SYSTEMATIC REVIEW

Intraoral distalizer effects with conventional and

skeletal anchorage: A meta-analysis
Roberto Henrique da Costa Grec,a Guilherme Janson,b Nuria Castello Branco,a Patr
ıcia Garcia Moura-Grec,c

Fernando Castanha Henriquesb
Mayara Paim Patel,a and Jose
Bauru, S~ao Paulo, Brazil

Introduction: The aims of this meta-analysis were to quantify and to compare the amounts of distalization and
anchorage loss of conventional and skeletal anchorage methods in the correction of Class II malocclusion with
intraoral distalizers. Methods: The literature was searched through 5 electronic databases, and inclusion criteria
were applied. Articles that presented pretreatment and posttreatment cephalometric values were preferred.
Quality assessments of the studies were performed. The averages and standard deviations of molar and premo-
lar effects were extracted from the studies to perform a meta-analysis. Results: After applying the inclusion and
exclusion criteria, 40 studies were included in the systematic review. After the quality analysis, 2 articles were
classified as high quality, 27 as medium quality, and 11 as low quality. For the meta-analysis, 6 studies were
included, and they showed average molar distalization amounts of 3.34 mm with conventional anchorage and
5.10 mm with skeletal anchorage. The meta-analysis of premolar movement showed estimates of combined
effects of 2.30 mm (mesialization) in studies with conventional anchorage and 4.01 mm (distalization) in
studies with skeletal anchorage. Conclusions: There was scientific evidence that both anchorage systems
are effective for distalization; however, with skeletal anchorage, there was no anchorage loss when direct an-
chorage was used. (Am J Orthod Dentofacial Orthop 2013;143:602-15)

F
or Class II malocclusion, several forms of
correction produce different dental and skeletal
effects depending on the type of treatment.1
When the problems of this malocclusion are predomi-
nantly skeletal, it is likely to be corrected by functional
or mechanical orthopedic appliances. However, to
achieve satisfactory results, these protocols usually
require patient compliance in using the appliances.2-4
Lack of compliance can increase treatment time and
create an uneasy relationship between parents, patient,
and doctor, thus compromising the final treatment
result.3 When the problems of Class II malocclusions
are predominantly dental, these malocclusions can be
corrected by extractions in at least 1 dental arch,5,6
without extractions by using intermaxillary elastics,7,8
From Bauru Dental School, University of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
a
b
Postgraduate student, Department of Orthodontics.
Professor, Department of Orthodontics.
c
Postgraduate student, Department of Public Health.
The authors report no commercial, proprietary, or financial interest in the
producets or companies described in this article.
Reprint requests to: Roberto Henrique da Costa Grec, Department of Orthodon-
tics, Bauru Dental School, University of S~ao Paulo, Alameda Oct
avio Pinheiro
Brisolla 9-75, Bauru, SP 17012-901, Brazil; e-mail, robertogrec@usp.br.
Submitted, June 2012; revised and accepted, November 2012.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2012.11.024
602
or by distalizing the maxillary molars to create a Class I
relationship.9
For several years, the extraoral appliance was the most
widely used distalizing device, but it is no longer estheti-
cally acceptable. Also, it is removable and depends on pa-
tient compliance, which can compromise the results.2-4
Therefore, as alternatives to compliance-dependent
headgear, many intraoral methods to distalize the maxil-
lary molars have been proposed, such as repelling mag-
nets,10 distal jet appliance,11 Jones jig appliance,12
nickel-titanium coil springs,13 pendulum and pendex ap-
pliances,14,15 Wilson bimetric distalizing arch system
(Rocky Mountain Orthodontics, Denver, Colo),16 first class
appliance (Leone, Firenze, Italy),17 and others, giving
clinicians a wide variety of treatment options.
Intraoral appliances have proven to be effective for
maxillary molar distalization independently of patient
compliance.3 However, distalizers generally use the
Nance button as anchorage, but it is not enough
to neutralize the side effects of anchorage loss,18
represented by maxillary anterior crowding, maxillary
incisor labial inclination increasing the overjet, and
tipping of premolars and canines.19-25
To prevent anchorage loss, mini-implants can be
used as an efficient skeletal anchorage unit for molar
distalization, decreasing the side effects with more
Grec et al 603

