Resultados Del Tratamiento Completo de Ortodoncia Con Aparatos Fijos

THE KOREAN JOURNAL of
Review Article ORTHODONTICS
pISSN 2234-7518 • eISSN 2005-372X

https://doi.org/10.4041/kjod.2017.47.6.401
Outcomes of comprehensive fixed appliance

orthodontic treatment: A systematic review with
meta-analysis and methodological overview
Spyridon N. Papageorgiou Objective: The aim of this systematic review was to assess the occlusal outcome
Damian Höchli and duration of fixed orthodontic therapy from clinical trials in humans with the
Theodore Eliades Objective Grading System (OGS) proposed by the American Board of Orthodontics.
Methods: Nine databases were searched up to October 2016 for prospective/
retrospective clinical trials assessing the outcomes of orthodontic therapy with
fixed appliances. After duplicate study selection, data extraction, and risk of bias
assessment according to the Cochrane guidelines, random-effects meta-analyses
Clinic of Orthodontics and Pediatric of the mean OGS score and treatment duration were performed and 95% con
Dentistry, Center of Dental Medicine,
fidence intervals (CIs) were calculated. Results: A total of 34 relevant clinical
University of Zurich, Zurich, Switzerland
trials including 6,207 patients (40% male, 60% female; average age, 18.4 years)
were identified. The average OGS score after treatment was 27.9 points (95%
CI, 25.3–30.6 points), while the average treatment duration was 24.9 months
(95% CI, 24.6–25.1 months). There was no significant association between
occlusal outcome and treatment duration, while considerable heterogeneity
was identified. In addition, orthodontic treatment involving extraction of four
premolars appeared to have an important effect on both outcomes and duration
of treatment. Finally, only 10 (39%) of the identified studies matched compared
groups by initial malocclusion severity, although meta-epidemiological evidence
suggested that matching may have significantly influenced their results.
Conclusions: The findings from this systematic review suggest that the occlusal
outcomes of fixed appliance treatment vary considerably, with no significant
association between treatment outcomes and duration. Prospective matched
clinical studies that use the OGS tool are needed to compare the effectiveness of
orthodontic appliances.
[Korean J Orthod 2017;47(6):401-413]
Key words: Orthodontics, Treatment outcome, Treatment duration, Meta-analysis
Received January 10, 2017; Revised February 21, 2017; Accepted March 29, 2017.
Corresponding author: Spyridon N. Papageorgiou.

Senior Teaching and Research Assistant, Clinic of Orthodontics and Pediatric Dentistry,
Center of Dental Medicine, University of Zurich, Plattenstrasse 11, Zurich 8032, Switzerland.
Tel +41-44-634-32-87 e-mail [email protected]
The authors report no commercial, proprietary, or financial interest in the products or companies
described in this article.
© 2017 The Korean Association of Orthodontists.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.
401
Papageorgiou et al • Occlusal outcome of orthodontic treatment
INTRODUCTION MATERIALS AND METHODS

Fixed appliances have become an integral part of Protocol and registration
comprehensive orthodontic treatment as versatile The protocol for this systematic review was prepared a
tools that enable three-dimensional control of tooth priori and registered in PROSPERO (CRD42016049203),
movement. Through the years, considerable effort and all post hoc changes were appropriately noted.
has been invested in the optimization of orthodontic This systematic review was conducted and reported in
appliances to increase their treatment efficiency,1-5 with accordance with the Cochrane Handbook14 and PRISMA
the primary goals of developing interventions that aim statement,15 respectively.
to enhance the therapeutic effects of fixed appliances
or interventions that aim to reduce the duration of Eligibility criteria
orthodontic treatment. We initially aimed to assess the comparative effective
Assessment of the success of orthodontic treatment ness of various orthodontic fixed appliances in terms
generally involves evaluations of the patient’s post- of occlusal outcomes using parallel randomized and
treatment records. However, without a valid and reliable prospective nonrandomized trials in human patients.
evaluation method, treatment outcome assessments are However, the pilot search indicated that very limited
difficult and often subjective. The American Board of material was available (only two prospective trials);
Orthodontics (ABO) developed the Objective Grading therefore, the review protocol was based on the
System (OGS) for the precise evaluation of orthodontic inclusion of prospective or retrospective cohort studies
treatment outcomes using the final dental casts and assessing fixed appliance orthodontic treatment to
panoramic radiographs of patients. 6 The OGS rates provide an explorative overview of treatment outcomes
eight criteria that contribute to ideal intercuspation (Appendix A). Studies where the OGS was not used or
and function. Best occlusion and alignment receive improperly used, nonclinical studies, and animal studies
a score of 0 points, while deviations from ideal are were excluded. Studies regarding novel orthodontic
given penalty points. Consequently, a high percentage appliances with an unclear evidence base were excluded
of accordance can be achieved in both interexaminer from the clinical part of the review but included in the
and intraexaminer assessments, as reported in the explorative methodological overview.
orthodontic literature.7 In addition to functioning as
an objective clinical examination tool, the OGS is also Information sources and literature search
used for the assessment of treatment progress and Nine electronic databases were systematically searc
final outcomes with increased reliability, validity, and hed, without any limitations, from inception up to
precision. 8 The ABO also developed the discrepancy October 7, 2016 (Appendix B). Two additional sources,
index (DI) as a pretreatment scoring system, which namely Google Scholar and the ISRCTN registry, and the
has become an accepted and reliable index for the reference/citation lists of included studies and relevant
quantification of treatment complexity on the basis of reviews were manually searched for additional studies
orthodontic diagnostic records.9 or protocols. There were no limitations concerning
A systematic evaluation of the range of typical language, publication year, or publication status.
treatment outcomes is crucial for the development
of a standard of care 10 that can be used to judge Study selection and data collection
the quality of orthodontic treatment. 11 To the best Titles identified from the search were screened by one
of our knowledge, no objective quality assessment author (SNP), and the corresponding abstracts/full texts
using the ABO OGS has been performed in the field were subjected to subsequent duplicate, independent
of orthodontics. Although previous systematic reviews checking using the eligibility criteria by a second author
have investigated the typical duration of orthodontic (DH), while conflicts were resolved by a third author (TE).
treatment,12,13 they have not assessed the possible asso The characteristics of included studies and numerical
ciation between treatment duration and outcome, nor data were extracted in duplicate by two authors (SNP,
between treatment duration and initial discrepancy. DH) using predetermined and piloted extraction forms.
Therefore, the aim of this systematic review was to Missing or unclear information was requested from the
assess the occlusal outcomes and duration of fixed authors of the studies.
appliance orthodontic therapy from clinical trials in
humans with the OGS of the ABO. Risk of bias in individual studies
The risk of bias in the included nonrandomized studies
was assessed using the Downs and Black checklist16 after
initial calibration. Because the primary aim of this review
402 https://doi.org/10.4041/kjod.2017.47.6.401 www.e-kjo.org

was to provide an overview of possible OGS scores after subgroup sensitivity analyses according to precision.
orthodontic treatment, a main risk of bias assessment We planned to seek possible sources of heterogeneity
was included using the Downs and Black checklist for through prespecified random-effects meta-regressions
cohort studies. In a separate methodological over with the Knapp and Hartung adjustment at the study
view of comparative cohort studies with two or more level. These were based on the patient age, sex (% male
experimental groups, we also assessed whether con patients), extraction rate, and mean baseline DI. In
founding due to baseline differences in malocclusion addition, a possible interrelation between the mean OGS
severity measured using the DI between compared score and treatment duration was investigated.
groups was appropriately addressed by matching or Sensitivity analyses were performed by dividing
covariate adjustment. included cohort studies into (a) those that explicitly re
ported the use of only one-phase fixed-appliance treat
Data synthesis: cohort studies ment and (b) those that reported the use of two-phase
The outcome of fixed appliance treatment is bound treatment or those that did not provide clear reports.
to be affected by patient- and appliance-related cha If considerable differences were identified between
racteristics.3-5 Accordingly, a random-effects model pro these subsamples, the subsample with clear reporting
posed by Paule-Mandel17 was deemed appropriate to of one-phase fixed appliance treatment was used,
incorporate this variability18 because it outperforms the because direct comparison between one- and two-phase
older DerSimonian and Laird estimator.17 A weighted treatment was neither possible nor within the scope of
mean with the corresponding 95% confidence interval this study. All statistical analyses were performed using
(CI) was calculated across studies for the primary and Stata SE 14.2 (Stata Corp, College Station, TX, USA)
secondary outcome as a primary analysis. The produced by one author (SNP). A two-tailed p -value of 0.05 was
forest plots were augmented with contours denoting the considered significant for hypothesis testing, although
magnitude of the observed effects.19 for heterogeneity testing and reporting bias testing, a
value of 0.10 was considered significant because of low
Data synthesis: comparative cohort studies with at least power.21
two groups
The mean difference (MD) was used to pool the RESULTS
influence of reported treatment-related characteristics
across included case–control studies. The effect of Study selection
matching by initial discrepancy on the results of the A total of 480 and 23 papers were identified through
meta-analyses was assessed by calculating the difference electronic (Appendix B) and manual searches, respec
in MDs (∆MD) between matched and nonmatched tively (Figure 1). After the removal of duplicates and
groups through random-effects meta-regression. Then,
the absolute ΔMDs were pooled across comparisons
using random-effects meta-analysis.
Identification
Records identified through Additional records identified

database searching through other sources
Heterogeneity (n = 480) (n = 23)
Absolute and relative between study heterogeneity

were quantified using tau2 and I2 statistics, respectively. Records after duplicates removed (n = 263)
Screening
Relative heterogeneity was defined as the proportion

of total variability in the results as explained by hete Records excluded (n = 180)
rogeneity, not by chance. To quantify our uncertainty,

