class III patients meaningful OI and AI mean deviations from normal occlusion (0.76, 95% credible interval [CrI]
= 0.55–0.98 and 0.61, 95% CrI = 0.35–0.87, respectively), while in Class II patients we found a meaningful mean deviation
from normal occlusion only for OI (−0.28, 95% CrI = −0.52–−0.05). Concerning gender impact, male patients presented
higher OI (0.30, 95% CI = 0.00–0.59) and AI (0.41, 95% CI = 0.00–0.83) mean values than female patients in Class I.
Conclusion: Normal occlusion OI and AI mean values differ from Bolton’s original values. Class II division 2, for OI
mean values, and Class III, for both OI and AI, are proportionally larger than normal occlusion patients. Gender had
almost no impact on teeth mesiodistal proportion.
Keywords
tooth size, tooth size discrepancy, Bolton ratios, meta-analysis, systematic review
Date received: 16 February 2019; revised: 14 September 2019; accepted: 13 October 2019
The concept of a proportional balance between the mesi- and malocclusions in multiple populations (Endo et al., 2008;
odistal sums of maxillary and mandibular teeth may have Kumar et al., 2013; Manopatanakul and Watanawirun, 2011;
arisen from the beginnings of dental articulation theories. O’Mahony et al., 2011; Ricci et al., 2013; Santoro et al., 2000),
Bonwill (1899) stated that ‘Nature left to herself, always there is no consensus about its correlation with the different
brings proposition. . . the proportions of upper teeth to the types of malocclusions classified by Angle.
lower teeth are as exact as any’. This nature theory was per-
vasive in early orthodontics and was seen in the strict non- Objectives
extraction period started by Edward Angle. The mesiodistal
widths of teeth were initially investigated by Black (1902). No study has investigated, in an evidence-based manner,
Historically, Young (1923) was the first to study the inter- normative values for mesiodistal proportions of normal
maxillary tooth width ratio in occlusion and, thereafter, occlusion and Angle’s malocclusion, from worldwide
Gilpatric (1923) found that the upper arch was 8–12 mm researched data. For that reason, the primary aim of this sys-
wider than the lower arch. Over the years, to account and be tematic review was to synthesise worldwide estimates for
aware of this proportion, several methods have been sug- normal occlusion OI and AI mean values, and to compare
gested to assess the interarch tooth size relationship (Bolton, such values with those proposed by Bolton, to address the
1968, 1962; Kesling, 1945; Neff, 1949, 1957), but Bolton’s following focused question: Are current standards globally
ratios have become widely applied in orthodontics research. appropriate? Second, we aimed to compare the obtained val-
In this regard, the overall index (OI) is the percentage ues between gender for normal occlusion and each malocclu-
obtained by summing the widths of the 12 mandibular teeth sion type. Finally, we intended to obtain OI and AI pooled
divided by the sum of the widths of the 12 maxillary teeth. estimates for each type of Angle’s malocclusion and com-
The anterior index (AI) is the percentage obtained by sum- pare them against the obtained values for normal occlusion
ming the widths of the six mandibular anterior teeth divided under a multilevel Bayesian network meta-analysis model.
by the sum of the widths of the six maxillary anterior teeth
(Bolton, 1958, 1962). On average, the OI was 91.3% (± Materials and methods
1.91) and AI was 77.2% (± 1.65); these promptly became
standard values in the diagnosis and guidance of orthodon- Protocol and registration
tic treatments. The protocol for this systematic review was made a priori,
Over time, Bolton’s analyses have proved to be clini- agreed upon by all authors and registered in PROSPERO
cally useful in extreme teeth size discrepancies. However, (ID number: CRD42018088438). This systematic review
without neglecting its value, its methodology and conclu- was conducted according to the Cochrane Handbook
sions should be carefully evaluated. First, these studies had (Higgins et al., 2003) and reported according to the
a potential selection bias since the population was not spec- PRISMA statement (Preferred Reporting Items for
ified, particularly concerning race, ethnicity and gender. Systematic Reviews and Meta-Analyses) (Liberati et al.,
Second, although the author has stated that his ratios were 2009) (Supplement S1) and its extension for abstracts
based on 55 cases ‘where excellent occlusions existed’, 44 (Beller et al., 2013).
models were from patients who underwent orthodontic
treatment and only 11 were untreated (Bolton, 1958).
Eligibility criteria
According to the literature, teeth size variation is ethnic-
and gender-related (Bishara et al., 1989; Black, 1902; Studies were eligible for inclusion based on the following
Hattab et al., 1996; Lavelle, 1972; Santoro et al., 2000; criteria:
Smith et al., 2000), pointing out an anthropological signifi-
cance with genetic underpinnings (Dempsey and Townsend, 1. Randomised and non-randomised (cohort/longitudi-
2001; Hughes et al., 2000). For this reason, the application nal or cross-sectional studies);
of Bolton analyses and the proposed standard values for a 2. English language studies;
harmonious dentition might not be valid for other popula- 3. Human study population;
tions. Therefore, this population-based variation has 4. Determined Bolton’s analysis with normal occlusion
become a subject of interest for many researchers, resulting and/or Angle’s Class I, Class II, Class II division 1,
in several attempts to establish normative standards for dif- Class II division 2 and/or Class III, in patients with-
ferent racial groups (Al-Khateeb and Abu Alhaija, 2006; out previous orthodontic treatment;
Al-Omari et al., 2008; Bernabé et al., 2004; Lavelle, 1972; 5. Dental casts or digital models with all permanent
Santoro et al., 2000). teeth from the maxillary and mandibular right first
Another relevant question is the relationship between the molar to the left first molar completely erupted,
tooth size discrepancy for both OI and AI and the various types without tooth deformities (Scheid and Weiss, 2012),
of Angle’s malocclusion. Although several investigators have mesiodistal restorations, caries or abrasion that
emphasised the relationship between Bolton ratio discrepancies could affect the teeth’s mesiodistal diameter;
Machado et al. 9
2010; Kansal et al., 2012; Lavelle, 1972; Lee et al., 2011; 2013; Kansal et al., 2012; Lee et al., 2011; Machado et al.,
Lombardo et al., 2016; Machado et al., 2018; Manopa- 2018; Nie and Lin, 1999; Saritha et al., 2017; Ta et al.,
tanakul and Watanawirun, 2011; Maurya et al., 2015; Mol- 2001) and seven determined the sample size (Bugaighis
labashi et al., 2019; Mulimani et al., 2018; O’Mahony et al., et al., 2015; Cançado et al., 2015; Celikoglu et al., 2013;
2011; Oktay and Ulukaya, 2010; Patel et al., 2017; Ricci Ismail and Abuaffan, 2015; McSwiney et al., 2014; Shahid
et al., 2013; Sakoda et al., 2016; Shahid et al., 2016; Shastri et al., 2016; Ta et al., 2001). Strategies to minimise the
et al., 2015; Škrinjarić et al., 2018; Uysal et al., 2005; Vela potential sources of bias were not clearly described in most
et al., 2011; Zerouaoui et al., 2014). Five were of low qual- articles. Twelve articles fail to explain how they evaluated
ity (Anil and Monika, 2010; Devi et al., 2017; Kumar and intra- and/or inter-examiner errors or random error determi-
Chitra, 2017; Mirzakouchaki et al., 2007; Subbarao et al., nation (Anil and Monika, 2010; Devi et al., 2017; Kachoei
2014) and, consequently, were excluded. et al., 2011; Kansal et al., 2012; Kumar et al., 2015; Lee
Moreover, two articles were excluded (Kachoei et al., et al., 2011; Mirzakouchaki et al., 2007; Mollabashi et al.,
2011; Poosti and Jalali, 2007) due to abnormal SD values 2019; Mulimani et al., 2018; Poosti and Jalali, 2007;
(10 and 100 times lower than the mean value of SD pre- Škrinjarić et al., 2018; Subbarao et al., 2014).
