Evidence based orthodontics /certified fixed orthodontic courses by Indian dental academy

Evidence Based OrthodonticsEvidence Based Orthodontics
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INDIAN DENTAL ACADEMY
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INDEXINDEX
• IntroductionIntroduction
• DefinitionDefinition
• HistoryHistory
• Need for evidence based orthodonticsNeed for evidence based orthodontics
• Traditional Orthodontic practiceTraditional Orthodontic practice
• Evidence based orthodontic practiceEvidence based orthodontic practice
- 6 STEPS- 6 STEPS

• Advantages and disadvantagesAdvantages and disadvantages
• LimitationsLimitations
• Clinical implicationsClinical implications
• ConclusionConclusion
• ReferencesReferences

IntroductionIntroduction
Evidence based orthodonticEvidence based orthodontic
practice is all aboutpractice is all about
• doing the right thingdoing the right thing
• to the right patientto the right patient
• in the right wayin the right way
• at the right timeat the right time
• at the right costat the right cost
• in the right placein the right place

An approach to clinical orthodonticsAn approach to clinical orthodontics
in which the clinician is aware ofin which the clinician is aware of
the evidence in support of clinicalthe evidence in support of clinical
practice and the strength of thatpractice and the strength of that
evidenceevidence

DefinitionDefinition
• ““a conscientious, explicit, and judiciousa conscientious, explicit, and judicious
use of current best evidence inuse of current best evidence in
conjunction with clinical experience toconjunction with clinical experience to
make decisions regarding patient care”make decisions regarding patient care”
David Sackett

HistoryHistory
• Post revolutionary paris; around 1850sPost revolutionary paris; around 1850s
• China B.CChina B.C
• Some tools of EBD can be traced back toSome tools of EBD can be traced back to
biblical timesbiblical times
• 19701970s : MacMaster Univ, Canadas : MacMaster Univ, Canada
• 19801980s : Harvard Univ, USs : Harvard Univ, US
• 19951995 : Oxford Univ, UK: Oxford Univ, UK

How does it workHow does it work
• Efficient effective diagnosisEfficient effective diagnosis
• Scientific foundation to complementScientific foundation to complement
mechanical skillsmechanical skills
• Thoughtful identification, compassionateThoughtful identification, compassionate
use of individual patient problems, rights,use of individual patient problems, rights,
preferences in clinical problem decisionpreferences in clinical problem decision
making.making.

Need for Evidence basedNeed for Evidence based
orthodonticsorthodontics
““simply because we, as health caresimply because we, as health care
professionals, owe it to our patientsprofessionals, owe it to our patients
to provide the currently best careto provide the currently best care
available”available”

How does the Evidence basedHow does the Evidence based
approach differ from what youapproach differ from what you
already practicealready practice
• Accessing new evidence on a regularAccessing new evidence on a regular
basisbasis
• Identification of new risk factors, analysis,Identification of new risk factors, analysis,
continuous improvement in efficacy ofcontinuous improvement in efficacy of
carecare
• Patient centered approachPatient centered approachwww.indiandentalacademy.comwww.indiandentalacademy.com

Traditional Orthodontic practiceTraditional Orthodontic practice
TREATEMENT
ADVICE
DECISIONS
COMPLAINTS
SYMPTOMS
SIGNS

``
Clinical decision making will be based onClinical decision making will be based on
CLINICAL EXPERTISECLINICAL EXPERTISE ==
KnowledgeKnowledge ++ExperienceExperience
May be out of date
Increasingly difficult to
keep up with New ideas
and concepts
Acquisition of new
knowledge is slow and
haphazard
May be limited
Subject to
personal bias
May out weigh
knowledge
DRAWBACKS:

Evidence based orthodonticEvidence based orthodontic
practicepractice
6 Steps6 Steps to perform EBOto perform EBO
1.1. Framing a questionFraming a question
2.2. Finding evidenceFinding evidence
3.3. Appraising the evidenceAppraising the evidence
4.4. Applying the evidenceApplying the evidence
5.5. Assessing the outcomeAssessing the outcome
6.6. Summarizing and storing recordsSummarizing and storing records

