Review question
The main question addressed by this review is how effective are orthodontic appliances in moving the upper teeth backwards in children and adolescents.
Background
Orthodontic treatment is a type of dental care that corrects crooked or sticking out teeth by moving the teeth into different positions. When orthodontic treatment is provided with braces it is sometimes necessary to move the upper molar teeth backwards (distalise). This is achieved by special types of braces (appliances) that are placed either before or at the same time as the normal braces. Appliances which move the upper molar teeth backwards can be placed inside the mouth (intraoral appliance) or attached to the back of the head (extraoral appliance). The most commonly used extraoral appliance is headgear. The biggest disadvantage of headgear is that children and adolescents must wear it for prolonged hours during the day. In addition, serious eye injuries have been reported while wearing headgear. As an alternative, several intraoral appliances have been developed. Unfortunately, their effects have not been completely evaluated.
Study characteristics
This review of existing studies was carried out by the Cochrane Oral Health Group, and the evidence is current as of December 2012. In this review there are 10 studies published between 2005 and 2011 in which a total of 354 children were randomised to receive treatment with a distalising orthodontic appliance and compared to either no treatment, headgear or another distalising appliance. The age range of children in nine of the studies was from 11 to 15 years, although the children recruited to one study were younger, from nine to 10 years old. Both girls and boys participated in the studies.
Where it was mentioned, the funding was from a university or dental research foundation. The authors did not assess the impact of the funding sources.
Key results
When intraoral appliances are compared to headgear they will probably move the upper molar teeth backwards more than headgear. However, the use of intraoral appliances was also associated with movement of the upper front teeth when compared to extraoral appliances in four studies. This is an unwanted effect that was not observed with the use of the headgear appliances.
Harm, injury from the appliances and other characteristics of the appliances which may be important to patients were not reported in the studies.
Quality of the evidence
The evidence presented is generally of low quality. The main shortcomings were related to trial design.
It is suggested that intraoral appliances are more effective than headgear in distalising upper first molars. However, this effect is counteracted by loss of anterior anchorage, which was not found to occur with headgear when compared with intraoral distalising appliance in a small number of studies. The number of trials assessing the effects of orthodontic treatment for distilisation is low, and the current evidence is of low or very low quality.
When orthodontic treatment is provided with fixed appliances, it is sometimes necessary to move the upper molar teeth backwards (distalise) to create space or help to overcome anchorage requirements. This can be achieved with the use of extraoral or intraoral appliances. The most common appliance is extraoral headgear, which requires considerable patient co-operation. Further, reports of serious injuries have been published. Intraoral appliances have been developed to overcome such shortcomings. The comparative effects of extraoral and intraoral appliances have not been fully evaluated.
To assess the effects of orthodontic treatment for distalising upper first molars in children and adolescents.
We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 10 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 10 December 2012) and EMBASE via OVID (1980 to 10 December 2012). No restrictions were placed on the language or date of publication when searching the electronic databases.
Randomised clinical trials involving the use of removable or fixed orthodontic appliances intended to distalise upper first molars in children and adolescents.
We used the standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of the risk of bias independently and in duplicate. We contacted authors to clarify the inclusion criteria of the studies.
Ten studies, reporting data from 354 participants, were included in this review, the majority of which were carried out in a university dental hospital setting. The studies were published between 2005 and 2011 and were conducted in Europe and in Brazil. The age range of participants was from nine to 15 years, with an even distribution of males and females in seven of the studies, and a slight predominance of female patients in three of the studies. The quality of the studies was generally poor; seven studies were at an overall high risk of bias, three studies were at an unclear risk of bias, and we judged no study to be at low risk of bias.
We carried out random-effects meta-analyses as appropriate for the primary clinical outcomes of movement of upper first molars (mm), and loss of anterior anchorage, where there were sufficient data reported in the primary studies. Four studies, involving 159 participants, compared a distalising appliance to an untreated control. Meta-analyses were not undertaken for all primary outcomes due to incomplete reporting of all summary statistics, expected outcomes, and differences between the types of appliances. The degree and direction of molar movement and loss of anterior anchorage varied with the type of appliance. Four studies, involving 150 participants, compared a distalising appliance versus headgear. The mean molar movement for intraoral distalising appliances was -2.20 mm and -1.04 mm for headgear. There was a statistically significant difference in mean distal molar movement (mean difference (MD) -1.45 mm; 95% confidence interval (CI) -2.74 to -0.15) favouring intraoral appliances compared to headgear (four studies, high or unclear risk of bias, 150 participants analysed). However, a statistically significant difference in mean mesial upper incisor movement (MD 1.82 mm; 95% CI 1.39 to 2.24) and overjet (fixed-effect: MD 1.64 mm; 95% CI 1.26 to 2.02; two studies, unclear risk of bias, 70 participants analysed) favoured headgear, i.e. there was less loss of anterior anchorage with headgear. We reported direct comparisons of intraoral appliances narratively due to the variation in interventions (three studies, high or unclear risk of bias, 93 participants randomised). All appliances were reported to provide some degree of distal movement, and loss of anterior anchorage varied with the type of appliance.
No included studies reported on the incidence of adverse effects (harm, injury), number of attendances or rate of non-compliance.