predictable results and less treatment time, and

Table I. PICO format
consequently creating a new perspective in intraoral
distalizer appliances.26,27 Population Subjects with Class II malocclusion
Intervention Intraoral distalizers with conventional anchorage
Previously, 2 systematic reviews on the use of
Comparison Intraoral distalizers with skeletal anchorage
noncompliance distalizing intramaxillary appliances Outcome Efficiency in the correction of Class II malocclusion
with conventional anchorage and skeletal anchorage
were performed.28,29 However, there is still no
The quality of each article was scored by using an
comparison between the efficiency of these 2
adapted version of 3 methods previously used by Fudalej
techniques of anchorage.
and Antoszewska,29 Cozza et al,31 and Chen et al.32 The
The aims of this meta-analysis were to quantify and
following characteristics were evaluated: study design,
to compare the amounts of molar distalization and
sample size, sample description, error analysis, and
anchorage loss of conventional and skeletal anchorage
statistical analysis. Each characteristic received a score
methods in the correction of Class II malocclusion with
according to the criteria described in Table III. The
intraoral distalizers.
quality of each study was categorized as high (7-9
MATERIAL AND METHODS points), medium (4-6 points), or low (0-3 points).
The data from the selected articles were divided into 2
This systematic review/meta-analysis was based on
groups according to the type of anchorage used:
the PRISMA guidelines, and the main question was
conventional or skeletal. There was no distinction
defined with the PICO format (Table I).30 Using
between the different types of distalizers.
the main terms distalizers, distalization appliance,
A meta-analysis was performed according to
orthodontic distalization, noncompliance appliances,
a method proposed by Antonarakis and Kiliaridis28 and
first molar distalization, upper molar distalization,
Perillo et al.33 Data from each group (conventional and
and maxillary molar distalization, an electronic search
skeletal anchorage) were individually compared with
was conducted from 1970 to September 2010 in the
a control group in which the average was zero. Among
following databases: PubMed, Embase, Web of Science,
untreated subjects, these variables are about zero
Scopus, and Cochrane Library (Table II).
because of the short time of distalization.28 The standard
To identify potential articles, the initial search was
deviation is equal to the method error in the correspond-
performed by title and abstract. Initially, the selected
ing study. In studies that did not mention the method
articles were preferred to have the following inclusion
error, the mean error from studies that gave the data
criteria: published in English, human clinical trial, re-
was used. Only articles of medium and high quality
garding the correction of Class II malocclusion with non-
were included in the meta-analysis. The averages and
compliance molar distalization appliances, no reviews or
standard deviations of molar and premolar movements
opinion articles, no annals, and no theses. Duplicate
were extracted from the articles and subsequently
studies were eliminated. The selection process was
entered into RevMan software (version 5.0 for Windows;
independently conducted by 2 researchers (R.H.C.G.
Nordic Cochrane Centre, Copenhagen, Denmark) to
and M.P.P.), and their results were compared to identify
perform the meta-analysis.
discrepancies.
Heterogeneity was assessed by calculating the I2
When the abstract did not provide enough informa-
index. If there was evidence of heterogeneity, the
tion to make a decision, the article was completely
random effects model should be used.33-35 Forest plots
analyzed. Interexaminer conflicts were resolved by
were drawn, mean and confidence interval values were
discussion of each article to reach a consensus regarding
calculated (95% confidence interval), and significance
all selection criteria. Furthermore, hand searches of the
tests were carried out (to calculate P values).
reference lists of the selected articles were conducted.
At this stage, the previously selected articles were
rescreened according to the following additional RESULTS
inclusion criteria: correction of Class II malocclusion After the electronic database search, 947 studies were
with a noncompliance molar distalization appliance retrieved from PubMed, 138 from Embase, 151 from
without concomitant use of other appliances, descrip- Web of Science, and 185 from Scopus. No studies were
tion of measurable pretreatment and posttreatment identified from the Cochrane Library (Fig 1). After appli-
cephalometric variables, measurement of the amount cation of the initial inclusion and exclusion criteria and
of first or second premolar anchorage loss (mesial elimination of studies indexed in more than 1 database,
movement), minimum of 10 patients in each sample 178 were retrieved. The full texts were accessed, and all
group, no case reports, and growing patients. articles with adult patients (age, $18 years), sample size

American Journal of Orthodontics and Dentofacial Orthopedics May 2013  Vol 143  Issue 5
604 Grec et al

Table II. Search strategy

Database Key words Limits
PubMed Distalizers OR distalization appliance OR orthodontic distalization English language; humans, 1970 to September
OR noncompliance appliances OR first molar distalization OR 2010
upper molar distalization OR maxillary molar distalization
Embase Distalizers OR distalization appliance OR orthodontic distalization Only English; humans, 1970 to September 2010
OR noncompliance appliances OR first molar distalization OR
upper molar distalization OR maxillary molar distalization
Web of Science Distalizers OR distalization appliance OR orthodontic distalization English language; only articles (not reviews, letters,
OR noncompliance appliances OR first molar distalization OR abstracts, meetings, and editorials);1970 to
upper molar distalization OR maxillary molar distalization September 2010
Scopus Distalizers OR distalization appliance OR orthodontic distalization English language; only articles (not reviews, letters,
OR noncompliance appliances OR first molar distalization OR abstracts, meetings, and editorials);1970 to
upper molar distalization OR maxillary molar distalization September 2010
Cochrane Library Distalizers; distalization and appliance; orthodontic and
distalization; noncompliance and appliances, first and molar and
distalization; upper and molar and distalization; maxillary and
molar and distalization

