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    A Comparison of The Efficacy of Fixed

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    sharyl

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    © All Rights Reserved
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    European Joumal of Ortodontcs, 208, 821-850 oi 10 108joj098 ‘Advance Access publication 30 November 2015, Systematic review A comparison of the efficacy of fixed versus removable functional appliances in children with Class Il malocclusion: A systematic review Moaiyad Moussa Pacha, Padhraig S. Fleming and Ama Johal Oral Growth and Development, Institute of Dentistry, Queen Mary University of London, London, UK Correspondence to: Ama Johal, Oral Growth and Dovelopmont, Institute of Dentistry, Queen Mary University of London, ‘Whitechapel, London E1 2AD, UK. E-mail asjohalqmulac.uk ‘Summary Objectives: To systematically compare the efficacy of fixed and removable functional appliances in Class II malocclusion in terms of morphological and patient-centred outcomes. Search methods: A comprehensive search of electronic databases without language or time restrictions was undertaken, applying a pre-specified search strategy. Supplementary electronic searching of orthodontics journals and references list of included studies was performed, Selection eriteria: Randomized (RCTs) and controlled (CCTs) clinical trials involving children under 16 years with Class Il malocclusion and overjet more than 5mm were included. Data collection and analysis: A range of clinician- and patient-centred outcomes were evaluated and compared, Risk of bias assessment was carried out using the Cochrane Collaboration tool Results: Only four clinical trials were found to meet our criteria, of which two were RCTs, comparing the Herbst and the Twin Block appliances. Two further CCTs, compared the Activator to the Forsus and theTwin Force Bite Corrector, respectively. One study was assessed to be at unclear and the remaining at high risk of bias, precluding meta-analysis. There was also significant clinical heterogeneity in terms of methodology, type of intervention and the measured outcomes. Both modalities were effective in correcting the overjet with litle differences found in cephalometric changes and a shortage of data concerning patient-centred outcomes. Conclusion: There is little evidence concerning the relative effectiveness of fixed and functional appliances or in relation to patient experiences and perceptions of these treatment modalities. Further well-designed clinical trials assessing the relative merits of both clinician- and patient- centred outcomes are needed. Introduction oer) Furetional appliances have been used for over a century in agement of Clas I malocclusion being proven to produce a combi tion of dental snd skeletal effects during the testment phase 0 cifectively reduce overt in growing patients (I). There ate marked dlferences in the specific choice of functional appliance type inter nationally with, for example the Herbst most popular among USA and mainland European orthodontists (2) and the Twin Block (FB) most prevalent inthe UK (3). (©The Athor 205, Pulshed by Oslo rivers Pras on eb fhe European Otho Soi ih For poisson, 8 eal jeurtalsperissionsdoup.com “The primary difference herweun fixed, removable and hybsid fone tional appliances is che premium on compliance with removable aad hybrid varans whilst fllsime wear is guaranteed withthe fixed type. Fixed functional appliances may be further sub-class asf righ fixed flexible and fxed hybvid (4) The fixed sig variants including the Herbst apliance have been shown to have both skeletal and den toalveolar effets (5), Other appliances in this group include the fixed tin block and mandkibalar anterior repositioning apanse (MARA). Amongthe five sible group isthe Jasper Jumper Fsed hybrid fone sionals encompass features of igi and exible pplances with epring cd on foo'dno 2uuepeney edu wow papeoRUMER 1202 uoteW 62 vo yson6 Aq sessezz/\Z9IB/86/ ANI 2 European Journal of Orthodontics, 2016, Vol. 38, No. 6 providing the leit to the device for example Fors fatigue device and Tin Forse bie corrector (4 5). These applinces may give con stant horizontal forces, parsculsely when the mouth ielosed and have annadditive headgear eet (6), Whilecompliance ies important with fixed fnctional appliances, they maybe less fongving in other eespests may require addtional chacsde ime an laboratory support andl may he more prone to satstrophic breakages (7)- However the refinement ‘of fixed functional particularly the more exible variants, offer greater freedom in mandibular excursion and forward movement, potentially enhancing patient comfort |S). Previous systematic eviews have attempted to evaluate the effets ‘of functional appliances (9, 10) Others have ben eesti to the “analysis ofa single type of Functional appliances (11-14). Sims, ‘others have been confined