sented in the remaining studies, respectively) (Supplements
S7–S10). These unusual SD values frame narrow confi-
dence intervals (CIs) gaining unreasonable weight in the
Meta-analysis findings
meta-analysis. We unsuccessfully tried to contact the Pairwise MA findings for normal occlusion. In normal occlu-
authors and, therefore, we decided to exclude these, pon- sion group, the assessment of OI and AI was sourced from
dering the likely negative consequences for the veracity of 25 and 26 studies, respectively (Figures 3 and 4). All the 26
the results. studies provided data for AI assessment, while one study
More specifically, only seven studies reported the (Jóias and Scanavini, 2011) had no data regarding OI.
setting, locations and relevant dates of cast models (Asma, Overall pooled results suggest an OI mean of 91.78% (95%
Table 1. Baseline characteristics for studies included in pairwise meta-analysis and Bayesian network meta-analysis.
12
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Normal occlusion
Mollabashi et al. (2019) Asia 60 30 / 30 Digital calliper 92.73 (1.74) 78.43 (2.31) NS NS Yes Yes
(Iran) (Hamadan) (0.01 mm)
Machado et al. (2018) Europe 29 10 / 19 Digital calliper 92.10 (2.20) 78.40 (3.50) 91.70 (2.20) / 92.9 (2.10) 77.90 (3.10) / 79.3 (4.10) Yes Yes
(Portugal) (Almada) (0.01 mm)
Patel et al. (2017) (India) Asia 50 25 / 25 Digital calliper 92.73 (2.69) 80.80 (2.86) 91.92 (3.40) / 93.55 (1.36) 80.34 (3.27) / 80.60 (2.45) Yes No
(Pune) (0.01 mm)
Sakoda et al. (2016) (Brazil) America 90 45 / 45 Digital calliper 91.63 (1.95) 77.57 (2.45) 91.35 (1.87) / 91.91 (2.04) 77.30 (2.28) / 77.85 (2.64) Yes No
(São Paulo) (0.01 mm)
Shahid et al. (2016) Asia 128 64 / 64 Digital calliper 92.80 (2.79) 79.25 (3.81) 93.10 (2.40) / 92.50 (3.10) 79.50 (3.60) / 79.00 (4.40) Yes No
(Pakistan) (different states) (0.01 mm)
Lombardo et al. (2016) Europe 56 22 / 34 Intraoral Scanner 91.56 (2.00) 77.65 (2.46) 91.55 (2.00) / 91.57 (2.00) 77.88 (2.00) / 77.30 (3.00) Yes No
(USA) (New York) (3shape)
Chugh et al. (2015) (India) Asia 50 25 / 25 Digital calliper 91.88 (1.99) 79.64 (2.61) 91.80 (2.34) / 91.96 (1.63) 79.16 (2.23) / 80.12 (1.73) Yes Yes
(Lucknow) (0.01 mm)
Bugaighis et al. (2015) (Libya) Africa 15 NS Digital calliper 90.24 (1.89) 76.88 (2.42) NS NS Yes Yes
(Benghazi) (0.01 mm)
Ismail and Abuaffan (2015) Africa 55 25 / 30 Digital calliper 91.47 (2.83) 77.46 (3.16) 91.25 (2.94) / 91.73 (2.90) 77.22 (3.43) / 77.73 (2.82) Yes Yes
(Sudan) (Khartoum) (0.1 mm)
Hashim et al. (2015) (Sudan) Africa 60 30 / 30 Digital calliper 90.80 (3.50) 76.90 (3.60) 90.60 (3.10) / 91.00 (3.90) 77.00 (3.70) / 76.90 (3.60) Yes No
(Khartoum) (0.01 mm)
Ricci et al. (2013) (Brazil) America 35 NS Digital calliper 90.38 (1.58) 77.49 (2.20) 90.36 (1.70) / 90.44 (1.20) 77.73 (2.39) / 76.68 (1.19) Yes Yes
(São Paulo) (0.01 mm)
Celikoglu et al. (2013) Europe 26 14 / 12 CBCT 90.69 (2.21) 77.58 (2.71) NS NS Yes No
(Turkey) (Karadeniz Ereğli)
Jóias and Scanavini (2011) America 35 8 / 27 Digital calliper NS 77.48 (2.22) NS 77.61 (2.45) / 77.05 (1.10) Yes No
(Brazil) (São Paulo) (0.01 mm)
Fernandes et al. (2011) America 140 70 / 70 Digital calliper 91.32 (1.98) 77.00 (2.71) 90.87 (1.94) / 91.77 (1.96) 76.54 (2.79) / 77.46 (2.61) Yes No
(Brazil) (Bauru) (0.01 mm)
Manopatanakul and Asia 37 NS Digital calliper 91.66 (1.74) 77.09 (2.18) NS NS Yes No
Watanawirun (2011) (0.01 mm)
(Thailand) (Bangkok)
Lee et al. (2011) (South Asia 307 188 / Digital calliper 90.42 (1.94) 77.54 (2.54) 90.30 (2.00) / 90.50 (1.90) 77.60 (2.60) / 77.50 (2.50) Yes No
Korea) (Seoul) 119 (0.01 mm)
Oktay and Ulukaya (2010) Europe 100 61 / 39 RMI 550 3D (0.01 92.10 (1.95) 79.28 (2.53) 91.63 (2.04) / 92.39 (1.84) 79.17 (2.65) / 79.35 (2.47) Yes Yes
(Turkey) (Erzurum) mm)
Journal of Orthodontics 47(1)
(Continued)
Table 1. (Continued)
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Machado et al.