treatment time, and amounts of molar and premolar

Table III. Methodologic quality scoring protocol
(maximum score, 9 points)
Study design
3 points: randomized clinical trial
2 points: if randomization process was not well described,
or if it was a controlled prospective study
1 point: uncontrolled prospective study
0 point: retrospective study or not mentioned
Sample size
1 point: larger than or equal to 15 subjects or prior
estimate of sample size
0 point: less than 15 subjects and no prior estimate
of sample size
Sample description
2 points: description of all 3 items (age, sex, Class II
malocclusion severity)
1 point: only 2 items described
0 point: only 1 item described
Error analysis
1 point: error analysis value cited
0 point: error analysis value not cited, or error analysis not
performed
Statistical analysis
2 points: adequate
1 point: partially adequate
0 point: no statistical tests conducted
less than 10 in at least 1 group, no evaluation of anchor-
age loss through premolar mesial movement and of
lateral cephalometric radiographs taken immediately
after molar distalization, and measurements of only
dental casts were excluded. Therefore, 40 studies fulfill-
ing all inclusion and exclusion criteria were included in
this systematic review (Fig 1).
From the remaining articles, we independently
extracted the following data: author names, year of
publication, anchorage method, type of distalizing
appliances, sample size, mean age of groups, distalizer
distalization and tipping.
Molar distalization with conventional anchorage was
evaluated in 36 studies, and with skeletal anchorage in 6.
Two studies evaluated both types of anchorage and were
therefore subdivided and separately inserted in the
table.36,37 The summarized data of the 40 articles
included in the review are shown in Table IV.
Quality assessment
After quality analysis, 2 articles were classified as high
quality, 27 as medium quality, and 11 as low quality
(Table V).
Among the high-quality articles, only that by
Papadopoulos et al9 received a full score. These authors
evaluated the treatment effects of the first class
appliance in patients with Class II malocclusion in the
mixed dentition. The study was a randomized clinical
trial with a sample of 15 treated children (mean age,
9.2 years). Another 11 subjects served as the control
group (mean age, 9.7 years). The first class appliance
was placed on the 2 maxillary first molars and the second
deciduous molars or the second premolars. A modified
Nance butterfly-shaped button was used as anchorage.
The mean molar distal movement was 4 mm with distal
tipping of 8.56 in 4.01 months. The mean premolar or
first deciduous molar mesial movement was 1.86 mm
(31.84% of anchorage loss) with 1.85 of tipping. The
control group showed distal molar movement of 0.04
mm in the same period.9
The other study classified as high quality compared
the dentoalveolar changes of Class II patients treated
with the Jones jig and the pendulum appliances.25 Forty
Class II malocclusion patients were divided into 2 groups
of 20. Group 1 (11 boys, 9 girls), with a mean

May 2013  Vol 143  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Grec et al
Fig 1. PRISMA flow diagram.
pretreatment age of 13.17 years, was treated with the
Jones jig appliance for 0.91 years, and group 2 com-
prised 20 patients (8 boys, 12 girls) with a mean pretreat-
ment age of 13.98 years, treated with the pendulum
appliance for 1.18 years. The maxillary second premolars
showed greater mesial tipping and extrusion in the Jones
jig group, indicating more anchorage loss during molar
distalization with this appliance. The amounts and the
monthly rates of molar distalization were similar in
both groups.
According to each criterion for quality analysis, the
following results were obtained.
Study design: only 2 studies were randomized clinical
trials with the randomization process described in detail.9,38
Sample size: the authors of 30 studies performed
sample-size calculation or had sample sizes larger than
or equal to 15 patients.
Selection description: 7 studies mentioned the
severity of the malocclusions.9,19,23,25,39-41 One article
American Journal of Orthodontics and Dentofacial Orthopedics
605
did not mention the mean age,36 and 2 articles did not
mention the sex of the sample.24,42
Error analysis: the authors of 24 studies performed
and described the method error results. Some studies
stated that the error of the method was performed but
did not present the results.3,20-22,24,36,38,43-45
Statistical analyses: the authors of 4 studies
performed only a descriptive analysis.3,18,24,46
Maxillary molar distalization appliances with
conventional anchorage
Treatment effects of distalizers with conventional
anchorage were analyzed in 43 groups assessed in 36
studies (Table IV).
Fourteen distalizers were used: first class, pendu-
lum, distal jet, Jones jig, dual force, Keles slider,
greenfield, jig appliance modified, pendex, 3-
dimensional bimetric maxillary distalizing arch
(3D-BMDA), intraoral bodily molar distalizer (IBMD),
May 2013  Vol 143  Issue 5
606 Grec et al