95% CIs were calculated for the heterogeneity statistics. Full-text articles assessed for eligibility (n = 71)
Furthermore, 95% predictive intervals (95% PrI), which

Eligibility
incorporate existing heterogeneity and provide a range Full-text articles excluded, with reasons (n = 43)
of possible effects for a future clinical setting, were Full-text unobtainable (n = 9)
Not a clinical study (n = 1)
calculated for the meta-analyses of three or more ABO-OGS wasn t used (n = 4)
Not all 8 components of ABO-OGS scored (n = 29)
studies.20
Included
Trials included in the systematic review (n = 40 papers; 34 studies)

Risk of bias across studies and additional analyses
Indications for reporting biases (including small-study Figure 1. Study flowchart showing the identification and
effects) were assessed using Egger’s linear regression selection of eligible studies.
tests in meta-analyses of at least 10 studies. In cases ABO-OGS, Objective Grading System (OGS) proposed by
of bias, robustness of the results was checked using the American Board of Orthodontics.
www.e-kjo.org https://doi.org/10.4041/kjod.2017.47.6.401 403

404
Table 1. Characteristics of the studies included in our systematic review assessing the occlusal outcomes and duration of orthodontic fixed appliance treatment
No. Study Setting Patient Sex, male Mean age Extraction Malocclusion DI OGS Tx time Only FA Factors
(n) (%) (yr) (%)
1 Junqueira, 2012; BRA; uni Sao Paulo 68 56 NR 71 Cl. II/div1 No Yes No No Ex
Mendes, 2012
2 Marques, 2012 BRA; various practices 60 37 17.4 NR NR No Yes Yes No Clinician
3 Li, 2015* CHI; uni 76 36 32.2 Ex Cl. I Yes Yes Yes Yes Int*
4 Carvajal-Flórez, 2016 COL; uni Antioquia 10–11 34 44 20.9 NR NR No Yes Yes No Finishing†
5 Barbosa Lis, 2014 COL; uni Antioquia 11–12 39 48 NR Ex/nonEx NR No Yes Yes No -
6 Rodríguez, 2014 COL; uni Manizales 11–12 31 NR NR NR NR No Yes No Yes -
7 Anthopoulou, 2014; GRE; uni & 5 practices 55 35 14.9 45 Cl. I Ex/ No Yes No Yes Clinician; Ex
Mislik, 2016 nonEx
8 Jain, 2013 IND; college Manipal 40 NR 16.6 Ex NR Yes Yes Yes Yes Prescription†
9 Soltani, 2012 IRA; 2 practices 60 23 NR NonEx Cl. I No Yes No Yes Prescription†
10 Farhadian, 2005 IRA; uni 60 23 17.9 Ex/nonEx Cl. I No Yes Yes Yes Ex
11 Deguchi, 2011 JAP; uni 02–05 30 0 24.3 Ex Open bite Yes Yes No Yes Anchorage†
12 Deguchi, 2015 JAP; uni Okayama 25 20 24.2 Ex Cl. II Yes Yes Yes Yes Int*
13 Viwattanatipa, 2016 THA; TBO 200 NR NR NR NR Yes Yes No Yes -
14 Akinci Cansunar, 2014; TUR; 9 unis 1,098 40 16.3 49 Cl. II Yes Yes Yes Yes 1- or 2-phase;
Cansunar, 2014; Ex
Cansunar, 2016‡
15 Brown, 2015 USA; practice Bandeen 64 50 13.8 NonEx NR Yes Yes Yes Yes Int*
16 Kuncio, 2007* USA; practice Kuncio 11 9 26.8 NonEx NR No Yes Yes Yes -
17 Djeu, 2005* USA; practice Shelton 48 NR 23.7 NonEx NR Yes Yes Yes Yes -
18 Alford, 2011* USA; practice Snyder 63 51 17.8 NonEx NR Yes Yes Yes No -
19 Aszkler, 2014 USA; practice Wick 30 NR NR Ex/NonEx NR No Yes No Yes -
20 Chalabi, 2015 USA; uni Buffalo 50 38 NR NR Various No Yes No No Gender
21 Brown, 2011 USA; uni Detroit Mercy 714 NR NR NR NR Yes Yes No No -
03–07
22 Yang-Powers, 2002 USA; uni Illinois 124 44 14.5 37 Various No Yes Yes No Clinician
23 Knierim, 2006 USA; uni Indiana 01–03 437 42 17.8 28 Various No Yes Yes No Early debond;
Ex;
malocclusion
www.e-kjo.org
Table 1. Continued
Tx Only
No. Study Setting Patient Sex, male Mean age Extraction Malocclusion DI Factors
(n) (%) (yr) (%) OGS time FA
www.e-kjo.org
24 Vu, 2008 USA; uni Indiana 04–06 455 39 16.3 28 Various Yes Yes Yes No Canine impaction;
compliance; DI;
early debond; Ex; FFA;
gender; HG; malocclusion;
missed appointments;
oral hygiene; orthognathic
surgery; RME
25 Detterline, 2010 USA; uni Indiana 05–08 828 38 16.3 NonEx NR Yes Yes Yes Yes Slot size†
26 Park, 2008 USA; uni Indiana 97–07 200 31 15.2 25 Various Yes Yes Yes Yes Finishing†
27 Pinskaya, 2004; USA; uni Indiana 98–00 521 42 16.0 31 Various No Yes Yes No Ex
Hsieh, 2005
28 Campbell, 2007 USA; uni Indiana 98–03 382 45 15.3 NR Various Yes Yes Yes No Early debond; malocclusion
29 Deguchi, 2005 JAP; uni Okayama 02 72 26 18.7 58 Various Yes Yes Yes No -
30 Schabel, 2008 USA; uni Michigan 48 NR NR NR NR No Yes No No -
31 Hoybjerg, 2013 USA; uni Oklahoma 02–10 90 46 15.2 50 Various No Yes Yes Yes Ex
32 Santiago, 2012 USA; uni Puerto Rico 07–08 64 42 14.1 NR NR Yes Yes Yes No Compliance; gender
33 Ferguson, 2016* USA; uni Saint Louis 28 NR NR NonEx Cl. I No Yes No Yes -
34 Sohrabi, 2016 USA; uni Washington 12–13 102 NR 16.4 17 Cl. I/II/III No Yes Yes No -
Data modifications according to the eligibility of the included reports was as follows.
(i) Pulfer 2009 was excluded from the descriptives because it drew upon the data of Hsieh 2005 and Knierim 2006 to pool them together.
(ii) Junqueira 2012 and Mendes 2012 were judged to have mostly overlapping patients; only data from Mendes 2012 are reported, which were the more extensive of the two.
(iii) Anthopoulou 2014 and Mislik 2016 had overlapping patient populations where different factors were assessed. The demographics of Anthopoulou 2014 are reported
here.
(iv) Akinci Cansunar 2014, Cansunar 2014, and Cansunar 2016 were judged to have mostly overlapping patients in their report. Data from Akinci Cansunar 2014 are
reported here.
(v) Pinskaya 2004 and Hsieh 2005 were omitted as they included both labial and lingual appliances.
(vi) Only a subgroup of patients originating from the Okayama University was included from the Deguchi 2005 study, because the cohort from Indiana University was
described in multiple other reports.
*Patient groups pertaining to treatment alternatives noneligible for this review (aligners, lingual appliances, computer- or corticotomy-assisted orthodontics) were
excluded.
†
Intervention groups were pooled and not separately assessed because of the retrospective nature of the included studies.
‡
Some reported in different reports on the same cohort.
Ex, Extraction; DI, discrepancy index; OGS, Objective Grading System; Tx, treatment; FA, fixed appliances; uni, University; NR, not reported; Cl., class; div, division; Int,
intervention; Ex, extraction treatment; Non-Ex, nonextraction treatment; FFA, fixed functional appliance; TBO, Thai Board of Orthodontics; HG, headgear; RME, rapid
maxillary expansion.
405
initial screening, 71 papers were assessed using the Risk of bias within studies
eligibility criteria and 40 were included in our systematic The risk of bias assessment for the 34 included studies
review (Figure 1; Appendix C). In four instances, multiple is shown in Figure 2 and Appendix D–E. A high risk of
publications pertaining to the same or overlapping bias for at least one domain was found in 31 studies
patient cohorts were grouped together. Thus, a total of (91.2%). The most problematic domains included the
34 studies were finally included in our systematic review. study design (where 85% studies were retrospective) and
blinding (79% studies did not use blinding).
Study characteristics
The characteristics of the included studies can be Data synthesis and additional analyses: cohort studies
seen in Table 1. The 34 included studies originated A total of 29 (85.3%) of the 34 included studies could
from private practices or educational institutions from be used in the meta-analyses for the primary outcome
10 different countries and included a total of 6,207 (ABO OGS); the remaining either reported on overlapping
patients (median, 64 patients/study). There were 1966 patient populations or had missing data. The results
(39.6%) male patients and 3,000 (60.4%) female of the random-effects meta-analysis indicated that
patients with an average age of 18.4 years. Among the the overall OGS score after treatment was 27.9 points
34 included studies, 25 (73.5%) reported information (95% CI, 25.3–30.6 points) with high heterogeneity and
about the inclusion or exclusion of tooth extractions; no considerable differences between the subsample of
four included extraction patients, seven included none studies that included strictly one-phase fixed appliance
xtraction patients, and the remaining eleven studies had treatment (27.5 points; 95% CI, 24.5–30.5 points) and
reported an average extraction rate of 40%, and three the subsample of studies reporting two-phase/unclear
did not report the percentage of extractions. The treated treatment (28.3 points; 95% CI 24.5–32.1 points; p for
malocclusions were often unspecified, and the DI was difference between subsamples > 0.1) (Table 2, Figure 3).
used to gauge the severity of the initial malocclusion The meta-analysis of the 18 included studies reporting
in only 16 (47.1%) studies. In 18 (52.9%) studies, the the secondary outcome of treatment duration indicated
authors explicitly stated that only one-phase treatment that the mean treatment duration among all studies
with fixed appliances was performed, while in the rema was 24.9 months (95% CI, 24.6–25.1 months) with high
ining 16 (47.1%) studies, two-phase treatment was heterogeneity (Figure 4). The average treatment duration
performed for some of the included patients. All of differed significantly (p = 0.004) between the subsample
the included studies measured the post-treatment OGS of studies reporting one-phase fixed appliance treatment
score, which was the primary outcome, while 23 (67.6%) (24.8 months; 95% CI, 21.4–28.3 months) and the
studies also measured the treatment duration, which was subsample of studies reporting two-phase/unclear
the secondary outcome. treatment (31.6 months; 95% CI, 30.8–32.3 months).
The difference in the mean duration between the
Are the characteristics of the study's patients clearly described?

