Treatment effects of removable functional appliances in patients with Class II malocclusion: a systematic review and meta-analysis

Objective: To assess the treatment effects of removable functional appliances (RFAs) in treated versus untreated patients with Class II malocclusion by means of lateral cephalometric radiographs.

Search methods: Unrestricted electronic search of 18 databases and manual searches up to October 2013.

Selection criteria: Prospective randomized and non-randomized controlled trials reporting on cephalometric angular measurements of Class II patients treated with RFAs and their matched controls.

Data collection and analysis: Skeletal, dental, and soft tissue changes were annualized and stratified to short- and long-term effects. Methodological limitations were evaluated with the Cochrane Risk of Bias tool and the Downs and Black checklist. Mean differences (MDs) with their 95% confidence intervals (CIs) were calculated from random-effects meta-analyses. Patient- or appliance-related subgroup analyses and sensitivity analyses were performed with mixed-effects models.

Results: Seventeen studies were included (1031 patients; mean age: 10.6 years), with most of them originating from university clinics and reporting short-term effects (directly after the removal of RFAs). Treatment was associated with minimal reduction of SNA angle (11 studies, MD = -0.28 degree/year, 95% CI: -0.44 to -0.12 degree/year), minimal increase of SNB angle (11 studies, MD = 0.62 degree/year, 95% CI: 0.36-0.88 degree/year), and small decrease of ANB angle (10 studies, MD = -1.14 degree/year, 95% CI: -1.52 to -0.77 degree/year) compared to untreated Class II patients. RFAs caused significant dentoalveolar changes (predominantly retroclination of the upper incisors) and significant soft tissue changes. Skeletal changes were more pronounced with the Twin Block appliance. Various patient- or appliance-related factors influenced the results of the subgroup analyses, while the sensitivity analyses indicated robustness. Existing evidence was inadequate to assess the long-term effectiveness of RFAs.

Conclusions: The short-term evidence indicates that RFAs are effective in improving Class II malocclusion, although their effects are mainly dentoalveolar, rather than skeletal.