to the assesment of a specific sksletl change or have heen restricted to sot tse changes alone (15, 18) Moce recealy the effets of removable and fixed functional appl aces have ben also asst in isolation and in comparison to an tantreated control group (17, 18} with an emphasis on eephlometsi= changes. There is, however increasing emphasis on patent exper ‘enees during teatment and an appreciation that orthodontic research has typically been blinkered in concentrating om clinician-cenred esses of treatment outcome eather than more holistic assessment With consideration of patient perspectives (19). To date, there i 20 review comparing the efficacy of fixed versus removable functional appliances accounting for patient-cenred as well 5 tational ln an centred outcomes. Objectives “To systematically asses che literature in respect of the eficacy of fixed and cemovable functional appliances in young patients, with Class I malocchision, in tems of hath morphological skeletal, den: tal and sof sssue) and patiene-cenred outcomes, Materials and methods “The protocol forthe cusent systematic review was registered with the National Institute of Health Research Database (yrww:ced york, ‘e.tkiprospero, Protocol ID. CRDS#2015016730). This review hos boa reported inthe light of PRISMA statement (20) Inclusion eriteria 1 Participants Children es than 16 years old with Class I malo clusion and overee greater than Sn © Imerventions: Ay type of fixed functional appliances + Comparison: Ang typeof removable functional appliances + Outcome measures: The primary outcomes were measures of skeleal, dento-alvolar and soft dssue correction, including outer sources 0-9) ea | orate dupes ad raean aE ove in om ley 3) nn lot “ptosis Zone sees (2326) ‘eguateane sae foo ET Se G Figure. PRISMA flow diagram, 1202 vase 62 Uo yeen6 hq geageZz/LZaraRE/ANIR/OejLi9e dno oMepeDey edit Woy PaREOHLAOD os MM. Pacha eal Downloaded from htps:facademic.oup comiejtarce/38/61621/2738905 by quest on 29 March 2021 argos 9p ony pours 3 ne vas ou 08s 503 205 we HEHE YONS OL -sseqd vaso sas 20 ag eyo 2, “sgn 9 20) “pads Sapa yt ote ‘sy sao >s0u3 930} put smd Va SUE Uae 288 3 sour 9 0} ay sss 9 poo, ovo yu uonuaas a8 ‘so sop ade ae 28909 yor pur fap PS 119200 VC EOIN ANS 44 T-ORLL) OE Poe aguMN, (eovesnsy zt ‘snsiog Z1)"¥2 pamsopms sagan. PETE L9 TH HovesHDY S60 TTC TL sso (as 289) aa 2 9 29 per SUerer ny SOF OE LAF prstay som sone 9 woneap e099 96'S HSL 8H 1 yoy spogaus mausms2y "100 slop, yeu yay spoqpaus eowssnse97y "13 88899 st panodsy 39g amos Spun poodas oy pound aus >y Hsano9 jo 94 yan sony pe oe] rue yay spogenus ouineayy ed son on 2enf-z00 [e129 Dany, (ooh P sere ro 909 sovyny ssrostug sterg epesey (6 ‘Te es UE Se sea0580, womb smd fas syu08) vonELDs40, poe 70 nis papnul jo susueRELeYD European Journal of Orthodontics, 2016, Vol. 38, No. 6 “able 1. Continued peed Parisians (ovonthse SD} Method Seady and dental mcs eset Caste design, SWA when spplcale 2 2 EB 7 g E jen (7) on i : i 3 ; 6 4 E z g TB. 1128, ing period: March 1997-Iune 1998 [No Centers: 13 centers 2 z 2 = i : 2 5 % i : i second phase of SWA excep sport Age at baseline eas mean): TB: 12.41; Herbst 1247 § e 3 i $ i i i i ‘Corelsion bermeen 21s, and eaten Number of radomized 8 i st = 105 (55 Fy OM 8M) arsion and complitce Relation between gender sod ata were analysed Name evaluated: n= 183 ; 3 j i i s i , standard deviation; female M, male; SHA taght wie ap Bin Hoes TFC, infos bite corrector icon clinical and lateral cephalometric measurements and the dura tion of treatment. The sscondary outcomes inclided patients experiences of teatment and quality of life using validated indi ey haem arising during tearment (including traumatic injuries and appliance breakages) and costs of both treatment. + Randomized or non-randomized controlled clinical trials were tobe incladed Exclusion criteria “Trials involving patients with clef lip or palate orothee craniofacial syandromes were exchided, Other non-randomized studies including ‘observational retrospective designs were omitted. ‘Search methods for identification of studies A comprehensive clestrnic search without ine or language restric: tions eas sndertaken (Supplementary Tables 1 sn 2). Iv addition, the corresponding authors of included studies were to be contacted asking for futher clarifications where necessary or other related suis Data collection and management Study selection “The tdes and abstract of all tudis idemited chrough the searches ‘were assessed independently and in duplicate by ewe review authors [MM A), For studies remaining after the climination process on ‘the bass of tile and abstract, the fall article was ro be oktsined Disageeements were to be resolved through discussion with the thied author PSE) Date extraction “The following information was to be recorded using customized forms to aid assessment of heterogencty of included studies: study

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