Are the interventions of interest clearly defined?
Are the distributions of principal confounders in each group clearly described?
Does the study provide estimates of the random variability in the data for the main outcomes?
Were the subjects asked to participate in the study representative of the entire population?
Can we be confident that finishing quality not used as a patient selection criterion?
Were the treatment staff, places, and facilities representative of what the majority of patients receive?
Can we be confident that patients were treated?
Was the study prospectively planned and conducted?
Was an attempt made to blind those measuring the main outcome?
If any of the results of the study were based on "data dredging", was this made clear?
Were the main outcome measures used accurate (valid and reliable)?
Did the study have sufficient power to accurately detect an existing effect? 5 5 5 5 5 5 5 5 5 5 5 5 4 4 3 3 3 3 3 3 3 2 2 2 2 2 2 1 1 1 1 1 1 0
0% 20% 40% 60% 80% 100%
Low risk High risk
Definitely Probably Unclear Probably Definitely

yes yes no no
Figure 2. Summary of the risk of bias in the included studies.

Table 2. Results of the meta-analyses for the primary (OGS score) and secondary (treatment duration) outcomes of
orthodontic fixed appliance (FA) treatment
Tau2 I2 (95% CI),
Subgroup Studies, Difference
Outcome n Mean 95% CI (95% CI) % 95% PrI (95% CI) p -value
ABO-OGS Overall 29 27.93 25.31–30.55 50.00 99.1 13.17–42.70

score (34.11–50.00) (98.7–99.1)
Only FA No 14 28.29 24.53–32.06 50.00 99.1 12.33–44.26 −0.70 0.800
(41.39–50.00) (98.9–99.1) (−6.28 to 4.88)
Yes 15 27.51 24.47–30.54 33.91 98.2 14.49–40.53
(17.90–50.00) (96.7–98.8)
Tx duration Overall 16 24.86 24.60–25.12 0.00 0.0 24.58–25.14
(mo) (50.00–50.00) (99.3–99.3)
Only FA No 8 31.56 30.79–32.33 0.00 0.0 30.60–32.52 −13.22 0.004
(49.03–50.00) (96.7–96.7) (−21.60 to −4.84)
Yes 8 24.84 21.41–28.27 23.36 99.2 12.26–37.42
(10.81–50.00) (98.3–99.6)
OGS, Objective Grading System; CI, confidence interval; PrI, predictive interval; ABO; American Board of Orthodontics; Tx,
treatment.
two treatment subsamples was 13.2 months (95% CI, occlusal outcomes, as indicated by the OGS score (MD,
4.8–21.6 months), although considerable heterogeneity −4.9 points; 95% CI, −11.8 to 1.9 points; p = 0.159),
remained even after the separate analysis. and a moderate increase in the treatment duration (MD,
Meta-regressions failed to identify a significant infl 6.4 months; 95% CI, 1.4 to 11.5 months; p = 0.013).
uence of any study-level characteristics on the primary However, only the increase in treatment duration was
outcome of OGS score or the secondary outcome of statistically significant at the 5% level. Finally, no
treatment duration (Appendix F). However, significant considerable differences in occlusal outcomes could
signs of reporting bias (Appendix G) were identified for be found between patients treated in the orthodontic
the secondary outcome of treatment duration through department at a university and those treated in a private
Egger’s test (p = 0.031), where small/imprecise studies orthodontic clinic.
tended to report longer treatment durations compared
with the remaining studies (Appendix G). Stratified Methodological overview
subgroup analyses according to study precision indicated Additionally, the methodological status of all available
that bias was mainly concentrated in the subgroup comparisons included in the studies identified from this
of studies reporting two-phase or unclear treatment systematic review was assessed, regardless of whether
(Appendix G), while the subgroup of studies reporting they were eligible for the clinical part of the systematic
one-phase fixed appliance treatment was relatively review (Table 4). From the 26 comparisons regarding
robust (Egger’s test, p > 0.05). Finally, we could not various treatment factors reported in the included
perform sensitivity analyses on the basis of risk of bias studies, 10 (38.5%) used matching to form patient
in the included studies, because most of them (91%) groups that were comparable in terms of the severity
had a high risk of bias. of the baseline malocclusion. However, in one case, the
pre-treatment ABO OGS score was used to match the
Data synthesis and additional analyses: comparative severity of the baseline pre-treatment malocclusion, and
cohort studies with at least two groups this was identified as problematic. In four (15.4%) of the
Signs of discordant results (i.e., significant differences 26 identified comparisons, the severity of the baseline
between subgroups; Table 2) and reporting bias (Appen malocclusion in the compared groups was considered by
dix G) were found for the subgroup of studies with using it as a covariate in the statistical analyses. Overall,
two-phase/unclear treatment. Therefore, factors from baseline confounding was adequately assessed, in one
comparative two-group cohort studies were assessed way or the other, in only 10 (38.5%) of the included
only for those studies that strictly reported one-phase comparisons.
fixed appliance treatment, which were free from bias Among the available comparisons, two included
(Table 3). Orthodontic treatment with extraction of four both matched and nonmatched studies and enabled
premolars was associated with a slight improvement in an assessment of the influence of matching on the

Figure 3. Overall pooling for occlusal outcomes of fixed appliance (FA) treatment assessed using the Orthodontic
Grading System proposed by the American Board of Orthodontics Mean Orthodontic Grading System scores and
their corresponding 95% confidence intervals (CIs) for each included study are given as boxes with horizontal lines,
respectively. The weighted pooled summary estimates with and their corresponding 95% CIs for the two subgroups
or overall are given as diamonds. Horizontal lines at the diamonds represent the 95% prediction that gives a range of
possible values to be clinically seen, while incorporating existing heterogeneity.
results (Appendix H). In the comparison of aligner vers DISCUSSION

us fixed appliance treatment, studies with matched
patient samples tended to find considerably greater Summary of evidence
differences in occlusal outcomes. Moreover, studies with This systematic review summarizes evidence from
baseline matching tended to find considerably smaller 34 clinical cohort studies including a total of 6,207
differences in occlusal outcomes between extraction patients who received comprehensive orthodontic fixed
and nonextraction treatment groups compared with appliance treatment. The pooled analysis for the primary
studies without matching. Finally, the absolute outcome, which was occlusal outcomes as measured
pooled difference in the OGS score between matched using the OGS score, indicated an average OGS score
and nonmatched patient samples across studies was of 27.9 OGS points (95% CI, 25.3–30.6 points), which
calculated as ΔMD = 7.20 OGS points (95% CI, −2.16 was relatively consistent regardless of one-phase or two-
to 16.57 points; p = 0.132; Appendix I). This could phase treatment (p = 0.800; Table 2).
possibly have clinical implications, although evidence Analysis of the secondary outcome, which was the
was very limited. treatment duration, revealed an average treatment
duration of 24.9 months (95% CI, 24.6–25.1 months).
However, a considerable difference of 13.2 months

