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1134 ANTONARAKIS, KILIARIDIS ance intramaxillary appliances for molar distalization for the purpose of analyzing their effects as a whole and when grouped according to types of appliances. Appliance groups were categorized as (1) those with a buccal application and those with a palatal force application, and (2) those with a friction-free mechanism and those with a sliding mechanism. MATERIALS AND METHODS Literature Search A literature search was performed with the use of PubMed, Ovid, and the Cochrane Library to identify orthodontic articles that reported on the use of noncompliance intramaxillary molar distalization appliances for the management of Class II malocclusion. Terms used in the search included ‘‘Class II,’’ ‘‘noncompliance,’’ and ‘‘molar distalization.’’ The search was expanded with use of the Related Articles function in PubMed to locate lists of articles consulted, names of individual appliances used, and names of individual authors who have worked with a particular appliance. Full text sources available on the Internet for the American Journal of Orthodontics and Dentofacial Orthopedics, European Orthodontic Journal, and The Angle Orthodontist were also searched to validate that the search had identified all relevant articles. 4 Articles were selected for inclusion and analysis if the following criteria were met: • Human studies • Pertained to the use of intramaxillary noncompliance molar distalization appliances in the management of Class II malocclusion • Treatment carried out with an appliance alone without the concomitant use of other appliances (eg, fixed appliances) and without the use of absolute or bony anchorage (eg, palatal implants, miniscrews) • Mention of which appliance was used, along with a description if necessary • Studies designed as prospective or retrospective studies, with the type of study mentioned (case studies/reports or case series excluded) • Sample size mentioned (minimum, 10 patients) • Appliances used in growing patients; age ranges and mean age at the start of treatment mentioned • Duration of treatment mentioned (maximum duration, 12 months) • Measurable pretreatment and posttreatment cephalometric values, as well as changes during treatment • Measured molar distal movement and at least one other measurement from the following: incisor mesial movement, premolar mesial movement, molar distal tipping, incisor mesial tipping, premolar mesial tipping, molar vertical movement, incisor vertical movement, premolar vertical movement • Sufficient data available for statistical calculations (mean and standard deviations for each measurement presented) • Error of the method values stated and calculated by retracing radiographs with the use of Dahlberg’s formula 5 ; statement of how many radiographs/patients were used to calculate this. When using Dahlberg’s 2 formula d/2n, d 2 denotes the sum of the squared differences between pairs of recordings, and n denotes the number of duplicate measurements • When more than one publication about the same patient group was identified, the most informative and relevant article was selected for inclusion Data Analysis The data provided in selected studies were collected and analyzed with no distinction made between different types of appliances. From the identified studies, investigators examined molar distal movement, premolar mesial movement, incisor mesial movement, molar distal tipping, premolar mesial tipping, incisor mesial tipping, molar vertical movement, premolar vertical movement, and incisor vertical movement. The data from each group were compared with a constant that had a mean of zero and a standard deviation equal to the error of the method. According to the authors’ assumptions, without treatment, the mean changes in the variables looked at would have been zero or negligible after a period of a few months, with a variance around the zero due to methodologic error. The error of the method was thus taken into account by using this as the standard deviation of the constant. Data were subsequently entered into the meta-analysis program of the Cochrane Collaboration Review Manager Software (RevMan Version 4.2 for Windows. Copenhagen, Denmark. The Nordic Cochrane Centre. The Cochrane Collaboration, 2003). With the use of the random effects model, forest plots were drawn, mean and confidence interval values calculated, and significance tests carried out (to calculate P values). The results of individual studies thus were statistically combined into a single outcome measure, a feature distinctive of meta-analyses, 6 but the studies included were not only prospective controlled studies; thus, the term ‘‘meta-analysis’’ is not used here. Studies were divided into those with buccal force application and those with palatal force application, and data were grouped accordingly. Once again, in accordance with the random effects model, forest plots were drawn, mean and confidence interval values calculated, and significance tests carried out (to calculate Angle Orthodontist, Vol 78, No 6, 2008
ANALYSIS OF NONCOMPLIANCE MOLAR DISTALIZATION 1135 Table 1. Details of Studies Included for Data Analysis a Study Type of Study Appliance Bondemark, 2000 7 Retrospective Superelastic NiTi coils with Nance button Repelling magnets with Nance button Bondemark and Karlsson, 2005 8 Bondemark and Kurol, Prospective randomized Superelastic NiTi coils with Nance button Prospective Repelling magnets with Nance button Bondemark Prospective Superelastic NiTi coils/ 1998 10 button and Kurol, magnets, with Nance Bondemark et Prospective Superelastic NiTi coils/ al, 1994 11 magnets, with Nance button Buccal or Palatal Anchorage Premolars Tx Duration, m n N, Error of Method Age at Start, y 7s Present Palatal 2 6.5 21 20 14.4 Yes Buccal 2 5.8 21 20 13.9 Yes Palatal 2 5.2 20 20 11.4 No Buccal 2 3.9 10 10 13.4 Yes Buccal 2 6 18 10 14.7 Yes Buccal 2 6 18 10 14.9 Yes Chaqués- Asensi and Kalra, 2001 12 Retrospective Pendulum Palatal 2 6.5 26 10 11.2 11 Yes, 15 No Erverdi et al, Prospective Repelling magnets with Buccal 2 3 15 15 12.3 Yes 1997 13 Nance button NiTi coil appliance with Buccal 2 3 15 15 12.3 Yes Nance button Ferguson et Retrospective Distal Jet Palatal 2 8 25 10 12.5 Not stated al, 2005 14 GMD appliance Palatal and 2 11 25 10 11.5 Not stated buccal Karlsson and Retrospective NiTi coil appliance with Palatal 2 5.2 20 20 11.4 No 2006 15 Bondemark, Nance button NiTi coil appliance with Palatal 2 6.5 20 20 14.6 Yes Nance button Kinzinger et al, Prospective Modified Pendulum Palatal 4 5.5 10 30 12.8 No 2005 16 Mavropoulos Prospective Superelastic NiTi coils Buccal 2 4.1 10 10 13.2 Yes et al, 2005 17 with Nance button Papadopoulos Retrospective Superelastic NiTi coils Buccal 2 3.8 14 14 13.4 Yes et al, 2004 18 with Nance button Sayinsu et al, 2006 19 Prospective Modified Keles Palatal 2 6 17 10 13.6 Not stated a Studies are listed in alphabetic order by first author. Listed for each study are the type of study, the appliance used, whether force application was buccal or palatal, the number of premolars that were made part of the anchorage setup, treatment (Tx) duration in months (m), sample size (n), sample size (N) of the retracings used for the error of the method, mean age at start of treatment in years, and whether or not second molars (7s) were present. The numeric difference between the sample size (n) and the sample size (N) of the retracings used for the error of the method measurements is due to the fact that for some studies, not all radiographs were retraced to calculate the error of the method, only a selected number were chosen at random, and other studies retraced a larger patient sample. P values) for the different variables. Studies were not formally divided into friction and (sliding) friction-free mechanisms as was initially planned because the number of studies in which a friction-free appliance was used was limited. RESULTS Results of Search The original search located 395 articles, including 376 human studies. Of these, 64 pertained to molar distalization of Class II malocclusion with an intraoral intramaxillary appliance. The articles that contained relevant and sufficient data for this study were further narrowed down to 13 (Table 1) by application of the inclusion criteria (Figure 1). 7–19 The results described below are summarized in Table 2 and in Figures 2 through 4. Overall Treatment Effects Sagittal treatment effects, namely, mesiodistal movement and tipping, were detected for molars, in- Angle Orthodontist, Vol 78, No 6, 2008
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