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Angle class II correction: stepwise mandibular advancement or bite jumping?

A systematic review and meta-analysis of skeletal, dental and condylar effects

Therapie der Angle-Klasse II: Schrittweise mandibuläre Vorverlagerung oder Bite-Jumping?

Ein systematisches Review mit Metaanalyse skelettaler, dentaler und kondylärer Effekte

  • Systematic Reviews and Meta-Analyses
  • Published:
Journal of Orofacial Orthopedics / Fortschritte der Kieferorthopädie Aims and scope Submit manuscript

Abstract

Introduction

There is no consensus regarding which mode of activation or mandibular advancement (stepwise [SW] or maximum bite-jumping [BJ]) of fixed or removable functional appliances (FFA; RFA) for correction of Angle class II malocclusion is advantageous to produce dental, skeletal or condylar effects and has the lowest rate of undesired dental or technical side-effects.

Methods

A systematic search was conducted up to Oct. 20, 2019 in the MEDLINE, EMBASE, Scopus, Central Cochrane Library, and BBO databases. Included were preadolescent, adolescent, and adult humans with initial (pretreatment) Angle class II malocclusion, without further restriction. The intervention group was composed of subjects treated with FFA or RFA in SW mandibular advancement; the control group received BJ advancement. Search terms included prospective randomized and nonrandomized trials in English, German, Spanish, and Portuguese with the primary outcomes of skeletal and dental class II correction, effects on condylar growth, lower incisor proclination, overjet and overbite reduction. The risk of bias (ROB) was assessed using the Cochrane Collaboration’s ROB2 tool. Mean differences were calculated and pooled by a meta-analysis using a random effects model.

Results

Data from five randomized controlled trials (RCT) with 401 participants (mean age 13.84 years; SD 1.53) were included; 331 derived from four studies were included in the meta-analysis. The ROB in the selected articles was high. We detected a slightly increased reduction of the ANB (mean difference [MD] −0.95°, 95% confidence interval [CI] −1.80 to −0.10°; I2 = 72%) that may be attributed to a slightly more pronounced increase of the SNB angle in SW-advanced mandibles (MD 0.27°; 95% CI −0.47 to 1.00°; I2 = 38%). SW advancement tended to reduce the undesired side effect of lower incisor proclination (MD = −1.59°; 95% CI −3.98 to 0.8°; I2 = 0%), indicating more pronounced mandibular incisor changes with bite-jumping advancement.

Conclusion

There is weak evidence indicating a slightly increased reduction of the ANB and less lower incisor proclination with SW advancement compared to BJ, but the clinical relevance is debatable due to the small overall magnitude and small number of high-quality papers.

Registration

Prospero #CRD42017075469 (www.crd.york.ac.uk/prospero)

Zusammenfassung

Einleitung

Es gibt keinen Konsens dazu, welche Art der Aktivierung von festen bzw. herausnehmbaren funktionskieferorthopädischen Geräten (FFA, RFA) bzw. des Vorverlagerns des Unterkiefers (schrittweise [SW] oder maximales Bite-Jumping [BJ]) zur Korrektur von Angle-Klasse-II-Malokklusion Vorteile auf skelettaler, dentaler und kondylärer Ebene bietet sowie die geringsten unerwünschten dentalen oder technischen Nebenwirkungen zeitigt.

Methode

Eine systematische Literatursuche wurde bis einschließlich 20. Oktober 2019 in den Datenbanken MEDLINE, EMBASE, Scopus, Central Cochrane Library und BBO durchgeführt. Inkludiert wurden präadoleszente, adoleszente und erwachsene Patienten mit initial bestehender Angle-Klasse-II-Malokklusion, ohne weitere Einschränkung. In der Interventionsgruppe wurde der Unterkiefer mit FFA oder RFA schrittweise vorverlagert; in der Kontrollgruppe hingegen per Bite-Jumping. Die Suche konzentrierte sich auf prospektive randomisierte und nicht-randomisierte Studien in Englisch, Deutsch, Spanisch oder Portugiesisch mit den primären Endpunkten der skelettalen und dentalen Klasse-II-Korrektur, der Effekte auf das Kondylenwachstum, der Proklination der unteren Schneidezähne, sowie der Reduktion der sagittalen und vertikalen Frontzahnstufe. Die Bestimmung des Risk-of-Bias (ROB) erfolgte mit dem ROB2-Tool der Cochrane Collaboration. Mittelwertunterschiede wurden berechnet und in einer Metaanalyse unter Verwendung eines Random-Effects-Modells zusammengefasst.