Figure 4. Overall pooling for the fixed appliance (FA) treatment duration in months. Mean treatment durations and
their corresponding 95% confidence intervals (CIs) for each included study are given as boxes with horizontal lines,
respectively. The weighted pooled summary estimates with and their corresponding 95% CIs for the two subgroups
or overall are given as diamonds. Horizontal lines at the diamonds represent the 95% prediction that gives a range of
possible values to be clinically seen, while incorporating existing heterogeneity.
(4.8–21.6 months; p = 0.004; Table 2) in treatment systematic review than in the present review (22 and 8
duration was found between studies that strictly repor studies, respectively), because the use of the ABO OGS
ted one-phase fixed appliance treatment and those that was not an inclusion criterion in the former.
reported two-phase or unclear treatment. Therefore, Interestingly, we found no association of the ave
this systematic review focuses on the clearly defined rage outcome of orthodontic treatment with the
subsample of studies on one-phase fixed appliance mean treatment duration, mean severity of the initial
treatment with an average treatment duration of 24.8 malocclusion as assessed using the DI, and various
months (95% CI, 21.4–28.3 months). This is slightly patient- or treatment-related characteristics (Appendix
higher than the average treatment duration of 19.9 F). Although this is in agreement with the findings
months reported by Tsichlaki et al.22 However, a fixed- of two included studies23,24 that found nonsignificant
effect model was used by the authors of that study, correlation coefficients of −0.18 to −0.30 for the
which cannot be easily justified in such a broad clinical association between the ABO OGS and DI, this does not
scenario18 and could, in combination with the reported mean that the DI is not a crucial component of the ABO
statistical inconsistency, have had a profound impact OGS framework in clinical investigations of treatment
on the meta-analysis results.19 In addition, contrary to effects.
the studies included in the previous systematic review The only factor that appeared to considerably infl
of Tsichlaki et al., 22 the studies assessed in the pre uence the outcomes of orthodontic treatment was the
sent review included the assessment of final occlusal inclusion of tooth extractions. First, on a study level,
outcomes using the ABO OGS in their scope and could the mean OGS score was significantly associated with
possibly have paid extra attention to the finishing the extraction rate in each study (Appendix F). On an
stage of orthodontic treatment. Finally, the number of average, every 10% increase in the extraction rate was
studies included was considerably higher in the previous significantly associated with a decrease in the OGS

score by 0.7 point, which indicated better occlusal
ABO, American Board of Orthodontics; OGS, Objective Grading System; n, number of studies; MD, mean difference; CI, confidence interval; PrI, predictive interval; NA,
Table 3. Results of the meta-analyses regarding the effect of characteristics from included comparative case–control studies reporting one-phase fixed appliance
0.013
outcomes. In addition, analysis of within-study data
-
from case-control studies indicated that comprehensive
I2 (95% CI), % 95% PrI

treatment involving extraction of the four premolars
NA
-
was associated with improved treatment outcomes, as
indicated by a decrease in the OGS score (MD, −4.9 OGS
points; 95% CI, −11.8 to 1.9 OGS points; p = 0.159),
83.6 (NA)
and a prolonged treatment duration (MD, 6.4 months;
-
95% CI, 1.4 to 11.5 months; p = 0.013). Although only
Treatment duration
the increase in the treatment duration was statistically

significant at the 5% level, this was most probably
Tau2 (95% CI)
due to imprecision caused by a small sample size; the

11.21 (NA)
addition of future studies may rectify this.

Finally, a methodological overview was conducted of
-
all identified clinical case-control studies that assessed

occlusal outcomes according to various treatment-
related factors (Table 4). This also included study
1.38–11.45
arms that assessed novel interventions (aligners and

95% CI
individualized or lingual appliances) that were excluded

-
from the clinical part of the systematic review because

of their basic design. 25,26 The results indicated that
6.41
MD
the majority of studies neither matched the compared

-
patient groups according to their baseline malocclusion

severity nor used the baseline malocclusion severity as a
n
2
covariate in the statistical analyses (Table 4). As a result,

0.159
0.818
only 10 (38.5%) of the available comparisons were free

p
from baseline confounding. This might be important, as

treatment on the primary (OGS score) and secondary outcome (treatment duration)
Tau (95% CI) I (95% CI), % 95% PrI
meta-epidemiological analysis indicated that matching

NA
NA
of experimental groups according to the baseline ma

locclusion severity may considerably influence the obser
ved results (Appendixes H and I).
85.3 (NA)
Some additional methodological flaws were found

NA
among the included studies. First, a large number (n =

29) of possibly relevant clinical studies identified from
ABO OGS score
the literature search did not assess all eight components

2
of the ABO OGS and were consequently excluded from

21.02 (NA)
the present review because of pooling incompatibility.

Second, an included study used the ABO OGS to
-
measure the baseline malocclusion severity and match

2
the compared groups,27 and this contradicts the rationale

behind this index which might be problematic28,29 and
−3.77 to 4.77
2 −4.94 −11.82 to 1.94
does not justify substitution of the DI.9 Finally, some

95% CI
included studies measured the baseline severity with

the DI and performed statistical tests to determine
baseline differences in DI among the compared groups.
This practice is inherently wrong30 because the results
MD
0.5
can be easily distorted by increasing the sample size;

furthermore, it cannot substitute proper matching or
n
Private practice vs. 1
covariate adjustment.
university clinic
four premolars
The strengths of this systematic review include

not applicable.
the a priori registration in PROSPERO, the extensive

Extraction of
Factor
unrestricted literature search, which included studies

in languages other than English, the use of robust
methodology pertaining to the qualitative and

Table 4. Methodological overview of comparison-specific characteristics obtained from of identified case-control studies
Initial malocclusion severity
Selection bias
No Study* Intervention Comparison Used as addressed?
Matching How covariate
1 Detterline, 2010 18”-slot CB 22”-slot CB Yes DI Yes Yes
2 Ferguson, 2016 Corticotomy & CB CB No - No
3 Anthopoulou, 2014 Ex Non-Ex Yes Discriminant No Yes
analysis
4 Farhadian, 2005 Ex Non-Ex No - No No
5 Hoybjerg, 2013 Ex Non-Ex No - No No
6 Knierim, 2006 Ex Non-Ex No - No No
7 Pinskaya, 2004 Ex Non-Ex No - No No
8 Sohradi, 2016 Ex Non-Ex No - No No
9 Vu, 2008 Ex Non-Ex No - No No
10 Akinci Cansunar, 2014 Ex Non-Ex No - No No
11 Carvajal-Flórez, 2016 Finishing protocol Conventional No - No No
finishing
12 Park, 2008 Finishing protocol Conventional Yes DI Yes Yes
finishing
13 Deguchi, 2011 Skeletal anchorage No skeletal anchorage No −(ΔDI = 14.5) No No
14 Brown, 2015 Indirect bracket Direct bracket Yes DI No Yes
placement placement
15 Brown, 2015 Insignia appliance CB Yes DI No Yes
16 Djeu, 2005 Invisalign aligners CB Yes DI No Yes
17 Kuncio, 2007 Invisalign aligners CB No - No No
18 Li, 2015 Invisalign aligners CB Yes DI + RCT No Yes
19 Deguchi, 2015 Lingual appliance CB Yes DI No Yes
20 Jain, 2013 MBT prescription CB Roth prescription CB No −(ΔDI = 3.8) Yes Yes
21 Soltani, 2012 MBT prescription CB SE prescription CB No - No No
22 Marques, 2012 Orthodontist General dentist Yes ABO OGS No No
23 Hoybjerg, 2013 3 Retention protocols - No - No No
24 Alford, 2011 SureSmile appliance CB No ΔDI = 2.6 Yes Yes
25 Mislik, 2016 University clinic Private practice Yes Discriminant No Yes
analysis
26 Yang-Powers, 2002 University clinic ABO-submitted cases No - No No
*Mendes et al. (2012) was excluded because patients were matched in terms of the final ABO OGS score.
CB, Conventional brackets; DI, discrepancy index; Ex, extraction treatment; Non-Ex, nonextraction treatment; RCT,
randomized clinical trial; MBT, McLaughlin–Bennett–Trevisi; SE, standard edgewise; ABO, American Board of Orthodontics;
OGS, Objective Grading System.
quantitative synthesis of data,31 transparent reporting retrospective clinical studies, and this is bound to have
of quantitative data for all outcomes from the included influenced the results of the meta-analyses.25 Therefore,
studies, the use of the new robust Paule–Mandel we planned a priori not to focus on the comparative
random-effects estimator,17 and the use of subgroup, effectiveness of various interventions, considering it
meta-regression, and sensitivity analyses to check the would require experimental prospective controlled
robustness of the results. However, some limitations studies. Instead, we provided an overview of expected
cannot be overlooked. First and foremost, this systematic treatment outcomes and possible influencing factors
review included mostly observational, nonrandomized, and assessed methodological issues in existing studies.

