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Resultados Del Tratamiento Completo de Ortodoncia Con Aparatos Fijos
Resultados Del Tratamiento Completo de Ortodoncia Con Aparatos Fijos
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]
Received January 10, 2017; Revised February 21, 2017; Accepted March 29, 2017.
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
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
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
https://doi.org/10.4041/kjod.2017.47.6.401
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
Papageorgiou et al • Occlusal outcome of orthodontic treatment
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
https://doi.org/10.4041/kjod.2017.47.6.401
Papageorgiou et al • Occlusal outcome of orthodontic treatment
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
Papageorgiou et al • Occlusal outcome of orthodontic treatment
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
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
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.
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
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
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
0.818
NA
0.5
covariate adjustment.
university clinic
four premolars
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.
long does treatment with fixed orthodontic appli ationship between discrepancy index and the
ances last? A systematic review. Am J Orthod Den objective grading system in thai board of ortho
tofacial Orthop 2016;149:308-18. dontics patients. Orthod Waves 2016;75:54-63.
14. Higgins JPT, Green S. Cochrane Handbook for 25. Papageorgiou SN, Xavier GM, Cobourne MT. Basic
Systematic Reviews of Interventions. Version 5.1.0 study design influences the results of orthodontic
[Internet]. The Cochrane Collaboration; 2011 [up clinical investigations. J Clin Epidemiol 2015;
dated 2011 Mar; cited 2016 Dec 3]. Available from: 68:1512-22.
http://handbook.cochrane.org/. 26. Papageorgiou SN, Koretsi V, Jäger A. Bias from
15. Liberati A, Altman DG, Tetzlaff J, Mulrow C, historical control groups used in orthodontic resea
Gøtzsche PC, Ioannidis JP, et al. The PRISMA rch: a meta-epidemiological study. Eur J Orthod
statement for reporting systematic reviews and 2017;39:98-105.
meta-analyses of studies that evaluate health care 27. Marques LS, Freitas Junior Nd, Pereira LJ, Ramos-
interventions: explanation and elaboration. J Clin Jorge ML. Quality of orthodontic treatment perfor
Epidemiol 2009;62:e1-34. med by orthodontists and general dentists. Angle
16. Downs SH, Black N. The feasibility of creating a Orthod 2012;82:102-6.
checklist for the assessment of the methodological 28. CoHong M, Kook YA, Baek SH, Kim MK. Comparison
quality both of randomised and non-randomised of treatment outcome assessment for class I malo
studies of health care interventions. J Epidemiol cclusion patients: peer assessment rating versus
Community Health 1998;52:377-84. American board of orthodontics-objective grading
17. Veroniki AA, Jackson D, Viechtbauer W, Bender R, system. J Korean Dent Sci 2014;7:6-15.
Bowden J, Knapp G, et al. Methods to estimate the 29. Hong M, Kook YA, Kim MK, Lee JI, Kim HG,
between-study variance and its uncertainty in meta- Baek SH. The Improvement and Completion of
analysis. Res Synth Methods 2016;7:55-79. Outcome index: A new assessment system for qua
18. Papageorgiou SN. Meta-analysis for orthodontists: lity of orthodontic treatment. Korean J Orthod
Part I--How to choose effect measure and statistical 2016;46:199-211.
model. J Orthod 2014;41:317-26. 30. Pocock SJ, Assmann SE, Enos LE, Kasten LE.
19. Papageorgiou SN. Meta-analysis for orthodontists: Subgroup analysis, covariate adjustment and baseline
Part II--Is all that glitters gold? J Orthod 2014; comparisons in clinical trial reporting: current
41:327-36. practice and problems. Stat Med 2002;21:2917-30.
20. IntHout J, Ioannidis JP, Rovers MM, Goeman JJ. 31. Papageorgiou SN, Papadopoulos MA, Athanasiou
Plea for routinely presenting prediction intervals in AE. Reporting characteristics of meta-analyses in
meta-analysis. BMJ Open 2016;6:e010247. orthodontics: methodological assessment and stati
21. Ioannidis JP. Interpretation of tests of heterogeneity stical recommendations. Eur J Orthod 2014;36:74-
and bias in meta-analysis. J Eval Clin Pract 2008; 85.
14:951-7. 32. Hernández AV, Steyerberg EW, Habbema JD. Co
22. Tsichlaki A, Chin SY, Pandis N, Fleming PS. How variate adjustment in randomized controlled trials
long does treatment with fixed orthodontic with dichotomous outcomes increases statistical
appliances last? A systematic review. Am J Orthod power and reduces sample size requirements. J Clin
Dentofacial Orthop 2016;149:308-18. Epidemiol 2004;57:454-60.
23. Djeu G, Shelton C, Maganzini A. Outcome assessment 33. Papageorgiou SN, Kloukos D, Petridis H, Pandis
of Invisalign and traditional orthodontic treatment N. Publication of statistically significant research
compared with the American Board of Orthodontics findings in prosthodontics & implant dentistry
objective grading system. Am J Orthod Dentofacial in the context of other dental specialties. J Dent
Orthop 2005;128:292-8; discussion 298. 2015;43:1195-202.
24. Viwattanatipa N, Buapuean W, Komoltri C. Rel
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/
Same with PubMed - 4
(CENTRAL) cochranelibrary/search/
http://www.embase.com/#ad
Embase Same with PubMed - 14
vancedSearch/default
Virtual Health http://pesquisa.bvsalud.org/p
Same with PubMed - 7
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
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9 Excluded by title
2006;130(2):133-40. Epub 2006/08/15.