Jóias et al. (2010) (Brazil) America 35 8 / 27 Intraoral Scanner 91.58 (2.20) 78.66 (2.72) NS NS Yes No
(São Paulo) (3shape)
Freire et al. (2007) (Brazil) America 30 15 / 15 Digital calliper 91.46 (1.63) 77.83 (2.19) NS NS Yes No
(Rio de Janeiro) (0.01 mm)
Endo et al. (2007) (Japan) Asia 60 30 / 30 Digital calliper 91.60 (2.11) 78.39 (2.18) 91.69 (2.35) / 91.51 (1.88) 78.57 (2.19) / 78.21 (2.18) Yes No
(Niigata) (0.01 mm)
Cİğer et al. (2006) (Turkey) Europe 125 55 / 70 Digital calliper 91.95 (2.20) 77.95 (2.35) 91.82 (1.99) / 91.97 (1.65) 78.43 (2.41) / 78.62 (2.24) Yes Yes
(Hacettepe) (0.01 mm)
Carreiro et al. (2005) America 41 20 / 21 Microscribe 3DX 91.76 (2.51) 78.24 (3.40) NS NS Yes Yes
(Brazil) (Paraná)
Uysal et al. (2005) (Turkey) Europe 150 72 / 78 Digital calliper 91.90 (3.21) 78.56 (3.23) 91.73 (2.26) / 89.83 (2.33) 78.33 (2.42) / 78.18 (2.82) Yes Yes
(Konya) (0.01 mm)
Alkofide and Hashim (2002) Asia 60 NS Digital calliper 93.58 (2.12) 78.86 (2.55) 92.36 (2.37) / 92.12 (1.67) 78.79 (3.19) / 78.75 (2.27) Yes Yes
(Saudi Arabia) (Jeddah) (0.01 mm)
Nie and Lin (1999) (China) Asia 60 30 / 30 Software 93.27 (2.48) 81.52 (2.82) 93.11 (2.64) / 93.44 (2.35) 81.10 (2.27) / 81.95 (2.28) Yes Yes
(Beijing)
Lavelle (1972) Europe 40 20 / 20 Digital calliper 91.25 (2.00) 77.15 (1.60) 90.80 (1.85) / 91.70 (2.04) 77.50 (1.62) / 76.80 (1.49) Yes No
(0.1 mm)
Africa 40 20 / 20 Digital calliper 93.20 (2.11) 79.00 (2.02) 92.90 (1.78) / 93.50 (2.35) 78.60 (1.89) / 79.40 (2.06) Yes No
(0.1 mm)
Asia 40 20 / 20 Digital calliper 92.75 (1.53) 78.45 (1.55) 92.10 (1.55) / 92.60 (2.47) 78.20 (1.38) / 78.70 (1.66) Yes No
(0.1 mm)
Class I
Mollabashi et al. (2019) Asia 60 30 / 30 Digital calliper 92.61 (2.29) 78.79 (2.85) NS NS - Yes
(Iran) (Hamadan) (0.01 mm)
Mulimani et al. (2018) Asia 15 NS Digital calliper 90.80 (2.15) 77.1 (2.3) NS NS - Yes
(Malaysia) (Melaka) (Indian) (0.01 mm)
Asia 27 NS Digital calliper 91.0 (1.72) 77.9 (2.3) NS NS - Yes
(Chinese) (0.01 mm)
Asia 10 NS Digital calliper 92.10 (2.37) 79.10 (2.86) NS NS - Yes
(Malay) (0.01 mm)
Škrinjarić et al. (2018) Europe 39 20/19 ATOS II SO 91.57 (1.81) 78.19 (2.70) 91.24 (1.61) / 91.89 (1.99) 77.65 (2.49) / 78.75 (2.86) - Yes
(Croatia) (Zagreb)
Machado et al. (2018) Europe 50 29 / 21 Digital calliper 92.90 (2.70) 79.30 (4.00) 93.4 (2.30) / 92.50 (2.90) 79.60 (2.90) / 79.00 (4.60) - Yes
(Portugal) (Almada) (0.01 mm)
Saritha et al. (2017) (India) Asia 168 110 / 58 Digital calliper 92.38 (1.86) 79.37 (2.98) 92.39 (1.95) / 92.38 (1.82) 79.49 (2.37) / 79.30 (3.27) - Yes
(Telangana) (0.01 mm)
13
(Continued)
Table 1. (Continued)
14
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Mahmoud et al. (2017) Asia 52 NS Digital calliper 91.37 (2.98) 78.44 (2.91) NS NS - Yes
(Sudan) (Khartoum) (0.05 mm)
Elsheikhi et al. (2017) (Libya) Africa 20 10 / 10 Digital calliper 89.91 (1.79) 74.42 (2.06) NS NS - Yes
(Benghazi) (0.01 mm)
Cançado et al. (2016) (Brazil) America 321 NS Digital calliper 91.61 (2.04) 78.37 (2.68) NS NS - Yes
(Dourados) (0.01 mm)
Al-Duliamy et al. (2016) Asia 70 NS Digital calliper 91.23 (2.20) 78.72 (4.53) NS NS - Yes
(Iraq) (Baghdad) (0.01 mm)
Al-Duliamy et al. (2016) Africa 70 NS Digital calliper 91.63 (2.58) 78.85 (2.79) NS NS - Yes
(Egypt) (Cairo) (0.01 mm)
Chugh et al. (2015) (India) Asia 50 25 / 25 Digital calliper 93.06 (2.28) 79.60 (3.02) 93.35 (2.31) / 92.79 (2.28) 80.17 (3.13) / 79.09 (2.92) - Yes
(Lucknow) (0.01 mm)
Shastri et al. (2015) (India Asia 40 NS Digital calliper 91.73 (3.6) 76.89 (4.16) NS NS - Yes
(North)) (Lucknow)
Bughaighis et al. (2015) Africa 220 NS Digital calliper 91.55 (2.40) 78.29 (2.53) NS NS - Yes
(Libya) (Benghazi) (0.01 mm)
Ismail et al. (2015) (Sudan) Africa 49 26 / 23 Digital calliper 91.47 (2.83) 77.46 (3.16) 91.51 (3.27) / 91.39 (2.54) 77.00 (4.65) / 76.55 (3.34) - Yes
(Khartoum) (0.1 mm)
Maurya et al. (2015) (India) Asia 60 30 / 30 Digital calliper 92.38 (2.51) 80.13 (3.48) 93.03 (2.34) / 91.72 (2.58) 80.86 (3.28) / 79.40 (3.64) - Yes
(Madhya Pradesh) (0.01 mm)
Zerouaoui et al. (2014) Africa 30 NS Digital calliper 91.37 (2.05) 77.93 (2.60) NS NS - Yes
(Morocco) (Rabat)
Jindal and Bunger (2013) Asia 300 150 / Digital calliper 92.75 (3.15) 79.82 (3.85) 93.93 (3.34) / 91.58 (2.44) 80.87 (43135) / 78.77 - Yes
(India) (Punjab) 150 (0.01 mm) (3.38)
Asma (2013) (Malaysia) Asia 50 NS Digital calliper NS 78.83 (4.06) NS NS - Yes
(Selangor) (0.01 mm)
Ricci et al. (2013) (Brazil) America 35 NS Digital calliper 91.19 (2.70) 78.16 (2.87) 91.25 (3.24) / 91.17 (2.58) 78.66 (3.64) / 78.01 (2.66) - Yes
(São Paulo) (0.01 mm)
Hyder et al. (2012) Asia 40 20 / 20 Digital calliper 90.40 (2.69) 77.70 (2.81) 89.82 (3.06) / 91.06 (2.18) 77.92 (2.80) / 77.49 (2.87) - Yes
(Bangladesh) (Dhaka) (0.01 mm)
Kansal et al. (2012) (India) Asia 231 NS Digital calliper 91.80 (3.30) 79.20 (3.80) NS NS - Yes
(Karnataka) (0.01 mm)
O’Mahony et al. (2011) Europe 60 30 / 30 OrhoAnalyzer 92.30 (2.20) 79.00 92.4 (2.20) / 92.10 (2.20) 78.40 (2.90) / 79.60 (3.20) - Yes
(Ireland) (Cork) (Software) (43376)
Vela et al. (2011) (USA) America 207 110 / 97 Digital calliper NS 78.97 (2.29) NS 79.12 (1.99) / 78.84 (2.49) - No
(Texas) (0.01 mm)
Endo et al. (2010) (Japan) Asia 66 33 / 33 Digital calliper 91.10 (2.20) NS 91.18 (2.27) / 91.01 (2.17) NS - Yes
(Niigata) (0.01 mm)
Journal of Orthodontics 47(1)
(Continued)
Table 1. (Continued)
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Machado et al.