Ergebnisse

Daten von 5 RCT („randomized controlled trials“) mit 401 Probanden (Durchschnittsalter: 13,84 Jahre; SD [„standard deviation“] 1,53) wurden in das Review einbezogen, 331 Probanden aus 4 Studien in die Metaanalyse. Das ROB in den inkludierten Studien war hoch. Es zeigte sich eine etwas größere Reduktion des ANB mit SW-Vorverlagerung (MD −0,95°, 95 %-KI [Konfidenzintervall] −1,80 bis −0,10°; I2 = 72 %), die möglicherweise auf eine etwas stärkere Zunahme des SNB-Winkels in der Interventionsgruppe zurückzuführen ist (MD 0,27°, 95 %-KI −0,47 bis 1,00; I2 = 38 %). Die schrittweise Vorverlagerung zeigt die Tendenz, die unerwünschte Nebenwirkung der Proklination der unteren Schneidezähne zu verringern (MD = −1,59°; 95 %-KI −3,98 bis 0,8°; I2 = 0 %), was im Vergleich auf eine erhöhte mandibuläre Inzisivi-Protrusion beim Bite-Jumping hindeutet.

Schlussfolgerung

Es wurde eine schwache Evidenz für eine etwas größere Reduktion des ANB und eine geringere Proklination der mandibulären Schneidezähne mit schrittweiser Aktivierung im Vergleich zum Bite-Jumping festgestellt. Die klinische Relevanz dieser Ergebnisse ist jedoch aufgrund der geringen Größe der Unterschiede und der geringen Anzahl der inkludierten Studien disputabel.

Registrierung

Prospero #CRD42017075469 (www.crd.york.ac.uk/prospero)

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References

  1. O’Brien K, Wright J, Conboy F, Sanjie Y, Mandall N, Chadwick S, Connolly I, Cook P, Birnie D, Hammond M, Harradine N, Lewis D, McDade C, Mitchell L, Murray A, O’Neill J, Read M, Robinson S, Roberts-Harry D, Sandler J, Shaw I (2003) Effectiveness of treatment for Class II malocclusion with the Herbst or Twin-block appliances: a randomized, controlled trial. Am J Orthod Dentofacial Orthop 124:128–137

    Article  Google Scholar 

  2. O’Brien K, Wright J, Conboy F, Sanjie Y, Mandall N, Chadwick S, Connolly I, Cook P, Birnie D, Hammond M, Harradine N, Lewis D, McDade C, Mitchell L, Murray A, O’Neill J, Read M, Robinson S, Roberts-Harry D, Sandler J, Shaw I (2003) Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1: dental and skeletal effects. Am J Orthod Dentofacial Orthop 124:234–243

    Article  Google Scholar 

  3. Thiruvenkatachari B, Harrison JE, Worthington HV, O’Brien KD (2013) Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children. Cochrane Database Syst Rev 11:CD3452

    Google Scholar 

  4. Koretsi V, Zymperdikas VF, Papageorgiou SN, Papadopoulos MA (2015) Treatment effects of removable functional appliances in patients with Class II malocclusion: a systematic review and meta-analysis. Eur J Orthod 37:418–434

    Article  Google Scholar 

  5. Perinetti G, Primožič J, Franchi L, Contardo L (2015) Treatment effects of removable functional appliances in pre-pubertal and pubertal Class II patients: a systematic review and meta-analysis of controlled studies. PLoS ONE 10:e141198

    Article  Google Scholar 

  6. Pancherz H, Bjerklin K, Hashemi K (2015) Late adult skeletofacial growth after adolescent Herbst therapy: a 32-year longitudinal follow-up study. Am J Orthod Dentofacial Orthop 147:19–28

    Article  Google Scholar 

  7. Banks P, Wright J, O’Brien K (2004) Incremental versus maximum bite advancement during Twin-block therapy: a randomized controlled clinical trial. Am J Orthod Dentofacial Orthop 126:583–588

    Article  Google Scholar 

  8. Yang X, Zhu Y, Long H, Zhou Y, Jian F, Ye N, Gao M, Lai W (2016) The effectiveness of the Herbst appliance for patients with Class II malocclusion: a meta-analysis. Eur J Orthod 38:324–333