Table IV. Characteristics of included studies

Number Study Appliance Anchorage n

Conventional anchorage
1 Papadopoulos et al,9 2010 First class Nance button 15
2 Acar et al,47 2010 Pendulum Nance button 15
3 Haq et al,78 2010 Distal jet Nance button 30
4 Patel et al,25 2009 Jones jig Nance button 20
5 Patel et al,25 2009 Pendulum Nance button 20
6 Polat-Ozsoy et al,37 2008 Pendulum Nance button 17
7 Sch€utze et al,79 2007 Pendulum Nance button 15
8 € g et al,36 2007
Onça Pendulum Nance button 15
9 Angelieri et al,19 2006 Pendulum Nance button 22
10 Fuziy et al,23 2006 Pendulum Nance button 31
11 Mavropoulos et al,46 2006 Keles slider Nance button 20
12 Sayinsu et al,80 2006 Keles slider Nance button 17
13 Chiu et al,22 2005 Pendulum Nance button 32
14 Chiu et al,22 2005 Distal jet Nance button 32
15 Kinzinger et al,73 2005 Pendulum Nance button 10
16 Kinzinger et al,73 2005 Pendulum Nance button 10
17 Kinzinger et al,73 2005 Pendulum Nance button 10
18 Mavropoulos et al,18 2005 Jones jig Nance button 10
19 Ferguson et al,81 2005 Distal jet Enlarged acrylic Nance button 25
20 Ferguson et al,81 2005 Greenfield Enlarged acrylic Nance button 25
21 Fortini et al,82 2004 First class Modified acrylic Nance button 17
22 Papadopoulos et al,40 2004 Jig appliance modified Modified acrylic Nance button 14
23 Taner et al,83 2003 Pendex Nance button 13
24 Bolla et al,84 2002 Distal jet Nance button 20
25 Paul et al,38 2002 Jones jig Nance button 11
26 Nishii et al,85 2002 Distal jet Nance button 15
27 Chaqu
es-Asensi and Kalra,86 2001 Pendulum Nance button 26
28 Ngantung et al,39 2001 Distal jet Nance button 33
29 Keles,43 2001 Keles slider Nance button with an anterior bite plane 15
30 Toroglu et al,48 2001 Pendulum Nance button 14
31 Toroglu et al,48 2001 Pendulum Nance button 16
32 Bussick and McNamara,21 2000 Pendulum Nance button 101
33 €
Uçem et al,41 2000 3D-BMDA Intermaxillary elastic system 14
34 Brickman et al,20 2000 Jones jig Nance button 72
35 €
Haydar and Uner, 24
2000 Jones jig Nance button 10
36 Keles and Sayinsu,3 2000 IBMD Nance button 15
37 Bondemark,87 2000 Nickel-titanium coil Nance button 21
38 Bondemark,87 2000 Repelling magnets Nance button 21
39 Runge et al,45 1999 Jones jig Nance button 13
40 Gulati et al,42 1998 Sectional jig assembly Nance button 10
41 Byloff and Darendeliler,57 1997 Pendulum Nance button 13
42 Byloff et al,88 1997 Pendulum Nance button 20
43 Ghosh and Nanda,58 1996 Pendulum Nance button 41
Skeletal anchorage
1 Kinzinger et al,44 2009 Distal jet 2 mini-implants 10
2 Oberti et al,51 2009 Dual force 2 mini-implants used in maxillofacial 16
surgery for osteosynthesis 1 Nance button
3 Polat-Ozsoy et al,37 2008 Pendulum 1 or 2 mini-implants 1 Nance button 22
4 € g et al,36 2007
Onça Pendulum 1 implant 15
5 Escobar et al,49 2007 Pendulum 2 mini-implants 1 Nance button 15
6 Kircelli et al,50 2006 Pendulum 1 or 2 mini-implants 1 Nance button 10

nickel-titanium coil, magnets, and sectional jig and the Jones jig (6 articles). The most used anchorage
assembly. The pendulum appliance was the most reinforcement appliance was the Nance button and its
used (22 articles), followed by the distal jet (7 articles) variations (Table IV).

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Grec et al 607

Table IV. Continued

Distalization Molar Premolar Premolar
Average age (y) treatment time (mo) distalization (mm) Molar tipping ( ) movement (mm) tipping ( )
Conventional anchorage
9.2 4.3 4 8.56 1.86 1.85
15.0 3 4.53 5.13 0.27 2.2
12.8 7.11 2.93 3.41 0.95 7.33
13.2 10.92 3.12 9.54 2.55 9.29
13.9 14.16 3.51 10 2.23 2.37
13.6 5.1 2.7 5.3 2.3 3.8
12.6 8.46 3.83 6.45 1.18 1.94
– 7.25 5.03 6 2.16 2.98
14.5 5.85 2 9.4 3.6 6.6
14.6 5.87 4.6 18.5 2.65 2.5
13.1 4.37 3.1 4 3.2 6.1
13.5 – 2.85 2.56 2 2.21
12.5 7 6.1 10.7 1.4 1.7
12.3 10 2.8 5 2.6 0.3
9.9 6.22 3.93 6.35 1.05 0.7
11.6 4.45 3.43 5.05 1.4 0.4
12.6 5.95 4.20 2.55 0.8 1.8
13.2 4.37 1.9 6.8 2.08 7.5
12.5 7.87 3.4 3.2 1 3.1
11.5 10.4 3.9 6.5 2.9 0.2
13.4 2.4 4.0 4.6 1.7 2.2
13.4 4.12 1.4 6.8 2.6 8.1
10.6 7.31 3.81 11.77 0.73 4.08
12.6 5 3.2 3.1 1.3 2.8
14.8 6 1.17 4.56 0.18 –
14.6 6.4 2.4 1.9 1.4 –
11.2 6.5 5.3 13.06 2.21 4.84
12.8 6.7 2.12 3.26 2.6 4.33
13.3 6.1 4.92 0.89 1.31 1.25
13.1 5.7 5.9 14.9 4.8 3.9
12.9 5.03 4.1 13.4 6.6 5.9
12.0 7 5.7 10.6 1.8 1.5
12.2 1.5 3.5 1.8 2.1 1.4
13.7 6.35 2.51 7.53 2 4.76
10.7 2.5 2.80 7.85 3.35 6.05
13.5 7.5 5.23 1.15 4.33 2.73
14.4 6.5 2.5 2.2 1.2 2.1
13.9 5.8 2.6 8.8 1.8 6.7
14.5 6.5 2.23 4 2.23 9.47
12-15 4 2.95 3.5 1.05 2.6
11.1 4.15 3.39 14.5 1.63 –
13.1 6.81 4.14 6.07 2.22 –
12.4 6.2 3.37 8.36 2.55 1.29
Skeletal anchorage
12.1 6.7 3.92 3 0.72 0.79
14.3 5 5.9 5.68 4.26 5.43

