title: Early orthodontic treatment for Class III malocclusion: A systematic review and meta-analysis.
abstract: BACKGROUND
  Class III malocclusion affects between 5% and 15% of our population. The 2 most common dilemmas surrounding Class III treatment are the timing of treatment and the type of appliance. A number of appliances have been used to correct a Class III skeletal discrepancy, but there is little evidence available on their effectiveness in the long term. Similarly, early treatment of Class III malocclusion has been practiced with increasing interest. However, there has been no solid evidence on the benefits in the long term. The aim of this systematic review was to evaluate the effectiveness of orthodontic/orthopedic methods used in the early treatment of Class III malocclusion in the short and long terms.
  
  
  METHODS
  Several sources were used to identify all relevant studies independently of language. The Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase (Ovid), and MEDLINE (Ovid) were searched to June 2016. The selection criteria included randomized controlled trials (RCTs) and prospective controlled clinical trials (CCTs) of children between the ages of 7 and 12 years on early treatment with any type of orthodontic/orthopedic appliance compared with another appliance to correct Class III malocclusion or with an untreated control group. The primary outcome measure was correction of reverse overjet, and the secondary outcomes included skeletal changes, soft tissue changes, quality of life, patient compliance, adverse effect, Peer Assessment Rating score, and treatment time. The search results were screened for inclusion, and the data extracted by 2 independent authors. The data were analyzed using software (version 5.1, Review Manager; The Nordic Cochrane Centre, The Cochrane Collaboration; Copenhagen, Denmark). The mean differences with 95% confidence intervals were expressed for the continuous data. Random effects were carried out with high levels of clinical or statistical heterogeneity and fixed affects when the heterogeneity was low.
  
  
  RESULTS
  Fifteen studies, 9 RCTs and 6 CCTs, were included in this review. In the RCT group, only 3 of 9 studies were assessed at low risk of bias, and the others were at high or unclear risk of bias. All 6 CCT studies were classified as high risk of bias. Three RCTs involving 141 participants looked at the comparison between protraction facemask and untreated control. The results for reverse overjet (mean difference, 2.5 mm; 95% CI, 1.21-3.79; P = 0.0001) and ANB angle (mean difference, 3.90°; 95% CI, 3.54-4.25; P <0.0001) were statistically significant favoring the facemask group. All CCTs demonstrated a statistically significant benefit in favor of the use of each appliance. However, the studies had high risk of bias.
  
  
  CONCLUSIONS
  There is a moderate amount of evidence to show that early treatment with a facemask results in positive improvement for both skeletal and dental effects in the short term. However, there was lack of evidence on long-term benefits. There is some evidence with regard to the chincup, tandem traction bow appliance, and removable mandibular retractor, but the studies had a high risk of bias. Further high-quality, long-term studies are required to evaluate the early treatment effects for Class III malocclusion patients.
  
  
  BACKGROUND
  PROSPERO CRD42015024252.
authors.affiliation: School of Dentistry, University of Manchester, Manchester, United Kingdom.
authors.forename: See Choong
authors.initials: SC
authors.lastname: Woon
authors.affiliation: School of Dentistry, University of Manchester, Manchester, United Kingdom. Electronic address: Badri.T@manchester.ac.uk.
authors.forename: Badri
authors.initials: B
authors.lastname: Thiruvenkatachari
mesh_terms: D006801:Humans; D008313:Malocclusion, Angle Class III / Q000628:therapy*; D009971:Orthodontics, Corrective / Q000379:methods*; D016896:Treatment Outcome