    Article  Google Scholar 

  9. Hägg U, Rabie AB, Bendeus M, Wong RW, Wey MC, Du X, Peng J (2008) Condylar growth and mandibular positioning with stepwise vs maximum advancement. Am J Orthod Dentofacial Orthop 134:525–536

    Article  Google Scholar 

  10. Madurantakam P (2016) Fixed or removable function appliances for Class II malocclusions. Evid Based Dent 17:52–53

    Article  Google Scholar 

  11. Pacha MM, Fleming PS, Johal A (2016) A comparison of the efficacy of fixed versus removable functional appliances in children with Class II malocclusion: a systematic review. Eur J Orthod 38:621–630

    Article  Google Scholar 

  12. Hansen K, Pancherz H, Hägg U (1991) Long-term effects of the Herbst appliance in relation to the treatment growth period: a cephalometric study. Eur J Orthod 13:471–481

    Article  Google Scholar 

  13. Ruf S, Pancherz H (1998) Temporomandibular joint growth adaptation in Herbst treatment: a prospective magnetic resonance imaging and cephalometric roentgenographic study. Eur J Orthod 20:375–388

    Article  Google Scholar 

  14. Purkayastha SK, Rabie ABM, Wong R (2008) Treatment of skeletal Class II malocclusion in adults: stepwise vs single-step advancement with the Herbst appliance. World J Orthod 9:233–243

    PubMed  Google Scholar 

  15. Rabie AB, Chayanupatkul A, Urban Hägg U (2003) Stepwise advancement using fixed functional appliances: experimental perspective. Semin Orthod 9:41–46

    Article  Google Scholar 

  16. Aras I, Pasaoglu A, Olmez S, Unal I, Tuncer AV, Aras A (2017) Comparison of stepwise vs single-step advancement with the Functional Mandibular Advancer in Class II division 1 treatment. Angle Orthod 87:82–87

    Article  Google Scholar 

  17. Wey MC, Bendeus M, Li P, Hägg U, Rabie ABM, Robinson W (2007) Stepwise advancement versus maximum jumping with headgear activator. Eur J Orthod 29:283–293

    Article  Google Scholar 

  18. Du X, Hägg U, Rabie ABM (2002) Effects of headgear Herbst and mandibular step-by-step advancement versus conventional Herbst appliance and maximal jumping of the mandible. Eur J Orthod 24:167–174

    Article  Google Scholar 

  19. Voudouris JC, Kuftinec MM (2000) Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: growth relativity. Am J Orthod Dentofacial Orthop 117:247–266

    Article  Google Scholar 

  20. Schiöth T, von Bremen J, Pancherz H, Ruf S (2007) Complications during Herbst appliance treatment with reduced mandibular cast splints: a prospective, clinical multicenter study. J Orofac Orthop 68:321–327

    Article  Google Scholar 

  21. Zymperdikas VF, Koretsi V, Papageorgiou SN, Papadopoulos MA (2016) Treatment effects of fixed functional appliances in patients with Class II malocclusion: a systematic review and meta-analysis. Eur J Orthod 38:113–126

    Article  Google Scholar 

  22. Nucera R, Militi A, Lo Giudice A, Longo V, Fastuca R, Caprioglio A, Cordasco G, Papadopoulos MA (2018) Skeletal and dental effectiveness of treatment of Class II malocclusion with headgear: a systematic review and meta-analysis. J Evid Based Dent Pract 18:41–58

    Article  Google Scholar 

  23. Bock NC, von Bremen J, Ruf S (2016) Stability of Class II fixed functional appliance therapy—a systematic review and meta-analysis. Eur J Orthod 38:129–139

    Article  Google Scholar 

  24. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6:1000097

    Article  Google Scholar 

  25. Higgins JPT, Green S (eds) (2011) “Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0”,The Cochrane Collaboration. http://handbook.cochrane.org. Accessed 13.03.2019

  26. Langendam MW, Akl EA, Dahm P, Glasziou P, Guyatt G, Schünemann HJ (2013) Assessing and presenting summaries of evidence in Cochrane Reviews. Syst Rev 2:81

    Article  Google Scholar 

  27. Falck F, Fränkel R (1989) Clinical relevance of step-by-step mandibular advancement in the treatment of mandibular retrusion using the Fränkel appliance. Am J Orthod Dentofacial Orthop 96:333–341

    Article  Google Scholar 

  28. Sakai N, Miyazawa K, Tsutsui T, Tabuchi M, Shibata M, Goto S (2016) Comparative study of the treatment effects of bionator and bite jumping appliances on Class II malocclusions. Orthod Waves 75:1–9