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Appendix
Outcome of comprehensive fixed appliance orthodontic treatment: a systematic review
with meta-analysis and methodological overview
Appendix A. A priori eligibility criteria used in the review.

Domain Inclusion Exclusion
Human patients of any age*/sex*/ethnicity*/malocclusion* that are
Participants Animal studies
planned to receive comprehensive orthodontic treatment
Comprehensive orthodontic treatment with fixed appliances on all

Any orthodontic treatment that did not include a comprehensive
Interventions teeth (with the possible exception of second molars) in a one-phase
phase with fixed appliances at all
or a two-phase treatment with any co-interventions
Comprehensive orthodontic treatment with novel appliances
that have not yet been assessed by robust clinical evidence
-
(aligners, lingual appliances, CAD/CAM- or surgery-assisted
appliances)
Comparisons No separate comparison group (single-group cohort studies) -
Similar patients that receive comprehensive treatment differing from

the "Intervention" group only in the administered intervention or co-
-
intervention (including patient, appliance or treatment
characteristics)
Outcome – Occlusal outcome after fixed appliance orthodontic treatment,

-
primary assessed with the ABO OGS tool
Outcome –
Treatment duration in months -
secondary
Study design Randomized controlled trials (parallel) Cross-sectional studies that assess previous extractions
Non-randomized prospective or retrospective clinical cohort studies
Case reports/ case series
with a single patient group
Non-randomized prospective or retrospective clinical cohort studies
Non-clinical studies (in vitro, ex vivo, in silico, etc)
with at two or more experimental groups
Systematic reviews (after checked for additional studies)
*this factor's role is planned to be assessed through subgroup/meta-regression analyses
Appendix B. Literature databases searched (last search October, 2016).
Database Site Search strategy Limit Hits
Article types: Clinical Study; Clinical Trial;
Comparative Study; Controlled Clinical Trial;
Evaluation Studies; Journal article; Meta-
http://www.ncbi.nlm.nih.gov/ orthodon* AND ("American Board" OR ABO OR
PubMed analyses; Multicenter Study; Observational 185
pubmed/ "ABO-OGS" OR "objective grading")
Study; Pragmatic Clinical Trial; Randomized
Controlled Trial; Systematic Reviews
Species: Human
Cochrane Library http://onlinelibrary.wiley.com/
Same with PubMed - 0
(CDSR/DARE) cochranelibrary/search/
Cochrane Library http://onlinelibrary.wiley.com/
(CENTRAL) cochranelibrary/search/
http://www.embase.com/#ad
Embase Same with PubMed - 14
vancedSearch/default
Virtual Health http://pesquisa.bvsalud.org/p
Library ortal/advanced/?lang=en
TITLE-ABS-KEY ( orthodon* AND ( "American
Board" OR abo OR "ABO-OGS" OR "objective
grading" ) ) AND ( LIMIT-TO ( SUBJAREA ,
"DENT" ) ) AND ( LIMIT-TO ( EXACTKEYWORD ,
"Human" ) OR LIMIT-TO ( EXACTKEYWORD ,
Scopus http://www.scopus.com/ Research area: Dentistry 89
"Humans" ) ) AND ( EXCLUDE ( DOCTYPE ,
"re" ) OR EXCLUDE ( DOCTYPE , "ed" ) OR
EXCLUDE ( DOCTYPE , "le" ) ) AND
( EXCLUDE ( EXACTKEYWORD , "Case
Report" ) )
Research area: Dentistry oral surgery
ISI Web of http://apps.webofknowledge.
Same with PubMed medicine 181
Knowledge com
Document type: article
ClinicalTrials.gov https://clinicaltrials.gov/ Same with PubMed - 0
.
Appendix C. List of studies included/excluded from this systematic review with reasons.
AA Paper
Excluded during screening
[No authors] A Comparative-Study of the Ages of American Board of Orthodontics Diplomates. Am J Orthod Dentofac Orthop
1 Excluded by title
1991;100(5):482-3.
[No authors] ABO presents typical case report examples for future candidates. American journal of orthodontics.
2 Excluded by title
1978;73(1):79-84. Epub 1978/01/01.
3 [No authors] American Board of Orthodontics - Past, present, and future. Am J Orthod Dentofac Orthop 1996;110(1):108-10. Excluded by title
[No authors] American Board of Orthodontics sets new standards and requirements. American journal of orthodontics.
4 Excluded by title
1973;64(2):199-200. Epub 1973/08/01.
[No authors] American Board of Orthodontics. Why case reports do not pass the ABO Phase III clinical examination. Am J
5 Excluded by title
Orthod Dentofac Orthop 1996;110(5):559-60. Epub 1996/11/01.
6 [No authors] Foundations of excellence: the ABO in review--1984-1994. Am J Orthod Dentofac Orthop 1995;107(1):103-5. Excluded by title
[No authors] Presentation of the Ketcham,Albert,H Memorial Award, 1954 by Webster,Raymond,L President of the American
7 Excluded by title
Board of Orthodontics. Am J Orthod Dentofac Orthop 1954;40(10):783-9.
[No authors] Presentation of the Ketcham,Albert,H. Memorial Award, 1953, by Waugh,Leuman,M. President of the American-
8 Excluded by title
Board-of-Orthodontics. Am J Orthod Dentofac Orthop 1953;39(7):545-51.
Ackerman MB, Rinchuse DJ. ABO certification in the age of evidence and enhancement. Am J Orthod Dentofac Orthop
9 Excluded by title
2006;130(2):133-40. Epub 2006/08/15.
Ahmad Shokor FFB, Ab Rahman WSW, Khursheed Alam M. Craniofacial morphology with genetic influence of abo blood
10 Excluded by title
group in malaysian orthodontic patients. International Journal of Pharma and Bio Sciences. 2015;6(4):B412-B8.
Akyalcin S, Frels LK, English JD, Laman S. Analysis of smile esthetics in American Board of Orthodontic patients. The Angle
orthodontist. 2014;84(3):486-91. Epub 2013/10/29.
12 Anon. An interview with Marissa C. Keesler. Dental Press J Orthod. 2014;19(2):27-38. Excluded by title
Ashwinirani SR, Suragimath G, Sande AR, Kulkarni P, Nimbal A, Shankar T, et al. Comparison of lip print patterns in two
13 indian subpopulations and its correlation in abo blood groups. Journal of Clinical and Diagnostic Research. 2014;8(10):ZC40- Excluded by title
ZC3.
Baker RW, Jr., Subtelny JD, Iranpour B. An American Board of Orthodontics case report. Correction of a Class III mandibular
14 prognathism and asymmetry through orthodontics and orthognathic surgery. Am J Orthod Dentofac Orthop 1991;99(3):191- Excluded by title
201. Epub 1991/03/11.
15 Bilodeau JE. An American Board of Orthodontics case report. Am J Orthod Dentofac Orthop 1997;111(5):487-91. Excluded by title
Bishara SE, Nemeth R. Current challenges and future dilemmas facing the orthodontic profession. Proceedings of a
16 Workshop, The College of Diplomates of the American Board of Orthodontics. Sun Valley, Idaho, July 21-25, 2001. The Angle Excluded by title
Bond JA. Orthopedic/orthodontic treatment of a Class I malocclusion with a Class III skeletal pattern and maxillary deficiency.
An American Board of Orthodontics case report. Am J Orthod Dentofac Orthop 1987;91(5):429-37. Epub 1987/05/01.
Boskabadi H, Mafinezhad S, Bagher F, Bozorgnia Y. Incidence of thrombocytopenia in idiopathic hyperbilirubinemic
newborns. Macedonian Journal of Medical Sciences. 2014;7(2):259-62.
Briss BS, English JD, Riolo ML, Greco PM. A guide to writing ABO test items. Am J Orthod Dentofac Orthop 2005;128(3):397-
401. Epub 2005/09/20.
Bruner MK, Hilgers KK, Silveira AM, Butters JM. Graduate orthodontic education: the residents' perspective. Am J Orthod
Dentofac Orthop 2005;128(3):277-82. Epub 2005/09/20.
Carrillo R, Rossouw PE. Orthodontic treatment for a patient with congenital cutis laxa. Am J Orthod Dentofac Orthop
2009;136(2):282-9. Epub 2009/08/05.
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American Board of Orthodontics. Am J Orthod Dentofac Orthop 2015;147(5 Suppl):S232-3. Epub 2015/05/01.
Chan MD. An adult malocclusion requiring a combination of orthodontic and prosthodontic treatment. Am J Orthod Dentofac
Orthop 1997;111(1):100-5. Epub 1997/01/01.
Childers K. Case report Category 6: Class II Division 1 with severe crowding. Am J Orthod Dentofac Orthop 2004;126(2):245-
53. Epub 2004/08/19.
Cho HJ. Patient with severe skeletal Class III malocclusion and severe open bite treated by orthodontics and orthognathic
surgery - A case report. Am J Orthod Dentofac Orthop 1996;110(2):155-62.
Chojnacki W, Chojnacka A. ABO and Rh blood groups in children with harelip and cleft palate. Czasopismo Stomatologisczne.
1973;26(6):627-9.
Collins MK. A nonsurgical approach to treatment of a high angle Class II, Division 1 malocclusion in a nongrowing patient. Am
J Orthod Dentofac Orthop 1996;110(6):678-81. Epub 1996/12/01.
Coreil MN. Treatment of a patient with a Class II malocclusion and an extremely high mandibular plane angle and severe
crowding. Am J Orthod Dentofac Orthop 1997;111(1):93-9.
Cowan RG, Jr. Treatment of a patient with a Class II malocclusion, impacted canine, and severe malalignment. Am J Orthod
Cureton SL. A significant transverse discrepancy: a case with a high mandibular plane angle, a severe maxillary arch length
deficiency, and significant transverse discrepancy. Am J Orthod Dentofac Orthop 1998;114(3):307-10. Epub 1998/09/22.
31 Damone J. ABO working to improve board-certification process. Am J Orthod Dentofac Orthop 2002;121(2):16A-7A. Excluded by title
de Cuebas JO. Nonsurgical treatment of a skeletal vertical discrepancy with a significant open bite. Am J Orthod Dentofac