13.6 6.8 4.8 9.1 4.1 9.9

– 6.75 3.95 12.2 3.1 6.795
13.0 7.8 6.00 11.31 4.85 8.62
13.5 7 6.4 10.9 5.4 16.3

The included studies evaluated patients during the ranged from 9.29 to 1547 years. Treatment times were
growth period, and the mean initial chronologic age 1.50 to 14.16 months.

American Journal of Orthodontics and Dentofacial Orthopedics May 2013  Vol 143  Issue 5
608
Molars demonstrated distal movements from 1.17 to
6.10 mm with conventional anchorage. The pendulum
appliance showed the greatest distalization in 7
months.22 The least distalization was obtained with
the Jones jig in 6 months.38 The greatest molar distal
tipping was 18.5 ,23 and the least was 0.89 .43
Anchorage loss could be identified in the studies with
conventional anchorage through premolar movement,
which showed positive values indicating mesial
movement. These values ranged from 0.27 mm in 3
months47 to 6.6 mm in 5 months48 with the pendulum
appliance. The greatest premolar mesial tipping was
9.47 observed in the study of Runge et al.45
Maxillary molar distalization appliances with
skeletal anchorage
In 6 studies, the treatment effects of distalizers with
skeletal anchorage were analyzed. Four studies used the
pendulum appliance to distalize the maxillary
molars,36,37,49,50 one used the distal jet,44 and the other
used the dual force.51 One36,37,50 or 237,44,49,51 implants
or mini-implants were used in the paramedian region of
the midpalatal suture as anchorage. The screw was
connected to an acrylic plate37,49-51 except in the
€ g et al36 (Table IV).
studies of Kinzinger et al44 and Onça
The mean initial chronologic age ranged from 12.144
to 14.351 years. One study did not report the mean initial
age.36 Treatment time ranged from 5.051 to 7.849
months.
The mean molar distal movement ranged from 3.944 to
50
6.4 mm, and the mean molar distal tipping ranged from
3.0 44 to 12.2 .39 The greatest distalization was obtained
with the pendulum and the smallest with the distal jet.
Studies with mini-implant anchorage showed
negative values for premolar movement ( 3.1 to 5.4
mm) indicating distal movement of these teeth and no
anchorage loss. Only the study of Kinzinger et al44
showed mesial movement (0.72 mm) and mesial tipping
(0.79 ) of premolars, indicating anchorage loss even
when associated with mini-implants.
No article with skeletal anchorage was classified as
high quality, 4 were classified as medium quality, and
2 had low quality (Table V).
Meta-analysis
After we assessed the quality of the 36 studies with
conventional anchorage included in the systematic
review, 34 were rejected because of low or medium
quality. Thus, the meta-analysis was conducted with 2
high-quality studies with no heterogeneity (I2 5 0%).
However, in the group with skeletal anchorage, no study
had high quality, and 2 articles with low quality were
May 2013  Vol 143  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Grec et al
excluded. The meta-analysis was conducted with 4
studies of medium quality, with heterogeneity of I2 of
82% in the analysis of molar distalization, and of I2 of
69% in the analysis of premolars.
One study with more than 1 group was subdivided
according to the number of groups and separately
included in the meta-analysis.25 Therefore, 3 items
were analyzed with conventional anchorage and 4 items
with skeletal anchorage.
The meta-analysis of molar distal movement had
estimated combined effects of 3.34 mm in studies with
conventional anchorage and 5.10 mm in studies with
skeletal anchorage (Figs 2 and 3).
As for the premolars, the meta-analysis showed average
mesial movements of 2.30 mm in studies with conven-
tional anchorage and 4.01 mm of distal movement in
studies with skeletal anchorage (Figs 4 and 5).
DISCUSSION
Since the introduction of intraoral distalizers for
Class II malocclusion treatment, studies have been
conducted to evaluate their distalizing effects and
anchorage losses with their use.
One systematic review evaluated the effects of intrao-
ral distalizers with conventional anchorage28 and the
other with skeletal anchorage.29 The purpose of this
meta-analysis was to compare the anchorage loss with
the use of these appliances with both types of anchorage.
There is no standardization regarding evaluation of
anchorage loss, which can be conducted by using the
premolars, incisors, and overjets as references. Because
anchorage loss can be underestimated by crowding of
the anterior teeth, the option was to determine loss of
anchorage by means of changes in premolar position.
Thus, studies that used the incisors and overjet as
references were excluded to decrease the variability
among the studies.
In a systematic review, it is important to evaluate the
quality of the articles and allow inclusion of better-
quality articles in the meta-analysis to decrease the
heterogeneity among them, with the goal of presenting
more reliable data.52 In health field investigations, which
involve patient treatments, significant degrees of
clinical, methodological, and statistical heterogeneity
are expected because of the nature of these studies
and the different variables involved, and the entire sys-
tematic review project must address this issue.34
Various factors should be considered to explain
this heterogeneity. One is the degree of occlusal
severity of the Class II malocclusions; this has a direct in-
fluence on the amounts of distalization and
anchorage loss after treatment. In other words, a complete
Grec et al 609