Oktay and Ulukaya (2010) Europe 100 65 / 35 RMI 550 3D (0.01 92.27 (2.16) 78.61 (2.80) 92.33 (1.88) / 92.24 (2.32) 78.66 (2.41) / 78.58 (3.01) - Yes
(Turkey) (Erzurum) mm)
Strujić et al. (2009) (Croatia) Europe 110 68 / 42 Digital calliper 91.81 (1.99) 78.25 (2.58) NS NS - Yes
(Zagreb) (0.01 mm)
Endo et al. (2009) (Japan) Asia 101 59 / 42 Digital calliper 91.15 (2.14) 77.84 (2.46) 91.14 (2.33) / 91.15 (1.99) 77.97 (2.55) / 77.74 (2.39) - Yes
(Niigata) (0.01 mm)
Endo et al. (2008) (Japan) Asia 60 30 / 30 Digital calliper 91.01 (1.91) 77.48 (2.17) 91.14 (2.09) / 90.88 (2.20) 77.63 (1.82) / 77.33 (2.49) - Yes
(Niigata) (0.01 mm)
Al Sulaimani et al. (2006) Asia 98 62 / 36 Ortho-l software 93.90 (4.07) 81.11 (5.07) NS NS - Yes
(Saudi Arabia) (Jeddah)
Cİğer et al. (2006) (Turkey) Europe 125 70 / 55 Digital calliper 91.95 (2.20) 77.95 (2.35) 91.97 (1.65) / 91.82 (1.99) 78.62 (2.24) / 78.43 (2.41) - Yes
(Hacettepe) (0.01 mm)
Carreiro et al. (2005) America 44 22 / 22 Microscribe 3DX 92.13 (2.08) 77.13 (3.15) NS NS - Yes
(Brazil) (Panamá)
Uysal et al. (2005) (Turkey) Europe 156 150 / 6 Digital calliper 91.90 (3.21) 78.56 (3.23) 91.65 (3.51) / 91.57 (2.98) 78.18 (3.31) / 78.44 (3.18) - Yes
(Konya) (0.01 mm)
Laino et al. (2003) (Italy) Europe 57 31 / 26 Digital calliper 91.72 (2.20) 78.12 (2.41) NS NS - Yes
(Campania) (0.01 mm)
Araújo et al. (2003) (Brazil) America 100 58 / 42 Digital calliper NS 78.18 (2.85) NS NS - Yes
(Belo Horizonte) (0.01 mm)
Alkofide and Hashim (2002) Asia 60 30 / 30 Digital calliper 92.24 (2.04) 78.77 (2.74) 92.12 (1.67) / 92.36 (2.37) 78.75 (2.27) / 78.79 (3.19) - Yes
(Saudi Arabia) (Jeddah) (0.01 mm)
Ta et al. (2001) (Hong Kong) Asia 50 25 / 25 Digital calliper 90.65 (1.19) 77.55 (1.80) 91.10 (1.00) / 90.20 (1.20) 77.60 (1.80) / 77.50 (1.80) - Yes
(Sheung Wan) (0.01 mm)
Nie and Lin (1999) (China) Asia 60 30 / 30 Software (0,01 93.27 (2.48) 81.52 (2.82) 93.62 (2.42) / 93.41 (2.53) 81.87 (2.51) / 81.25 (2.87) - Yes
(Beijing) mm)
Crosby and Alexander America 30 NS Digital calliper 91.30 (2.40) 77.2 (2.70) NS NS - Yes
(1989) (USA) (Texas) (0.01 mm)
Class II
Mollabashi et al. (2019) Asia 120 60 / 60 Digital calliper 91.95 (2.21) 78.44 (2.84) NS NS - Yes
(Iran) (Hamadan) (0.01 mm)
Škrinjarić et al. (2018) Europe 55 34 / 23 ATOS II SO 91.27 (2.04) 77.46 (2.17) 91.50 (2.23) / 90.94 (1.71) 77.51 (1.93) / 77.39 (2.51) - Yes
(Croatia) (Zagreb)
Mulimani et al. (2018) Asia 14 NS Digital calliper 90.5 (2.18) 77.3 (2.44) NS NS - Yes
(Malaysia) (Melaka) (Indian) (0.01 mm)
Asia 14 NS Digital calliper 91.1 (1.83) 78.1 (1.75) NS NS - Yes
(Chinese) (0.01 mm)
15
(Continued)
Table 1. (Continued)
16
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
(Continued)
Table 1. (Continued)
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Machado et al.