Orthop 1997;112(2):124-31. Epub 1997/08/01.
Decker JD, Chen C. Adaptive response of the human dental alveolar process: correction of a Class I protrusive and mutilated
dentition, with 32-year follow-up. Am J Orthod Dentofac Orthop 2009;135(4 Suppl):S113-22. Epub 2009/04/23.
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2006;129(3):436-43. Epub 2006/03/11.
35 Devries BG. Some views of the American Board of Orthodontics on orthodontic education. American journal of orthodontics. Excluded by title
1949;35(4):289-91. Epub 1949/04/01.
Dewel BF. Editorial: The American Board of Orthodontics: a historic milestone. American journal of orthodontics.
1969;55(4):410-1. Epub 1969/04/01.
Dhane JM. An American Board of Orthodontics case report: treatment of a Class I malocclusion with a significant transverse
discrepancy and high mandibular plane angle. Am J Orthod Dentofac Orthop 1997;111(3):247-52. Epub 1997/03/01.
38 Dugoni SA, Lee JS. American Board of Orthodontics Case-Report. Am J Orthod Dentofac Orthop 1991;100(2):99-105. Excluded by title
Dunbar JP, Goldin B, Subtelny JD. An American Board of Orthodontics case report. Correction of Class I crowding in an
achondroplastic patient. Am J Orthod Dentofac Orthop 1989;96(3):255-63. Epub 1989/09/01.
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Efstratiadis SS. An American Board of Orthodontics case report. Treatment of an open bite malocclusion. Am J Orthod
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47 Fink FS. Preceptorship revisited. Am J Orthod Dentofac Orthop 2007;131(5):664-5. Epub 2007/05/08. Excluded by title
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192
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193
Classe II tratados com extrações de quatro pré-molares. Thesis, Faculdade de Odontologia de Bauru, 2013 used
Vasilakou ND. Quantitative assessment of the effectiveness of phase 1 orthodontic treatment utilizing the ABO discrepancy Excluded; ABO OGS not
194
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195
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197
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198
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199
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200
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201
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202
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203
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204
for worse. Am J Orthod Dentofac Orthop 2010;138(5):552-8. Epub 2010/11/09. OGS items scored
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205
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206
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207
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208
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Lieber WS, Carlson SK, Baumrind S, Poulton DR. Clinical use of the ABO-Scoring Index: reliability and subtraction frequency. Excluded; not all ABO
209
The Angle orthodontist. 2003;73(5):556-64. Epub 2003/10/29. OGS items scored
Ling KK, Ho CT, Kravchuk O, Olive RJ. Comparison of surgical and non-surgical methods of treating palatally impacted Excluded; not all ABO
210
canines. II. Aesthetic outcomes. Australian orthodontic journal. 2007;23(1):8-15. Epub 2007/08/08. OGS items scored
Lyotard N, Hans M, Nelson S, Valiathan M. Short-term postorthodontic changes in the absence of retention. The Angle Excluded; not all ABO
211
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212
system. Am J Orthod Dentofac Orthop 2005;127(4):444-50; quiz 516. Epub 2005/04/12. OGS items scored
Okunami TR, Kusnoto B, BeGole E, Evans CA, Sadowsky C, Fadavi S. Assessing the American Board of Orthodontics Excluded; not all ABO
213
objective grading system: digital vs plaster dental casts. Am J Orthod Dentofac Orthop 2007;131(1):51-6. Epub 2007/01/09. OGS items scored
Onyeaso CO, BeGole EA. Associations between pretreatment age and treatment time with orthodontic treatment outcome: a Excluded; not all ABO
214
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Onyeaso CO, Begole EA. Relationship between index of complexity, outcome and need, dental aesthetic index, peer
Excluded; not all ABO
215 assessment rating index, and American Board of Orthodontics objective grading system. Am J Orthod Dentofac Orthop
OGS items scored
2007;131(2):248-52. Epub 2007/02/06.
Ormiston JP, Huang GJ, Little RM, Decker JD, Seuk GD. Retrospective analysis of long-term stable and unstable orthodontic Excluded; not all ABO
216
treatment outcomes. Am J Orthod Dentofac Orthop 2005;128(5):568-74; quiz 669. Epub 2005/11/16. OGS items scored
Excluded; not all ABO
217 Saxe AK, Louie LJ, Mah J. Efficiency and effectiveness of SureSmile. World journal of orthodontics. 2010;11(1):16-22.
OGS items scored
Son WS, Cha KS, Chung DH, Kim TW. Quantitative evaluation and affecting factors of post-treatment relapse tendency. Excluded; not all ABO
218
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Song GY, Baumrind S, Zhao ZH, Ding Y, Bai YX, Wang L, et al. Validation of the American Board of Orthodontics Objective Excluded; not all ABO
219
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Stock GJ, McNamara JA, Jr., Baccetti T. Efficacy of 2 finishing protocols in the quality of orthodontic treatment outcome. Am J Excluded; not all ABO
220
Orthod Dentofac Orthop 2011;140(5):688-95. Epub 2011/11/05. OGS items scored
Struble BH, Huang GJ. Comparison of prospectively and retrospectively selected American Board of Orthodontics cases. Am Excluded; not all ABO
221
J Orthod Dentofac Orthop 2010;137(1):6 e1-8; discussion 6-8. Epub 2010/02/04. OGS items scored
Vincent S. Evaluation of Invisalign treatment utilizing the American Board of Orthodontics Objective Grading System for dental Excluded; not all ABO
222
casts. Oregon Health & Science University, Thesis, 2014. OGS items scored
Wes Fleming J, Buschang PH, Kim KB, Oliver DR. Posttreatment occlusal variability among angle Class I nonextraction Excluded; not all ABO
223
patients. The Angle orthodontist. 2008;78(4):625-30. Epub 2008/02/28. OGS items scored
Included
Akinci Cansunar H, Uysal T. Comparison of orthodontic treatment outcomes in nonextraction, 2 maxillary premolar extraction,
224 and 4 premolar extraction protocols with the American Board of Orthodontics objective grading system. Am J Orthod Dentofac Included
Orthop 2014;145(5):595-602. Epub 2014/05/03.
Alford TJ, Roberts WE, Hartsfield JK, Eckert GJ, Snyder RJ. Clinical outcomes for patients finished with the SureSmile (TM)
225 Included
method compared with conventional fixed orthodontic therapy. Angle Orthodontist. 2011;81(3):383-8.
Anthopoulou C, Konstantonis D, Makou M. Treatment outcomes after extraction and nonextraction treatment evaluated with
226 Included
the American Board of Orthodontics objective grading system. Am J Orthod Dentofac Orthop 2014;146(6):717-23.
Aszkler RM, Preston CB, Saltaji H, Tabbaa S. Long-term occlusal changes assessed by the American Board of Orthodontics'
227 Included
model grading system. Am J Orthod Dentofac Orthop 2014;145(2):173-8. Epub 2014/02/04.
Barbosa Lis DM, Zapata Noreña O, Carvajal A, Franco CM, Rodriguez Aguirre SA, Florez Pino AA, et al. Resultado de
228 Included
Tratamientos Ortodóncicos y su Relación con la Complejidad de la Maloclusión. Int j odontostomatol (Print). 2014;8(2):201-6.
Brown MW, Koroluk L, Ko CC, Zhang K, Chen M, Nguyen T. Effectiveness and efficiency of a CAD/CAM orthodontic bracket
229 Included
system. Am J Orthod Dentofac Orthop 2015;148(6):1067-74. Epub 2015/12/18.
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230 Included
orthodontic residency: a 5-year perspective. Am J Orthod Dentofac Orthop 2011;139(5):665-8. Epub 2011/05/04.
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231 Included
the American Board of Orthodontics malocclusion categories. Am J Orthod Dentofac Orthop 2007;132(6):822-9.
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232 Included
Model Grading System. J Orofac Orthop. 2016;77(4):233-41.
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233 Included
the American Board of Orthodontics criteria. The Angle orthodontist. 2014;84(6):974-9. Epub 2014/04/04.
Carvajal-Flórez A, Barbosa-Lis DM, Zapata-Noreña OA, Marín-Velásquez JA, Afanador-Bayona SA. Orthodontic treatment
234 Included
outcomes obtained by application of a finishing protocol. Dental Press J Orthod. 2016;21(2):88-94.
Chalabi O, Preston CB, Al-Jewair TS, Tabbaa S. A comparison of orthodontic treatment outcomes using the Objective
235 Included
Grading System (OGS) and the Peer Assessment Rating (PAR) index. Australian orthodontic journal. 2015;31(2):157-64.
Deguchi T, Honjo T, Fukunaga T, Miyawaki S, Roberts WE, Takano-Yamamoto T. Clinical assessment of orthodontic
236 outcomes with the peer assessment rating, discrepancy index, objective grading system, and comprehensive clinical Included
assessment. Am J Orthod Dentofac Orthop 2005;127(4):434-43. Epub 2005/04/12.
Deguchi T, Kurosaka H, Oikawa H, Kuroda S, Takahashi I, Yamashiro T, et al. Comparison of orthodontic treatment outcomes