    Article  Google Scholar 

  29. Illing HM, Morris DO, Lee RT (1998) A prospective evaluation of Bass, Bionator and Twin Block appliances. Part I—the hard tissues. Eur J Orthod 20:501–516

    Article  Google Scholar 

  30. Doshi UH, Mahindra R (2014) Effective temporomandibular joint growth changes after stepwise and maximum advancement with Twin Block appliance. J World Fed Orthod 3:e9–e14

    Article  Google Scholar 

  31. Bishop B, Verrett R, Girvan T (2014) A randomized crossover study comparing two mandibular repositioning appliances for treatment of obstructive sleep apnea. Sleep Breath 18:125–131

    Article  Google Scholar 

  32. Aras I, Pasaoglu A, Olmez S, Unal I, Aras A (2016) Upper airway changes following single-step or stepwise advancement using the Functional Mandibular Advancer. J Orofac Orthop 77:454–462

    Article  Google Scholar 

  33. Gill DS, Lee RT (2005) Prospective clinical trial comparing the effects of conventional Twin-block and mini-block appliances: Part 1. Hard tissue changes. Am J Orthod Dentofacial Orthop 127:465–472

    Article  Google Scholar 

  34. Kumar S, Sidhu S, Kharbanda OP (1996) A cephalometric evaluation of the dental and facial-skeletal effects using the Bionator with stepwise protrusive activations. J Clin Pediatr Dent 20:101–108

    PubMed  Google Scholar 

  35. Amuk NG, Baysal A, Coskun R, Kurt G (2019a) Effectiveness of incremental vs maximum bite advancement during Herbst appliance therapy in late adolescent and young adult patients. Am J Orthod Dentofacial Orthop 155:48–56

    Article  Google Scholar 

  36. Gul Amuk N, Kurt G, Baysal A, Turker G (2019b) Changes in pharyngeal airway dimensions following incremental and maximum bite advancement during Herbst-rapid palatal expander appliance therapy in late adolescent and young adult patients: a randomized non-controlled prospective clinical study. Eur J Orthod 41:322–330

    Article  Google Scholar 

  37. Hägg U, Du X, Rabie AB, Bendeus M (2003) What does headgear add to Herbst treatment and to retention? Semin Orthod 9:57–66

    Article  Google Scholar 

  38. Chaiyongsirisern A, Rabie AB, Wong RWK (2009) Stepwise Advancement Herbst Appliance versus Mandibular Sagittal Split Osteotomy. Angle Orthod 79:1084–1094

    Article  Google Scholar 

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Funding

This review has not been funded.

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Authors and Affiliations

  1. Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, Universidad de La Frontera (UFRO), Temuco, Chile

    Michael Knösel,  Paulo Sandoval-Vidal DDS, MSc. &  Carlos Zaror DDS, MSc, PhD

  2. Private Practice, Hamburg, Germany

    Michael Knösel

  3. Department of Orthodontics, University Medical Center Göttingen (UMG), Göttingen, Germany

    Michael Knösel

  4. Center for Research in Epidemiology, Economics and Oral Public Health (CIEESPO), Faculty of Dentistry, Universidad de La Frontera, Temuco, Chile

    Gerardo Enrique Espinoza-Espinoza DDS, MSc. &  Carlos Zaror DDS, MSc, PhD

  5. Faculty of Dentistry, Universidad San Sebastian, Puerto Montt, Chile

    Carlos Zaror DDS, MSc, PhD

Authors
  1. Michael Knösel
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  2. Gerardo Enrique Espinoza-Espinoza DDS, MSc.
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  3. Paulo Sandoval-Vidal DDS, MSc.
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  4. Carlos Zaror DDS, MSc, PhD
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Corresponding authors

Correspondence to Michael Knösel or Gerardo Enrique Espinoza-Espinoza DDS, MSc..

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M. Knösel, G. Espinoza-Espinoza, P. Sandoval-Vidal and C. Zaror declare that they have no competing interests.

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The authors M. Knösel and G. Espinoza-Espinoza contributed equally to the manuscript.

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Knösel, M., Espinoza-Espinoza, G., Sandoval-Vidal, P. et al. Angle class II correction: stepwise mandibular advancement or bite jumping?. J Orofac Orthop 81, 286–300 (2020). https://doi.org/10.1007/s00056-020-00226-6

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  • DOI: https://doi.org/10.1007/s00056-020-00226-6

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