Strujić et al. (2009) (Croatia) Europe 109 60 / 49 Digital calliper 91.14 (2.14) 77.73 (2.42) NS NS - Yes
(Zagreb) (0.01 mm)
Endo et al. (2009) (Japan) Asia 78 42 / 36 Digital calliper 91.57 (2.34) 77.68 (2.38) 91.47 (1.91) / 91.66 (2.65) 78.22 (2.25) / 78.07 (2.41) - Yes
(Niigata) (0.01 mm)
Endo et al. (2008) (Japan) Asia 60 30 / 30 Digital calliper 91.30 (1.94) 77.93 (2.25) 91.43 (1.98) / 91.17 (1.91) 77.92 (2.26) / 77.93 (2.29) - Yes
(Niigata) (0.01 mm)
Al Sulaimani et al. (2006) Asia 52 34 / 18 Ortho-l software 93.06 (3.65) 81.88 (4.31) NS NS - Yes
(Saudi Arabia) (Jeddah)
Uysal et al. (2005) (Turkey) Europe 191 105 / 86 Digital calliper 91.27 (3.35) 78.59 (3.48) NS NS - Yes
(Konya) (0.01 mm)
Laino et al. (2004) (Italy) Europe 24 18 / 6 Digital calliper 91.24 (1.85) 78.04 (2.35) NS NS - Yes
(Campania) (0.01 mm)
Araújo et al. (2003) (Brazil) America 100 48 / 52 Digital calliper NS 78.16 (2.21) NS NS - Yes
(Belo Horizonte) (0.01 mm)
Alkofide and Hashim (2002) Asia 60 60 / 60 Digital calliper 92.8 (2.20) 78.7 (2.45) 92.5 (2.17) / 93.1 (2.23) 78.56 (2.73) / 78.84 (2.17) - Yes
(Saudi Arabia) (Jeddah) (0.01 mm)
Ta et al. (2001) (Hong Kong) Asia 30 15 / 15 Digital calliper 91.40 (1.69) 77.75 (1.56) 91.4 (1.80) / 90.4 (0.70) 77.80 (1.70) / 77.70 (1.40) - Yes
(Sheung Wan) (0.01 mm)
Nie and Lin (1999) (China) Asia 120 60 / 60 Software (0.01 92.06 (2.50) 80.79 (3.19) 92.10 (2.66) / 92.02 (2.33) 80.69 (3.72) / 80.89 (2.54) - Yes
(Beijing) mm)
Crosby and Alexander America 79 NS Digital calliper 91.50 (2.56) 77.51 (3.90) NS NS - Yes
(1989) (USA) (Texas) (0.01 mm)
Class II – Division 1
Mollabashi et al. (2019) Asia 60 30 / 30 Digital calliper 91.57 (2.27) 78.53 (2.91) NS NS - Yes
(Iran) (Hamadan) (0.01 mm)
Machado et al. (2018) Europe 23 16 / 7 Digital calliper 91.40 (2.80) 78.60 (3.80) 90.50 (1.80) / 91.90 (3.10) 77.30 (3.30) / 79.20 (4.00) - Yes
(Portugal) (Almada) (0.01 mm)
Mahmoud et al. (2017) Asia 41 NS Digital calliper 90.73 (2.63) 78.11 (4.49) NS NS - Yes
(Sudan) (Khartoum) (0.01 mm)
Elsheikhi et al. (2017) (Libya) Africa 20 10 / 10 Digital calliper 91.38 (3.06) 76.29 (3.02) NS NS - Yes
(Benghazi) (0.01 mm)
Chugh et al. (2015) (India) Asia 40 20 / 20 Digital calliper 91.53 (2.49) 78.96 (3.56) 92.24 (2.43) / 90.83 (2.41) 79.95 (2.78) / 77.97 (3.66) - Yes
(Lucknow) (0.01 mm)
Bughaighis et al. (2015) Africa 73 NS Digital calliper 91.49 (2.58) 78.08 (2.8) NS NS - Yes
(Libya) (Benghazi) (0.01 mm)
(Continued)
17
Table 1. (Continued)
18
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Cİğer et al. (2006) (Turkey) Europe 71 40 / 31 Digital calliper 90.83 (3.9) 78.04 (2.57) 90.54 (3.4) / 91.05 (4.24) 77.94 (2.46) / 78.11 (2.65) - Yes
(Hacettepe) (0.01 mm)
Carreiro et al. (2005) America 54 26 / 28 Microscrrib 3DX 92.24 (2.56) 79.79 (4.24) NS NS - Yes
(Brazil) (Panamá)
Uysal et al. (2005) (Turkey) Europe 157 82 / 75 Digital calliper 91.12 (3.34) 78.50 (3.30) 91.19 (2.53) / 91.07 (3.96) 78.68 (3.06) / 78.33 (2.42) - Yes
(Konya) (0.01 mm)
Nie and Lin (1999) (China) Asia 60 30 / 30 Software (0.01 92.16 (2.50) 80.56 (3.24) 92.11 (2.61) / 92.21 (2.39) 80.31 (3.87) / 80.8 (2.42) - Yes
(Beijing) mm)
Crosby and Alexander America 30 NS Digital calliper 91.70 (2.30) 78.20 (3.10) NS NS - Yes
(1989) (USA) (Texas) (0.01 mm)
Class II – Division 2
Mollabashi et al. (2019) Asia 60 30 / 30 Digital calliper 92.33 (2.08) 78.35 (2.76) NS NS - Yes
(Iran) (Hamadan) (0.01 mm)
Machado et al. (2018) Europe 28 20 / 8 Software (0.01 91.60 (2.60) 78.60 (3.40) 92.3 (2.00) / 91.30 (2.90) 78.50 (3.70) / 78.70 (3.30) - Yes
(Portugal) (Almada) mm)
Mahmoud et al. (2017) Asia 3 NS Software (0.01 92.42 (2.17) 78.57 (1.53) NS NS - Yes
(Sudan) (Khartoum) mm)
Bughaighis et al. (2015) Africa 12 NS Software (0.01 91.56 (1.21) 78.20 (2.29) NS NS - Yes
(Libya) (Benghazi) mm)
Asma (2013) (Malaysia) Asia 50 NS Software (0.01 NS 80.33 (4.71) NS NS - Yes
(Selangor) mm)
Kansal et al. (2012) (India) Asia 17 NS Software (0.01 91.80 (2.90) 79.10 (3.00) NS NS - Yes
(Karnataka) mm)
O’Mahony et al. (2011) Europe 60 30 / 30 OrhoAnalyzer 92.60 (2.20) 80.20 (3.00) 92.80 (2.10) / 92.30 (2.20) 81.10 (2.70) / 79.40 (3.10) - Yes
(Ireland) (Cork) (Software)
(Continued)
Journal of Orthodontics 47(1)
Table 1. (Continued)
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Machado et al.