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12 Anon. An interview with Marissa C. Keesler. Dental Press J Orthod. 2014;19(2):27-38. Excluded by title
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13 indian subpopulations and its correlation in abo blood groups. Journal of Clinical and Diagnostic Research. 2014;8(10):ZC40- Excluded by title
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14 prognathism and asymmetry through orthodontics and orthognathic surgery. Am J Orthod Dentofac Orthop 1991;99(3):191- Excluded by title
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15 Bilodeau JE. An American Board of Orthodontics case report. Am J Orthod Dentofac Orthop 1997;111(5):487-91. Excluded by title
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16 Workshop, The College of Diplomates of the American Board of Orthodontics. Sun Valley, Idaho, July 21-25, 2001. The Angle Excluded by title
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Bond JA. Orthopedic/orthodontic treatment of a Class I malocclusion with a Class III skeletal pattern and maxillary deficiency.
17 Excluded by title
An American Board of Orthodontics case report. Am J Orthod Dentofac Orthop 1987;91(5):429-37. Epub 1987/05/01.
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18 Excluded by title
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20 Excluded by title
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21 Excluded by title
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22 Excluded by title
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24 Excluded by title
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28 Excluded by title
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29 Excluded by title
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31 Damone J. ABO working to improve board-certification process. Am J Orthod Dentofac Orthop 2002;121(2):16A-7A. Excluded by title
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35 Devries BG. Some views of the American Board of Orthodontics on orthodontic education. American journal of orthodontics. Excluded by title
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38 Dugoni SA, Lee JS. American Board of Orthodontics Case-Report. Am J Orthod Dentofac Orthop 1991;100(2):99-105. Excluded by title
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44 Excluded by title
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Ernest Iii EA. Percutaneous thermal lesioning of the temporomandibular posterior-superior disc ligament to effect adequate
45 Excluded by title
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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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49 high mandibular plane angle, bimaxillary protrusion, and vertical maxillary excess. Am J Orthod Dentofac Orthop Excluded by title
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53 Excluded by title
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55 Gorman JC. Make ABO exam more user-friendly. Am J Orthod Dentofac Orthop 2005;128(1):7. Excluded by title
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59 Grob DJ. Extraction of a mandibular incisor in a Class I malocclusion. Am J Orthod Dentofac Orthop 1995;108(5):533-41. Excluded by title
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60 the American Board of Orthodontics: a modification in the case display requirements for adult and periodontally involved Excluded by title
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61 Gu Y, McNamara JA, Jr. Cephalometric superimpositions. The Angle orthodontist. 2008;78(6):967-76. Epub 2008/10/25. Excluded by title
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64 Hopkins SC. The Present Status of the American-Board-of-Orthodontics. Am J Orthod Dentofac Orthop 1952;38(7):552-5. Excluded by title
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68 Keim RG, Sinclair PM. Orthodontic graduate education survey, 1983-2000. Am J Orthod Dentofac Orthop 2002;121(1):2-8. Excluded by title
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71 Kim KR. Category 2: Adult malocclusion with open bite. Am J Orthod Dentofac Orthop 2009;135(1):127-32. Epub 2009/01/06. Excluded by title
72 King L. Category 1: Interceptive or early treatment. Am J Orthod Dentofac Orthop 2004;126(4):506-16. Epub 2004/10/08. Excluded by title
73 Klontz KJ. Category 5: Class II Division 1 malocclusion. Am J Orthod Dentofac Orthop 2005;127(2):242-8. Epub 2005/03/08. Excluded by title
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76 Martinek CE. The American-Board-of-Orthodontics. Am J Orthod Dentofac Orthop 1954;40(3):189-95. Excluded by title
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85 Noble R, English J. Category 7: anteroposterior skeletal discrepency. Am J Orthod Dentofac Orthop 2006;130(3):403-8. Excluded by title
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89 Owens SE. An American-Board-of-Orthodontics Case-Report. Am J Orthod Dentofac Orthop 1990;97(4):273-81. Excluded by title
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92 Prezzano WJ. Certification by the American Board of Orthodontics. American journal of orthodontics. 1970;57(3):293-4. Excluded by title
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94 Rathbone JS. American-Board-of-Orthodontics - Today and Future. Am J Orthod Dentofac Orthop 1976;69(2):185-93. Excluded by title
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96 Restrep LG, Peláez JF, Tadlock LP. IBC: índice Board CES. CES Odontol. 2014;27(1):106-17. Excluded by title
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105 Shepard E. The American Board of Orthodontics: milestones of progress. Am J Orthod Dentofac Orthop 1990;98(4):372-5. Excluded by title
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107 Shepard EE. The American-Board-of-Orthodontics - Then and Now. Am J Orthod Dentofac Orthop 1986;89(1):67-9. Excluded by title
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121 Wade DB. ABO certification: a worthy goal. Am J Orthod Dentofac Orthop 1993;103(5):478. Epub 1993/05/01. Excluded by title
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124 White OW. Report of the American-Board-of-Orthodontics. Am J Orthod Dentofac Orthop 1948;34(12):1027-8. Excluded by title
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142 Lemay M. Logistics in digital orthodontic models. International journal of orthodontics (Milwaukee, Wis). 2007;18(4):25-8. Excluded by abstract
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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
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 – matched
Comparison #1 – non-matched
Comparison #2 – matched
Comparison #2 – non-matched
-25 -4 0 4 25
(I2=43.0%)
-4 0 4 25