Step 1Step 1
• Framing a QuestionFraming a Question
(Formulating a relevant, focused, clinically important question(Formulating a relevant, focused, clinically important question
that is likely to be answered)that is likely to be answered)
• Framing a question in a proper format identifiesFraming a question in a proper format identifies
four crucial “ PICO” elements. These elementsfour crucial “ PICO” elements. These elements
are:are:
1.1.PPopulation or patient typeopulation or patient type
2.2.IInterventionntervention
3.3.CComparisonomparison
4.4.OOutcomeutcome

THE CLINICAL QUESTIONTHE CLINICAL QUESTION
PATIENTPATIENT
OROR
PROBLEMPROBLEM
INTERVENTIONINTERVENTION COMPARISONCOMPARISON
INTERVENTIONINTERVENTION
OUTCOMOUTCOM
EE
TIPSTIPS
FORFOR
BUIL-BUIL-
-DING-DING
Starting with yourStarting with your
patient,ask “Howpatient,ask “How
would I describe awould I describe a
group of patientsgroup of patients
similar tosimilar to
mine?”Balancemine?”Balance
precision withprecision with
brevity.brevity.
Ask “Which mainAsk “Which main
intervention am Iintervention am I
considering?”considering?”
Be specificBe specific
Ask “What is the mainAsk “What is the main
alternative to comparealternative to compare
with the intervention ?”with the intervention ?”
Again be specificAgain be specific
Ask “What can IAsk “What can I
hope tohope to
accomplish?”,oraccomplish?”,or
“What could“What could
this exposurethis exposure
really affect?”really affect?”
Again beAgain be
specificspecific
EXA-EXA-
MPLEMPLE
In uncooperativeIn uncooperative
children----children----
---would conscious---would conscious
sedation added tosedation added to
standard behaviorstandard behavior
managementmanagement
techniques----techniques----
---when compared to---when compared to
standard managementstandard management
techniques alone---techniques alone---
---lead to a---lead to a
better outcomebetter outcome
of dentalof dental
treatment?treatment?

Step 2Step 2
Finding the EvidenceFinding the Evidence
• Sources:Sources:
Primary researchPrimary research : articles in: articles in
journals (& even unpublishedjournals (& even unpublished
research work)research work)
Secondary researchSecondary research : systematic: systematic
reviews (with or without meta-reviews (with or without meta-
analysis), non-systematic reviews,analysis), non-systematic reviews,
guidelines, decision analysis,guidelines, decision analysis,www.indiandentalacademy.comwww.indiandentalacademy.com

• Search strategySearch strategy::
Manual searchManual search: library, correspondence: library, correspondence
Electronic searchElectronic search :: 1) PubMed (2)Database of1) PubMed (2)Database of
Abstracts of Reviews of Effects (DARE) of the Centre forAbstracts of Reviews of Effects (DARE) of the Centre for
Reviews and Dissemination(3) Cochrane Database ofReviews and Dissemination(3) Cochrane Database of
Systematic Reviews (Cochrane Reviews), (4) CochraneSystematic Reviews (Cochrane Reviews), (4) Cochrane
Central Register of Controlled Trials, (5) CochraneCentral Register of Controlled Trials, (5) Cochrane
Database of Methodology Reviews (MethodologyDatabase of Methodology Reviews (Methodology
Reviews), (5) Cochrane Methodology Register, (6)Reviews), (5) Cochrane Methodology Register, (6)
Health Technology Assessment Database, (7) NHSHealth Technology Assessment Database, (7) NHS
Economic Evaluation Database (NHS EED), and (8)Economic Evaluation Database (NHS EED), and (8)
About the Cochrane Collaboration (About)About the Cochrane Collaboration (About)..www.indiandentalacademy.comwww.indiandentalacademy.com

Levels of evidence:Levels of evidence:
To judge the quality of studies a “To judge the quality of studies a “hierarchy ofhierarchy of
evidenceevidence” exists the relative strength of various” exists the relative strength of various
studies.studies.
The evidence that is most likely to be useful for makingThe evidence that is most likely to be useful for making
decisions regarding patient managementdecisions regarding patient management
• Systematic reviews and meta-analysisSystematic reviews and meta-analysis
• Randomized controlled trialsRandomized controlled trials
• Cohort studiesCohort studies
• Case-control studiesCase-control studies
• Cross-sectional surveysCross-sectional surveys
• Case reportsCase reports