Oktay and Ulukaya (2010) Europe 100 63 / 37 RMI 550 3D (0.01 92.26 (2.22) 78.98 (2.67) 92.42 (2.15) / 92.16 (2.26) 78.76 (2.67) / 78.38 (2.69) - Yes
(Turkey) (Erzurum) mm)
Uysal et al. (2005) (Turkey) Europe 34 23 / 11 Software (0.01 91.94 (3.34) 79 (4.23) 90.81 (2.27) / 89.81 (4.65) 79.63 (3.35) / 78.70 (4.64) - Yes
(Konya) mm)
Nie and Lin (1999) (China) Asia 60 30 / 30 Software (0.01 91.95 (2.47) 81.02 (3.10) 92.09 (2.70) / 91.82 (2.26) 81.07 (3.52) / 80.97 (2.66) - Yes
(Beijing) mm)
Crosby and Alexander America 29 NS Software (0.01 91.50 (3.10) 76.80 (5.30) NS NS - Yes
(1989) (USA) (Texas) mm)
Class III
Mollabashi et al. (2019) Asia 60 30 / 30 Digital calliper 92.59 (2.19) 78.48 (2.74) NS NS - Yes
(Iran) (Hamadan) (0.01 mm)
Škrinjarić (2018) (Croatia) Europe 27 15 /12 ATOS II SO 91.50 (2.88) 78.08 (3.03) 92.23 (2.50) / 90.92 (3.12) 78.62 (3.22) / 77.67 (2.10) - Yes
(Zagreb)
Mulimani et al. (2018) Asia 3 NS Digital calliper 91.10 (2.54) 77.50 (2.96) NS NS - Yes
(Malaysia) (Melaka) (Indian) (0.01 mm)
Asia 9 NS Digital calliper 91.30 (1.53) 78.50 (2.83) NS NS - Yes
(Chinese) (0.01 mm)
Asia 11 NS Digital calliper 90.30 (1.88) 76.50 (2.64) NS NS - Yes
(Malay) (0.01 mm)
Machado et al. (2018) Europe 38 25 / 13 Software (0.01 92.00 (2.00) 78.00 (2.90) 91.80 (1.60) / 92.10 (2.30) 78.00 (2.90) / 78.10 (2.90) - Yes
(Portugal) (Almada) mm)
Saritha et al. (2017) (India) Asia 40 21 / 19 Software (0.01 92.967 79.72 (2.52) 92.99 (1.75) / 92.94 (1.38) 79.92 (3.06) / 79.54 (1.97) - Yes
(Telangana) mm) (1.546)
Mahmoud et al. (2017) Asia 11 NS Software (0.01 91.38 (2.04) 78.37 (3.16) NS NS - Yes
(Sudan) (Khartoum) mm)
Elsheikhi et al. (2017) (Libya) Africa 20 10 / 10 Software (0.01 92.05 (2.96) 76.65 (4.09) NS NS - Yes
(Benghazi) mm)
Cançado et al. (2016) (Brazil) America 66 NS Software (0.01 91.22 (2.07) 77.90 (2.85) NS NS - Yes
(Dourados) mm)
Al-Duliamy et al. (2016) Asia 10 NS Software (0.01 91.82 (2.24) 78.80 (2.15) NS NS - Yes
(Iraq) (Baghdad) mm)
Al-Duliamy et al. (2016) Africa 10 NS Software (0.01 90.65 (3.71) 78.65 (4.20) NS NS - Yes
(Egypt) (Cairo) mm)
Chugh et al. (2015) (India) Asia 30 NS Software (0.01 94.05 (2.01) 81.23 (3.11) 94.48 (1.83) / 93.47 (2.11) 81.96 (3.17) / 80.49 (2.98) - Yes
(Lucknow) mm)
(Continued)
19
Table 1. (Continued)
20
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Shastri et al. (2015) (India Asia 20 NS Software (0.01 91.33 (2.32) 77.51 (5.64) NS NS - Yes
(North)) (Lucknow) mm)
Bughaighis et al. (2015) Africa 13 NS Software (0.01 90.97 (2.93) 77.48 (3.51) NS NS - Yes
(Libya) (Benghazi) mm)
Ismail et al. (2015) (Sudan) Africa 43 27 / 16 Software (0.01 92.60 (3.01) 77.71 (4.20) 93.58 (2.71) / 92.02 (3.03) 78.01 (4.12) / 77.53 (4.24) - Yes
(Khartoum) mm)
Maurya et al. (2015) (India) Asia 24 12 / 12 Software (0.01 94.72 (1.13) 84.49 (1.33) 95.51 (0.72) / 93.93 (0.88) 85.56 (0.93) / 84.33 (1.57) - Yes
(Madhya Pradesh) mm)
Zerouaoui et al. (2014) Africa 30 NS Software (0.01 92.075 78.2358 NS NS - Yes
(Morocco) (Rabat) mm) (2.2062) (2.85751)
McSwiney et al. (2014) Europe 60 NS Software (0.01 92.25 (2.31) 78.35 (2.42) 92.30 (2.27) / 92.20 (2.41) 78.15 (2.37) / 78.55 (2.58) - Yes
(Ireland) (Dublin) mm)
Asma (2013) (Malaysia) Asia 50 NS Software (0.01 NS 79.09 (2.82) NS NS - Yes
(Selangor) mm)
Hyder et al. (2012) Asia 40 20 / 20 Digital calliper 91.40 (2.58) 78.50 (3.15) 91.58 (2.62) / 91.28 (2.60) 78.70 (3.28) / 78.43 (3.09) - Yes
(Bangladesh) (Dhaka) (0.01 mm)
Kansal et al. (2012) (India) Asia 24 NS Digital calliper 91.80 (3.10) 78.90 (5.30) NS NS - Yes
(Karnataka) (0.01 mm)
O’Mahony et al. (2011) Europe 60 30 / 30 OrhoAnalyzer 92.80 (2.20) 79.90 (3.10) 92.70 (2.20) / 92.90 (2.10) 80.30 (3.00) / 79.60 (3.20) - Yes
(Ireland) (Cork) (Software)
Endo et al. (2010) (Japan) Asia 66 33 / 33 Digital calliper 91.56 (1.89) NS 91.27 (1.56) / 91.85 (2.16) NS - Yes
(Niigata) (0.01 mm)
Oktay and Ulukaya (2010) Europe 100 58 / 42 RMI 550 3D (0.01 92.87 (1.92) 79.30 (2.94) 92.81 (2.05) / 92.92 (1.83) 79.39 (3.13) / 79.24 (2.83) - Yes
(Turkey) (Erzurum) mm)
Strujić et al. (2009) (Croatia) Europe 81 45 / 36 Digital calliper 92.08 (1.82) 78.23 (2.82) NS NS - Yes
(Zagreb) (0.01 mm)
Endo et al. (2009) (Japan) Asia 71 35 / 36 Digital calliper 91.54 (1.86) 77.84 (2.16) 91.28 (1.53) / 91.81 (2.12) 77.39 (1.93) / 78.31 (2.29) - Yes
(Niigata) (0.01 mm)
Endo et al. (2008) (Japan) Asia 60 30 / 30 Digital calliper 91.65 (1.86) 77.87 (2.18) 91.46 (1.46) / 91.83 (2.20) 77.54 (1.92) / 78.20 (2.40) - Yes
(Niigata) (0.01 mm)
Carreiro et al. (2005) America 46 23 / 23 Microscribe 3DX 92.30 (2.69) 79.54 (4.46) NS NS - Yes
(Brazil) (Panamá)
Uysal et al. (2005) (Turkey) Europe 113 55 / 58 Digital calliper 91.69 (3.66) 78.83 (3.46) 92.34 (3.67) / 91.01 (3,56) 79.59 (3.67) / 78.03 (3.06) - Yes
(Konya) (0.01 mm)
(Continued)
Journal of Orthodontics 47(1)
Table 1. (Continued)
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Machado et al.
Al Sulaimani et al. (2006) Asia 10 2/8 Ortho-l software 96.30 (1.45) 80.58 (3.74) NS NS - Yes
(Saudi Arabia) (Jeddah)
Laino et al. (2004) (Italy) Europe 13 6/7 Digital calliper 90.94 (2.26) 78.19 (2.27) NS NS - Yes
(Campania) (0.01 mm)
Araújo et al. (2003) (Brazil) America 100 49 / 51 Digital calliper NS 79.03 (2.35) NS NS - Yes
(Belo Horizonte) (0.01 mm)
Alkofide and Hashim (2002) Asia 60 60 / 60 Digital calliper 92.71 (2.12) 78.50 (2.53) 93.20 (2.15) / 92.21 (2.02) 79.66 (2.52) / 77.34 (1.98) - Yes
(Saudi Arabia) (Jeddah) (0.01 mm)
Ta et al. (2001) (Hong Kong) Asia 30 15 / 15 Digital calliper 91.45 (1.8) 79.43 (2.55) 91.20 (2.10) / 91.70 (1.40) 77.90 (3.10) / 79.20 (1.80) - Yes
(Sheung Wan) (0.01 mm)
Nie and Lin (1999) (China) Asia 120 60 / 60 Software (0.01 95.6 (2.62) 82.74 (2.76) 95.68 (2.78) / 95.52 (2.44) 82.60 (2.94) / 82.88 (2.56) - Yes
(Beijing) mm)
AI, Anterior Index; OI, Overall Index; CBCT, cone-beam computed tomography; NS, not stated; SD, standard deviation.