Table V. Assessment of the study quality

Method Adequacy of Judged
Study Sample Selection error statistical Quality quality
Number Study design 0-3 size 0-1 description 0-2 analysis 0-1 analysis 0-1 Score 0-9 standard
Conventional anchorage
1 Papadopoulos et al,9 2010 3 1 2 1 2 9 High
2 Acar et al,47 2010 1 1 1 1 1 5 Medium
3 Haq et al,78 2010 0 1 1 1 1 4 Medium
4 Patel et al,25 2009 2 1 2 1 2 8 High
5 Polat-Ozsoy et al,37 2008* 0 1 1 1 1 4 Medium
6 Sch€utze et al,79 2007 0 1 1 1 2 5 Medium
7 € g et al,36 2007*
Onça 2 1 0 0 1 4 Medium
8 Angelieri et al,19 2006 1 1 2 1 1 6 Medium
9 Fuziy et al,23 2006 1 1 2 1 1 6 Medium
10 Mavropoulos et al,46 2006 1 1 1 1 0 4 Medium
11 Sayinsu et al,80 2006 1 1 1 1 1 5 Medium
12 Chiu et al,22 2005 0 1 1 0 1 3 Low
13 Kinzinger et al,73 2005 1 1 1 1 1 5 Medium
14 Mavropoulos et al,18 2005 1 0 1 1 0 3 Low
15 Ferguson et al,81 2005 0 1 1 1 1 4 Medium
16 Fortini et al,82 2004 1 1 1 1 1 5 Medium
17 Papadopoulos et al,40 2004 1 0 2 1 2 6 Medium
18 Taner et al,83 2003 2 0 1 1 1 5 Medium
19 Bolla et al,84 2002 0 1 1 1 1 4 Medium
20 Paul et al,38 2002 3 1 1 0 1 6 Medium
21 Nishii et al,85 2002 1 1 1 1 1 5 Medium
22 Chaqu
es-Asensi and Kalra,86 2001 1 1 1 1 1 5 Medium
23 Ngantung et al,39 2001 0 1 2 1 1 5 Medium
24 Keles,43 2001 0 1 1 0 1 3 Low
25 Toroglu et al,48 2001 1 1 1 0 1 4 Medium
26 Bussick and McNamara,21 2000 0 1 1 0 1 3 Low
27 €
Uçem et al,41 2000 1 0 2 1 1 5 Medium
28 Brickman et al,20 2000 1 1 1 0 1 4 Medium
29 €
Haydar and Uner, 24
2000 2 0 0 0 0 2 Low
30 Keles and Sayinsu,3 2000 1 1 1 0 0 3 Low
31 Bondemark,87 2000 0 1 1 1 1 4 Medium
32 Runge et al,45 1999 0 0 1 0 1 2 Low
33 Gulati et al,42 1998 1 0 0 1 1 3 Low
34 Byloff and Darendeliler,57 1997 1 0 1 0 1 3 Low
35 Byloff et al,88 1997 1 1 1 0 1 4 Medium
36 Ghosh and Nanda,58 1996 0 1 1 1 1 4 Medium
Skeletal anchorage
1 Kinzinger et al,44 2009 1 0 1 0 1 3 Low
2 Oberti et al,51 2009 1 1 1 0 1 4 Medium
3 Polat-Ozsoy et al,37 2008* 0 1 1 1 1 4 Medium
4 € g et al,36 2007*
Onça 2 1 0 0 1 4 Medium
5 Escobar et al,49 2007 1 1 1 0 1 4 Medium
6 Kircelli et al,50 2006 1 0 1 0 1 3 Low

*Both studies compared the effects of the Pendulum on both anchorage types (conventional and skeletal).