237 in adults with skeletal open bite between conventional edgewise treatment and implant-anchored orthodontics. Am J Orthod Included
Dentofac Orthop 2011;139(4 Suppl):S60-8. Epub 2011/04/01.
Deguchi T, Terao F, Aonuma T, Kataoka T, Sugawara Y, Yamashiro T, et al. Outcome assessment of lingual and labial
238 appliances compared with cephalometric analysis, peer assessment rating, and objective grading system in Angle Class II Included
extraction cases. Angle Orthodontist. 2015;85(3):400-7.
Detterline DA, Isikbay SC, Brizendine EJ, Kula KS. Clinical outcomes of 0.018-inch and 0.022-inch bracket slot using the ABO
239 Included
objective grading system. The Angle orthodontist. 2010;80(3):528-32. Epub 2010/01/07.
Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the
240 Included
American Board of Orthodontics objective grading system. Am J Orthod Dentofac Orthop 2005;128(3):292-8.
Farhadian N, Miresmaeili AF, Soltani MK. Comparison of extraction and non extraction orthodontic treatment using the
241 Included
objective grading system. Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2005; Vol: 2, No.3)
Ferguson DJ, Nazarov AD, Makki L, Wilcko MT, Wilcko WM. Posttreatment and retention outcomes with and without
242 periodontally accelerated osteogenic orthodontics assessed using ABO objective grading system. APOS Trends Orthod Included
2016;6:194-9.
Hoybjerg AJ, Currier GF, Kadioglu O. Evaluation of 3 retention protocols using the American Board of Orthodontics cast and
243 Included
radiograph evaluation. Am J Orthod Dentofac Orthop 2013;144(1):16-22. Epub 2013/07/03.
Hsieh TJ, Pinskaya Y, Roberts WE. Assessment of orthodontic treatment outcomes: early treatment versus late treatment.
244 Included
The Angle orthodontist. 2005;75(2):162-70. Epub 2005/04/14.
Jain M, Varghese J, Mascarenhas R, Mogra S, Shetty S, Dhakar N. Assessment of clinical outcomes of Roth and MBT
245 bracket prescription using the American Board of Orthodontics Objective Grading System. Contemp Clin Dent. 2013 Included
Jul;4(3):307-12.
Junqueira CHZ. Influência de extrações de pré-molares na estética facial em longo prazo. 2012, Thesis, University of Sao
246 Included
Paolo.
Knierim K, Roberts WE, Hartsfield J, Jr. Assessing treatment outcomes for a graduate orthodontics program: follow-up study
247 Included
for the classes of 2001-2003. Am J Orthod Dentofac Orthop 2006;130(5):648-55, 55 e1-3. Epub 2006/11/18.
Kuncio D, Maganzini A, Shelton C, Freeman K. Invisalign and traditional orthodontic treatment postretention outcomes
248 Included
compared using the American Board of Orthodontics objective grading system. The Angle orthodontist. 2007;77(5):864-9.
249 Li W, Wang S, Zhang Y. The effectiveness of the invisalign appliance in extraction cases using the the ABO model grading Included
system: A multicenter randomized controlled trial. International J Clinical and Experimental Medicine. 2015;8(5):8276-82.
Marques LS, Freitas Junior N, Pereira LJ, Ramos-Jorge ML. Quality of orthodontic treatment performed by orthodontists and
250 Included
general dentists. The Angle orthodontist. 2012;82(1):102-6. Epub 2011/08/03.
Mendes LM. Influência em longo prazo dos protocolos de tratamento da Classe II na atratividade do perfil. Thesis, 2012,
251 Included
University of Sao Paolo.
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252 extraction and nonextraction patients: A comparative study with the American Board of Orthodontics Objective Grading Included
System. Am J Orthod Dentofac Orthop 2016;149(2):253-8. Epub 2016/02/02.
Park Y, Hartsfield JK, Katona TR, Eugene Roberts W. Tooth positioner effects on occlusal contacts and treatment outcomes.
253 Included
The Angle orthodontist. 2008;78(6):1050-6. Epub 2008/10/25.
Pinskaya YB, Hsieh TJ, Roberts WE, Hartsfield JK. Comprehensive clinical evaluation as an outcome assessment for a
254 Included
graduate orthodontics program. Am J Orthod Dentofac Orthop 2004;126(5):533-43. Epub 2004/11/03.
Pulfer RM, Drake CT, Maupome G, Eckert GJ, Roberts WE. The association of malocclusion complexity and orthodontic
255 Included
treatment outcomes. The Angle orthodontist. 2009;79(3):468-72. Epub 2009/05/06.
Rodríguez JEB, León DMM, Vargas CAH. Evaluación de los tratamientos terminados en un posgrado de ortodoncia según los
256 Included
parámetros ABOs. Revista Latinoamericana de Ortodoncia y Odontopediatría 20xx;1-17
Santiago JJ, Martinez CJ. Use of the Objective Grading System of the American Board of Orthodontics to evaluate treatment
257 at the Orthodontic Graduate Program Clinic, University of Puerto Rico, 2007-2008. Puerto Rico health sciences journal. Included
2012;31(1):29-34. Epub 2012/03/22.
Schabel BJ, McNamara JA, Baccetti T, Franchi L, Jamieson SA. The relationship between posttreatment smile esthetics and
258 Included
the ABO Objective Grading System. The Angle orthodontist. 2008;78(4):579-84. Epub 2008/02/28.
259 Sohrabi K. Does initial malocclusion predict the outcome of orthodontic treatment? Thesis, University of Washington 2016. Included
Soltani M, Saedi B, Mohammadi Z. Outcome of MBT and Standard Edgewise Techniques in Treating Cl I Malocclusion. AJDR
260 Included
2012; Vol.4, No.2:61-65.
Viwattanatipa N, Buapuean W, Komoltri C. Relationship between Discrepancy Index and the Objective Grading System in
261 Included
Thai board of orthodontics Patients. Orthodontic Waves 2016; 75(3):54-63.
Vu CQ, Roberts WE, Hartsfield JK, Jr., Ofner S. Treatment complexity index for assessing the relationship of treatment
262 Included
duration and outcomes in a graduate orthodontics clinic. Am J Orthod Dentofac Orthop 2008;133(1):9 e1-13.
Yang-Powers LC, Sadowsky C, Rosenstein S, BeGole EA. Treatment outcome in a graduate orthodontic clinic using the
263 Included
American Board of Orthodontics grading system. Am J Orthod Dentofac Orthop 2002;122(5):451-5. Epub 2002/11/20.
.
Appendix D. Downs and Black tool used for the risk of bias assessment of included cohort studies with guidance.
Category Item Guidance
Reporting Are the characteristics of the study's patients clearly described? Are the patients’ age, gender, and malocclusion described?
Are the appliances and the treatment approach (ex/non-ex)
Are the interventions of interest clearly defined?
described to a minimum?
Are the distributions of principal confounders in each group
Are confounders (DI, Tx time) described in each group?
clearly described?
Does the study provide estimates of the random variability in the
Is the variability of the estimate given (SD, SE or 95% CI)?
data for the main outcomes?
Are patients representative of the average orthodontic
Were the subjects asked to participate in the study
External validity patient in terms of age (10-20 years) and sex (%male 30%-
representative of the entire population?
60%)
Can we be confident that finishing quality not used as a patient Patients must not be selected according to the treatment
selection criterion? results.
Patients should be treated by a skilled clinician (either
Were the staff, places, and facilities where the patients were
orthodontist, last year postgraduate, or experienced
treated, representative of what the majority of patients receive?
clinician)
Can we be confident that patients were treated? In this case, treatment is fairly obvious to ascertain
Internal validity -bias Was the study prospectively planned and conducted? Prospective design
Was an attempt made to blind those measuring the main
Was blinding implemented during model scoring with OGS?
outcome?
If any of the results of the study were based on “data dredging”,
Are there more than 5 subgroups/comparisons?
was this made clear?
Were the main outcome measures used accurate (valid and
For us, it is straightforward, as OGS is very valid.
reliable)?
Power Sample size for the study (cohort) or for each compared
Did the study have sufficient power to accurately detect an group (comparative cohort studies with at least two groups).
existing effect? Cut-offs used to give 0, 1, 2, 3, 4 or 5 points: 0-20, 20-40,
40-60, 60-80, 80-100, >100 patients.
DI, discrepancy index; Tx, treatment; SD, standard deviation; SE, standard error; CI, confidence interval; OGS, objective grading system.
Appendix E. Risk of bias assessment for the included studies.
Akinci Cansunar
Rodríguez 2014
Ferguson 2016*
Farhadian 2005
Junqueira 2012
Carvajal-Flórez
Detterline 2010
Campbell 2007
Pinskaya 2004
Hoybjerg 2013
Santiago 2012
Marques 2012
Deguchi 2011
Deguchi 2015
Deguchi 2005
Schabel 2008
Yang-Powers
Viwattanatipa
Kuncio 2007*
Sohrabi 2016
Chalabi 2015
Knierim 2006
Aszkler 2014
Anthopoulou
Soltani 2012
Alford 2011*
Brown 2015
Brown 2011
Barbosa Lis
Djeu 2005*
Park 2008
Jain 2013
Vu 2008
Li 2015*
2016
2014
2014
2016
2014
2002
Are the characteristics of the study's
patients clearly described?
Are the interventions of interest clearly
Reporting
defined?
Are the distributions of principal
confounders in each group clearly
described?
Does the study provide estimates of the
random variability in the data for the
main outcomes?
Were the subjects asked to participate
in the study representative of the entire
population?
External validity
Can we be confident that finishing