21
22 Journal of Orthodontics 47(1)
Figure 2. Datasets by year and population group by normal occlusion and Angle’s malocclusion groups. Area of the circle is
proportional to sample size.
Figure 3. Forest plot of studies with OI mean values for normal occlusion patients. Mean effect size estimates have been
calculated with 95% CIs and are shown in the figure. Area of squares represents sample size, continuous horizontal lines and
diamond width represents 95% CI. Blue diamond centre and the vertical red dotted line point to the overall pooled estimate.
Machado et al. 23
Figure 4. Forest plot of studies with AI mean values for normal occlusion patients. Mean effect size estimates have been
calculated with 95% CIs and are shown in the figure. Area of squares represents sample size, continuous horizontal lines and
diamond width represents 95% CI. Blue diamond centre and the vertical red dotted line point to the overall pooled estimate.
CI = 91.42–92.14) and an AI mean of 78.25% (95% CI = possible. Thus, we adopted a Bayesian NMA approach to
77.87–78.62). In both syntheses, heterogeneity was high (I2 pool all available direct and indirect comparisons between
= 92.87% and I2 = 90.67% in OI and AI, respectively). normal occlusion versus Angle’s Class I, Class II, Class II
Next, we looked for gender differences on OI and AI division 1, Class II division 2 and Class III values. The net-
through gender subgroup meta-analysis. Only Class I pre- work fit statistic outcome included adjusted normal occlu-
sented a gender impact with male patients having a higher sion mean values for each Angle’s malocclusions and the
OI (0.30, 95% CI = 0.00–0.59) and AI (0.41, 95% CI = estimated normal versus malocclusion difference of means,
0.00–0.83) mean values than female patients (Supplement with the degree of certainty of such differences reported as
S5). The GRADE assessment is depicted in Table 5. CrIs and heterogeneity as I2 and Tau2 (Tables 3 and 4).
The mean change from normal occlusion for AI means
Pairwise MA normal occlusion versus Bolton’s original val- Class I, Class II, Class II division 1 and Class II division 2
ues. Direct comparison of the Pairwise MA pooled esti- was −0.01 (95% CrI = −0.26 to 0.24), −0.10 (95% CrI =
mates for AI and OI normal occlusion mean values with −0.35 to 0.15), −0.14 (95% CrI = −0.42 to 0.14) and 0.19
Bolton’s original values, through Z-test, revealed signifi- (95% CrI = −0.17 to 0.55), respectively, but in all, the 95%
cant differences in both AI and OI (P < 0.10) (Table 2). CrI included zero (Table 3). A similar trend was also
observed for OI means when we compared the means of
Bayesian network meta-analysis findings for Angle’s malocclu- Class I, Class II and Class II division 2 with normal
sions groups. The difference in mean change for normal occlusion (Table 4).
occlusion (baseline) compared with different Angle’s mal- In contrast, we found a meaningful difference between
occlusion groups is presented in Tables 3 and 4, and can be Angle’s Class III versus normal occlusion for both OI and
seen as a measure of the average effort required to treat each AI means (0.76, 95% CrI = 0.55–0.98, and 0.61, 95% CrI
represented malocclusion towards a proportional occlusion. = 0.35–0.87, respectively) and for Class II division 1
In studies with no normal occlusion data, the comparison (−0.28, 95% CrI = −0.52 to −0.05) against normal occlu-
with the different types of Angle’s malocclusions was not sion AI means, since the null difference is not within the
24 Journal of Orthodontics 47(1)
AI OI
PMA normal occlusion 1954 78.25 8.5 < 0.001 1919 91.78 4.1 0.08
Table 3. Results of pairwise MA of normal occlusion and Bayesian NMA of Angle’s malocclusion groups and difference to normal
occlusion in the AI.
AI Heterogeneity
Mean difference to
normal occlusion (%) Studies
Model n Mean [95% CI] [95% CrI] (n) Tau2 [SE] I2
Random effects
Normal occlusion 1954 78.25 [77.87–78.62] - 28 0.896 [0.623] 90.67
Bayesian NMA
Normal occlusion 780 78.29 [61.64–95.05] - - - -
(network adjusted)
Class I 3425 78.26 [61.58–95.01] −0.01 [−0.26 to 0.24] 11 0.100 [0.165] 27.36
Class II 2717 78.10 [61.60–94.66] −0.10 [−0.35 to 0.15] 8 0.07 [0.160] 25.73
Class II / division 1 1111 78.07 [61.47–94.69] −0.14 [−0.42 to 0.14] 10 0.265 [0.265] 49.93
Class II / division 2 453 78.41 [61.85–95.08] 0.19 [−0.17 to 0.55] 6 0 [0.231] 0
Class III 1503 78.86 [62.14–95.51] 0.61 [0.35–0.87] 10 0.135 [0.207] 31.41
credibility region (Tables 3 and 4). The GRADE assess- years have been of increased interest (Figure 2). Our results
ment is described in Table 5. in patients with normal occlusion demonstrated that the OI
mean was 91.78% (95% CI = 91.42–92.14) and AI mean
was 78.25% (95% CI = 77.87–78.62) worldwide, while the
Additional analyses values proposed by Bolton (1958) were respectively
Funnel plots revealed no evidence of publication bias smaller.
(Supplement S6). Clinically, and according to Bolton’s original values, if
the OI are > 91.3% and > 77.2%, respectively, it indicates
mandibular tooth material excess. In this case, maxillary
Discussion teeth are relatively smaller compared to the mandibular
teeth, and mandibular teeth stripping or extraction can be
Summary of main findings pondered as a treatment option. Since Bolton’s original val-
To the best of our knowledge, this is the first systematic ues are not the same as those found in this meta-analysis for
review that attempted to estimate overall OI and AI values normal occlusion patients, then unnecessary stripping or
in patients with normal occlusion and Angle’s malocclu- teeth extraction can be performed, which can lead to clini-
sion. Despite the apparent gap in observational studies cal complications when trying to reach a stable occlusion
about normal occlusion between 1972 and 1998, the last 20 based on Andrew’s six keys.
Machado et al. 25
Table 4. Results of Pairwise MA of normal occlusion and Bayesian NMA of Angle’s malocclusion groups and difference to normal
occlusion in OI.