Class II molar relationship requires greater molar distaliza-
tion and produces greater side effects on the anchorage
unit than does a quarter Class II molar relationship.8,53,54
Among the 40 studies included in the systematic
review, only 7 presented data regarding the initial occlu-
sal severity of the Class II malocclusions.9,19,23,25,39-41
Uç€em et al41 included only patients with a complete Class
II molar relationship; Papadopoulos et al40 included only
patients with over a half Class II molar relationship; and
Ngantung et al39 included only Class II up to 3 to 4 mm of
molar relationship discrepancy. The other articles in-
cluded patients with various severities.9,19,23,25,41 It
would be ideal if all investigators had selected patients
with a similar occlusal malocclusion severity, since it
would have allowed better comparisons among the
studies. However, obtaining sufficient numbers of
patients with the same characteristics in a clinical study
is difficult.55

American Journal of Orthodontics and Dentofacial Orthopedics May 2013  Vol 143  Issue 5
610 Grec et al

Fig 2. Forest plots representing molar distalization with conventional anchorage.

Fig 3. Forest plots representing molar distalization with skeletal anchorage.

Another factor related to heterogeneity is the use of
different cephalometric reference points.28 Some studies
have used the buccal cusps of the maxillary teeth, which
are difficult to locate because of image superimposition;
these teeth move excessively with accentuated
angulation and do not reflect actual molar and premolar
movements.56 Other studies were based on the center of
the clinical crown and the centroid point, which better
represent changes during treatment.20,39,45,57,58
Part of this heterogeneity is also related to the
different study designs (randomized clinical trials, case
control studies, and retrospective studies), lack of error
analyses, and different sample calculations with
consequent great variability in the numbers of patients
in the studies. In orthodontics, it is difficult to conduct
a randomized clinical trial on certain topics.31,59
Because there were only 2 randomized clinical trials,
we thought that other study designs that disclosed
important results on the effects of distalizers with
different anchorage systems should be included in this
systematic review. Therefore, quality assessment was
used instead of a risk of bias assessment, which is
more rigid and specific for randomized clinical trials.
The number of patients in the sample is important to
be able to represent part of a population; therefore, it
was 1 criterion for quality analysis.60
Another important criterion is a statistical analysis of
the data because it provides a mathematic interpretation
of the data.61 In this systematic review, the quality of 4
articles was compromised because the authors gave only
descriptive analyses.3,18,24,46
In all the evaluated studies, the patients were in
the growth stage, in which natural skeletal and dentoal-
veolar changes must be differentiated from the
appliance-induced effects.62 The mean initial chrono-
logic ages ranged from 9.29 to 1547 years. However,
craniofacial growth does not significantly interfere
when 2 distalization modalities are compared because
distalization time is short.
The different types of distalizers used was also
a methodologic variable that must be considered. These
appliances have an active unit that applies a distalizing

May 2013  Vol 143  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Grec et al 611

Fig 4. Forest plots representing premolar movement with conventional anchorage.

Fig 5. Forest plots representing premolar movement with skeletal anchorage.

force with various mechanisms. Because the intention
was to compare the changes in the 2 types of anchorage,
these differences would not play a significant role, since
the anchorage units were similar (a Nance button
supported on the premolars), except for Kinzinger
et al,63 who used the deciduous molars for conventional
anchorage. In the skeletal type, the anchorage unit was
a mini-implant37,44,49-51 or an implant.36
These methodologic limitations were the reason for
considering 11 studies to be low quality, 29 medium
quality, and only 2 high quality. Of these 2 studies,
only one obtained the maximum score possible.9 Of
the 11 low-quality studies, 7 were published over 10
years ago. The 2 studies considered to be high quality
were from 2009 and 2010, indicating greater concern
with quality because of increasingly demanding
scientific methodologic criteria.
In this review, we observed that the most frequently
used distalizer was the pendulum and its variations.
This might be explained because this distalizer has
a low cost and is easy to fabricate, whereas with other
distalizers (distal jet, Jones jig, first class), one needs to
buy a kit that requires more complex laboratory
fabrication.15 As anchorage, all used a Nance button,
€
except for Uçem et al,41 who used intermaxillary elastics
as recommended for the 3D-BMDA appliance.64,65
The great variation in distalization time (1.50-14.16
months) in the studies might be the result of variations
in the amount of force applied by each type of appliance
and the different Class II malocclusion occlusal severities
of the samples, which demanded different amounts of
distalization ( 1.17 to 6.10 mm).
In the same way as in conventional anchorage, the
pendulum appliance was the most used in the studies
that used skeletal anchorage. Associated with skeletal
anchorage, most also opted for the Nance button. Use
of the Nance button might be a way to reduce possible
movement of the mini-implants.66