quality not used as a patient selection
criterion?
Were the staff, places, and facilities
where the patients were treated,
representative of what the majority of
patients receive?
Can we be confident that patients were
treated?
Was the study prospectively planned
and conducted?
Internal validity -
Was an attempt made to blind those

measuring the main outcome?
bias
If any of the results of the study were

based on “data dredging”, was this
made clear?
Were the main outcome measures used
accurate (valid and reliable)?
Power
Did the study have sufficient power to

3 3 3 1 1 1 2 2 3 3 1 2 5 5 4 0 2 3 1 2 5 5 5 5 5 5 5 5 5 2 4 3 1 5
accurately detect an existing effect?
not applicable
definitely yes
probably yes
probably no
definitely no
unclear
Rationale for judging ‘Powe’ domain: 0-20 patients, 0 points; 20-40 patients, 1 point; 40-60 patients, 2 points; 60-80 patients, 3 points; 80-100 patients, 4 points; 5 >100 patients, 5 points.
Appendix F. Assessment of study-level explorative factors assessed with random-effects meta-regression for the subgroup of studies that assessed 1-
phase fixed appliance treatment,
ABO OGS score Tx duration
Factor Studies Coefficient 95% CI P n Coefficient 95%CI P
Mean age (yrs) 10 -0.12 -0.93,0.70 0.751 8 0.59 -0.33,1.51 0.166
% male 9 -7.92 -46.60,30.75 0.643 7 -15.12 -48.04,17.80 0.291
% extraction rate* (per 10%) 12 -0.65 -1.42,0.13 0.093 8 -0.01 -0.12,0.10 0.861
Mean duration/ABO OGS score 8 0.13 -1.26,1.52 0.826 7 0.05 -0.86,0.96 0.885
Mean DI 8 -0.02 -0.25,0.20 0.798 4 1.22 -4.45,6.89 0.453
¥Sohradi et al 2016 assessed the ABO OGS scores after 1-/2-phase treatment, but measured treatment duration only for the 1-phase treatment and was
excluded from the durations,
Appendix G. Results of the Egger’s test for reporting bias for the primary and secondary outcome.
¥
ABO OGS score Tx duration
Studies Coeff 95% CI P n Coeff 95%CI P
Overall 29 1.68 -2.87,6.24 0.455 16 6.96 0.74,13.19 0.031
For subgroup:
15 4.17 -1.15,9.49 0.114 8 1.70 -14.86,18.26 0.810
only FA
¥
Sohradi et al 2016 assessed the ABO OGS scores after 1-/2-phase treatment, but measured treatment duration only for the 1-phase treatment and was
excluded from the durations,
Appendix H. Meta-epidemiological assessment of matching within-studies.
Comparison: Intervention versus control
Study ABO OGS score MD (95% CI) Weight
Comparison #1: Invisalign versus fixed appliances
Comparison #1 – matched
Djeu 2005 13.14 (7.63, 18.65) 46.46
Li 2015 4.38 (2.20, 6.56) 53.54
Subtotal 8.45 (-1.04, 17.94) 100.00
Comparison #1 – non-matched
Kuncio 2007 -3.55 (-13.12, 6.02) 100.00
Comparison #2: Ex versus Non-Ex
Comparison #2 – matched
Anthopoulou 2014 -2.03 (-5.80, 1.74) 100.00
Comparison #2 – non-matched
Farhadian 2005 -7.93 (-11.83, -4.03) 100.00
-25 -4 0 4 25
Better occlusal outcome with Better occlusal outcome with

Intervention control
.
.
Appendix I. Meta-epidemiological assessment of matching across-studies.
Study Studies ABO OGS score ǀΔMDǀ (95% CI) Weight
Invisalign vs fixed appliances 3 11.93 (-5.23, 29.09) 21.60
Extraction vs non-extraction 2 5.90 (5.19, 6.61) 78.40
Overall 7.20 (-2.16, 16.56) 100.00
(I2=43.0%)
-4 0 4 25
Lower OGS (better occlusal Higher OGS (worse occlusal

outcome) in matched studies outcome) in matched studies

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THE KOREAN JOURNAL of

Review Article ORTHODONTICS

pISSN 2234-7518 • eISSN 2005-372X

Outcomes of comprehensive fixed appliance

Key words: Orthodontics, Treatment outcome, Treatment duration, Meta-analysis

Corresponding author: Spyridon N. Papageorgiou.

INTRODUCTION MATERIALS AND METHODS

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Records identified through Additional records identified

Absolute and relative between study heterogeneity

Relative heterogeneity was defined as the proportion

rogeneity, not by chance. To quantify our uncertainty,

Furthermore, 95% predictive intervals (95% PrI), which

Trials included in the systematic review (n = 40 papers; 34 studies)

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Are the characteristics of the study's patients clearly described?

0% 20% 40% 60% 80% 100%

Low risk High risk

Definitely Probably Unclear Probably Definitely

Figure 2. Summary of the risk of bias in the included studies.

406 https://doi.org/10.4041/kjod.2017.47.6.401 www.e-kjo.org

ABO-OGS Overall 29 27.93 25.31–30.55 50.00 99.1 13.17–42.70

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results (Appendix H). In the comparison of aligner vers­ DISCUSSION

408 https://doi.org/10.4041/kjod.2017.47.6.401 www.e-kjo.org

www.e-kjo.org https://doi.org/10.4041/kjod.2017.47.6.401 409

score by 0.7 point, which indicated better occlusal

I2 (95% CI), % 95% PrI

the increase in the treatment duration was statistically

due to imprecision caused by a small sample size; the

addition of future studies may rectify this.

all identified clinical case-control studies that assessed

arms that assessed novel interventions (aligners and

individualized or lingual appliances) that were excluded

from the clinical part of the systematic review because

the majority of studies neither matched the compared

patient groups according to their baseline malocclusion

covariate in the statistical analyses (Table 4). As a result,

only 10 (38.5%) of the available comparisons were free

from baseline confounding. This might be important, as

Tau (95% CI) I (95% CI), % 95% PrI

meta-epidemiological analysis indicated that matching

of experimental groups according to the baseline ma­

Some additional methodological flaws were found

among the included studies. First, a large number (n =

the literature search did not assess all eight components

of the ABO OGS and were consequently excluded from

the present review because of pooling incompatibility.

measure the baseline malocclusion severity and match

the compared groups,27 and this contradicts the rationale

does not justify substitution of the DI.9 Finally, some

included studies measured the baseline severity with

can be easily distorted by increasing the sample size;

Private practice vs. 1

The strengths of this systematic review include

the a priori registration in PROSPERO, the extensive

unrestricted literature search, which included studies

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Finally, as considerable heterogeneity was found in both REFERENCES

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Outcome of comprehensive fixed appliance orthodontic treatment: a systematic review

results (Appendix H). In the comparison of aligner vers DISCUSSION

of experimental groups according to the baseline ma