OI Heterogeneity
Random effects
Normal occlusion 1919 91.78 [91.42–92.14] - 27 0.828 [0.712] 92.87
Bayesian NMA
Normal occlusion 780 91.78 [75.46–108.05] - - - -
(network adjusted)
Class I 3134 91.92 [75.72–108.10] 0.16 [−0.04 to 0.37] 11 0.455 [0.294] 72.24
Class II 2641 91.71 [75.37–108-08] −0.06 [−0.27 to 0.15] 8 0.412 [0.317] 73.39
Class II / division 1 1061 91.50 [75.35–107-65] −0.28 [−0.52 to −0.05] 10 0.356 [0.269] 65.09
Class II / division 2 403 91.70 [75.39–107.92] 0.01 [−0.28 to 0.30] 6 0.553 [0.513] 73.41
Class III 1419 92.52 [76.27–108.89] 0.76 [0.55–0.98] 10 0.887 [0.553] 82.63
Table 5. GRADE evidence profile for OI and AI in normal occlusion and malocclusions.
Outcome Study design Risk of bias Inconsistency Indirectness Imprecision Publication bias
Normal OI Observational Not serious Serious* Not serious Not serious Not serious
occlusion studies (serious)
AI Observational Not serious Serious* Not serious Not serious Not serious
studies (serious)
Malocclusions OI Observational Not serious Serious* Not serious Not serious Not serious
studies (serious)
AI Observational Not serious Serious* Not serious Not serious Not serious
studies (serious)
*Downgraded for serious inconsistency: even considering the large sample sizes and the use of digital, some degree of heterogeneity is still
perceptible.
AI, Anterior Index; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; I Explanations: GRADE Working Group
grades of evidence; OI, Overall Index.
In fact, pooled Pairwise MA normal occlusion estimates representative of the continent as a whole. There is a lack of
were not significantly different from Bolton’s values; how- studies in the continents of North America and Oceania.
ever, this direct comparison, though necessary, is quite Similarly, the African continent is portrayed only by Libya,
unfair and disproportionate as shown by the extraordinarily Egypt, Morocco and Sudan, the European continent is repre-
low statistical power. Also, the computed SDs from meta- sented mainly by studies in Turkey and Ireland, the Asian
analytical pooled estimates revealed very discrepant and continent is mostly represented by studies from India, and the
elevated values when compared with Bolton’s, and we American continents only had two studies from North
believe that these direct comparisons are biased since it is America and the remaining studies are from Brazil. Despite
not adequate to compare so unequal samples. this restriction, future research should address race and
It is important to remark that we have not made geographic genetic backgrounds to weigh their influence on the mesio-
subgroups based on continent since the studies are not fully distal proportions since it was not possible to perform this in
26 Journal of Orthodontics 47(1)
this study due to the lack of such data. Still, globalisation and opinion, these results can be obtained from the lack of high
inter-racial/inter-ethnic mixing strongly support the concept methodological homogeneity, but also from a high varia-
of non-static proportions and the necessity for continued bleness of mesiodistal width proportions among the
research. Further, gender and geographic location, in general, populations.
are not factors that influence dental width proportions. Regarding methodology, most studies took teeth meas-
Regarding the relation between normal occlusion and urements from plaster models. Only one investigation used
Angle malocclusions, in general, our results determined that cone-beam computed tomography (CBCT) (Celikoglu
no significant difference in the tooth size discrepancy existed et al., 2013), five studies have digitised plaster models and
for the OI and AI between normal occlusion and different mal- subsequently performed the measurements (Al Sulaimani
occlusion groups, except for the Class III malocclusion in both and Afify, 2006; Jóias et al., 2010; Lombardo et al., 2016;
AI and OI, and Class I malocclusion in OI only. Under these O’Mahony et al., 2011; Škrinjarić et al., 2018) and three
circumstances, the results indicate that the discrepancy of also used an electronic measuring device (Carreiro et al.,
intermaxillary tooth size may be one of the important factors 2005; Nie and Lin, 1999; Oktay and Ulukaya, 2010).
in the cause of malocclusions, especially in Angle’s Class III. Although in the past calliper measurement in plaster mod-
The results also suggest that these OI and AI differences els was the gold standard, nowadays the study of models
for normal occlusion in Angle’s Class I and Class III may with virtual three-dimensional (3D) technology has higher
be explained by upper and/or lower discrepancy. For both reliability and accuracy (Aragón et al., 2016; De Luca
Angle’s Class I and III difference for normal occlusion, a Canto et al., 2015; Fleming et al., 2011; Luu et al., 2012)
possible clinical explanation for this discrepancy may be and should be used as the first choice for diagnosis and
due to smaller mesiodistal maxillary tooth sizes and/or treatment planning in orthodontics, specifically to deter-
greater mesiodistal mandibular widths. mine the width of teeth. Additionally, study models pro-
duced by CBCT are far from perfect for replacing digital
models. Hence, in the future, with proper improvement,
Quality of the evidence and potential biases CBCT will ensure a multiplicity of analyses from a single
in the review process record (Ferreira et al., 2017). Furthermore, it is imperative
All studies included in the meta-analysis presented overall that, in addition to the mesiodistal width, the labio-lingual
medium quality, according to our predefined quality assess- and inclination data should be evaluated since they may
ment and risk of bias. However, there are important matters also present great variability in populations. Thus, a 3D
that need to be pointed out. Hypothetical limitations would orthodontic diagnosis and treatment plan is more desirable
be the fact that this systematic review only contains obser- than a two-dimensional assessment.
vational studies and language biases, because only studies in The overall results of this study are in line with a previ-
English were included. However, except for restorative or ous comprehensive review (Othman and Harradine, 2006).
traumatic reasons, mesiodistal width of teeth remains pro- Although gender has no clinically significant effect on
spectively unchanged. Therefore, randomised controlled tri- tooth size discrepancy (TSD) in general, this study con-
als, and prospective or retrospective studies on this theme, firmed a significant difference in Class I malocclusion
would be inappropriate unless they were the result of a sec- between men and women. Besides, we proved what was
ondary observation. comprehensively stated that Class III malocclusions have
On the other hand, we must emphasise that most stud- higher average ratios (Othman and Harradine, 2006).
ies lack sample size calculation and are non-representa-
tive of the population, but are rather from an academic
setting. Besides, too many studies show a lack of informa- Conclusions
tion on calibration method or the number of examiners. The results of this systematic review show that overall
These items are extremely important to minimise selec- pooled OI and AI mean values for normal occlusion patients
tion bias and strengthen the generalisation of results, and are slightly above Bolton’s original values. Class I, for OI
its absence weakens the results of this systematic review. mean values, and Class III, for both OI and AI, are propor-
Additionally, no study has reported the existence of blind- tionally larger than normal occlusion patients. Gender had
ing examiners, since presumably the researchers them- almost no impact on teeth mesiodistal proportion.
selves were involved in measurements of teeth and
Angle’s evaluation. This potential bias should be consid-
ered in future research. Implications for clinical practice and
Significantly, the heterogeneity revealed by our meta- research
analysis refers, conceptually, to the variation in study out- Despite being one of several measures used in orthodon-
comes between studies. This variation could flag some tic planning, the results of this systematic review suggest
problems; however, we need to carefully assess this dis- that Bolton’s original values may be slightly underesti-
crepancy, contrary to common meta-analysis. In our mated as the OI and AI global standard. The use of
Machado et al. 27
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