American Journal of Orthodontics and Dentofacial Orthopedics May 2013  Vol 143  Issue 5
612
Studies that associated intraoral distalizers with
skeletal anchorage in the palate used devices with
various diameters and lengths. However, these factors
do not interfere with the stability or the effectiveness
of the mini-implant to increase anchorage.67,68 All
devices used had diameters greater than 1.0 mm,
because thinner mini-implants can have considerable
failure rates.69
The majority of the studies used 1 or 2 mini-implants
inserted in the paramedian region; this is considered
better for mini-implants in growing patients because
the midpalatal suture consists of connective tissue,
and insertion in this suture could compromise reten-
tion.70-72
Differently from conventional anchorage, there were
fewer variations in treatment times (5.0-7.8 months),
amounts of distalization ( 3.9 to 6.4 mm), and
anchorage loss ( 3.1 to 5.4 mm). Although the studies
with skeletal anchorage did not mention the anteropos-
terior occlusal severity of the malocclusion, it is believed
that there is a tendency to select patients with greater
severity for treatment with this type of anchorage.
Mini-implants can be used as direct or indirect
anchorage. In direct skeletal anchorage, mini-implants
directly receive the force of reaction resulting from
movement, whereas in indirect anchorage, the force is
received on the anchor teeth that are supported by the
mini-implants.73 Of the 6 studies included in the system-
atic review, 5 that used direct anchorage showed
spontaneous distal movement of the premolars,
probably due to stretching of the interseptal
fibers.36,37,49-51 In the study that used indirect
anchorage, loss of anchorage, although small, was
shown.44 This is because the reaction force, in conjunc-
tion with other factors, such as movement of the
mini-implants due to absence of osseointegration or
bone elasticity, flexibility of the premolar–mini-implant
connecting wire, or insufficient contact of the wire
with the mini-implant and the periodontal ligament,
might result in mesialization of premolars even when
associated with mini-implants.49,70
Kinzinger et al44 used the distal jet associated
with mini-implants in the palate, including the 2 first
premolars instead of the second premolars. After
distalization of the molars, the second premolars
underwent spontaneous distalization of 1.87 mm;
however, there was no reduction in anterior crowding,
because the first premolars that had indirect anchorage
showed mesialization of 0.72 mm.
To enable a meta-analysis, careful selection was
made, and only 2 studies in the group with conventional
anchorage were included because they were of high
quality. However, since there were no high-quality
May 2013  Vol 143  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Grec et al
articles in the group with skeletal anchorage, the
meta-analysis was performed with medium-quality
articles; this resulted in high heterogeneity.
When there is heterogeneity, alternative analyses
such as meta-analysis in subgroups and meta-
regression could be considered to explain the variability
among the groups; however, these types of analyses
require many studies.52 When this is not the case, the
random-effects model is recommended.74 This can
also be used when the researcher combines various
studies with the same objective that were not conducted
in the same manner.34,74 This justifies its use in this
study.
The clinical success of molar distalization and Class II
malocclusion correction was observed in both groups
(conventional and skeletal anchorage) evaluated in this
study. However, the meta-analysis showed a greater
mean distalization in the skeletal anchorage group,
similar to the results of Polat-Ozsoy et al.37 The
difference between the groups was 1.76 mm. The greater
distalization in the group with skeletal anchorage might
have been due to the tendency to include patients with
more severe Class II malocclusions, when greater
anchorage is desired.
The use of intraoral distalizing appliances with
conventional anchorage has shown anchorage loss,
which was confirmed in this meta-analysis.70,71,75 This
is because the Nance button and the anterior teeth
cannot resist the opposing forces of distalization
without moving in the opposite direction.36,44
Consequently, associating intraoral distalizers with
skeletal anchorage has been an approach to achieve total
anchorage during distalization.36,37,44,49-51,66,70 The 4
studies included in the meta-analysis used direct
anchorage, which explains the net distal movement of
the premolars.
Direct skeletal anchorage produces fewer side effects
resulting from distalization mechanics, due to sponta-
neous distal migration of the premolars; this
reduced anterior crowding, facilitating the fixed
appliance treatment phase and decreased treatment
time.36,49,50,71
Even though the studies with direct anchorage
showed no anchorage loss, side effects of anterior
movement of mini-implants can occur, caused by the
reaction force from the molars.36,49 Skeletal anchorage
does not eliminate the reaction force during
orthodontic treatment but transfers it to the bone,
which has plasticity when subjected to forces and thus
allows movement of mini-implants.76,77
The efficiency of intraoral distalizers in clinical
applications depends on a stable anchorage unit.75
Anchorage is a decisive factor for successful
Grec et al
orthodontic treatment with these appliance types and
must be an initial concern of orthodontists in this type
of treatment.
CONCLUSIONS
Molar distalization was shown to be effective with
both anchorage systems. The amounts of distal molar
movement were 3.34 mm with conventional anchorage
and 5.10 mm with the skeletal anchorage system.
The conventional anchorage system showed anchor-
age loss, represented by premolar mesial movement of
4.01 mm. The skeletal anchorage system showed no
anchorage loss and spontaneous distal premolar
movement of 2.30 mm when direct anchorage was
used. Therefore, intraoral distalizers associated with
direct skeletal anchorage seem to be a viable method
to minimize the effects of anchorage loss in the
treatment of Class II malocclusions.
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