THE EVIDENCE PYRAMID
USED TO ILLUSTRATE THE
EVOLUTION OF THE
LITERATURE
AS YOU MOVE UP THE
PYRAMID THE AMOUNT OF
AVAILABLE LITERATURE
DECEREASES BUT INCREASE IN
RELEVANCE FOR APPLICATION
FOR CLINICAL SETTINGS.
ANIMAL RESEARCH
IN VITRO (‘TEST TUBE ’) RESEARCH
CASE REPORTS
CASE CONTROL
STUDIES
COHORT
STUDIES
RANDOMIZED CONTROLLED
DOUBLE BLIND STUDIES
SYSTEMIC REVIEWS
IDEAS, EDITORIALS, OPINIONS
CASE SERIES
Hierarchy of EvidenceHierarchy of Evidence

SYSTEMATIC REVIEWSSYSTEMATIC REVIEWS
• Systematic reviews are a synopsis of theSystematic reviews are a synopsis of the
existing evidence on a specific topic.existing evidence on a specific topic.
• Provides means to keep up with numerousProvides means to keep up with numerous
articles published annually in every field.articles published annually in every field.
• Concentrates on a very specific and narrow,Concentrates on a very specific and narrow,
clinically relevant question.clinically relevant question.
• Team of expertsTeam of experts
• Inclusion and exclusion criteria is usedInclusion and exclusion criteria is used
• Bias unlikely to happenBias unlikely to happen

META ANALYSISMETA ANALYSIS
Meta-analytic procedures (MAPs) are consideredMeta-analytic procedures (MAPs) are considered
• the highest level of analysis in whichthe highest level of analysis in which
conclusions are made by combining the resultsconclusions are made by combining the results
of other types of studies with already strongof other types of studies with already strong
evidence—ie, randomized control trials.evidence—ie, randomized control trials.
• Meta-analyses (MAs) greatly increase theMeta-analyses (MAs) greatly increase the
overall sample size by combining data fromoverall sample size by combining data from
individual studies,thus increasing the statisticalindividual studies,thus increasing the statistical
power of the analysis and the precision topower of the analysis and the precision to
assess the treatment effects.assess the treatment effects.

RANDOMISED CONTROLRANDOMISED CONTROL
TRIALSTRIALS
• An experimental study on patients with aAn experimental study on patients with a
particular disease or disease –free subjects inparticular disease or disease –free subjects in
which the individuals are randomly assigned towhich the individuals are randomly assigned to
either an experimental intervention or a controleither an experimental intervention or a control
group to determine the ability of an agent or agroup to determine the ability of an agent or a
procedure to diminish symptoms, to decreaseprocedure to diminish symptoms, to decrease
risk of death from disease during follow uprisk of death from disease during follow up
period.period.
• Provide strongest evidence causation ofProvide strongest evidence causation of
evidence.evidence.

COHORT STUDIESCOHORT STUDIES
• An observational study that follows an exposedAn observational study that follows an exposed
cohort compared to an unexposed cohort tocohort compared to an unexposed cohort to
determine the incidence of given outcome.determine the incidence of given outcome.
• Well designed cohort study provides strongWell designed cohort study provides strong
support for causationsupport for causation
• Non concurrent cohort studies are relativelyNon concurrent cohort studies are relatively
weaker because they rely on existing records.weaker because they rely on existing records.
DisadvantagesDisadvantages : require large sample size: require large sample size
• Length of the studies result in misclassificationLength of the studies result in misclassification
in outcome statusin outcome status
• Continuous assessment of the exposure andContinuous assessment of the exposure and
outcome results.outcome results.

CASE CONTROLCASE CONTROL
STUDIESSTUDIES• These are observational studies where inThese are observational studies where in
cases with a particular outcome and controlscases with a particular outcome and controls
that do not have the same outcome are firstthat do not have the same outcome are first
selected and exposure assessment is doneselected and exposure assessment is done
retrospectively.retrospectively.
• Quick, relatively inexpensiveQuick, relatively inexpensive
• Appropriate in studying rare diseasesAppropriate in studying rare diseases
• Assessment of multiple risk factors for aAssessment of multiple risk factors for a
particular disease within the same studyparticular disease within the same study

CASE REPORT ANDCASE REPORT AND
CASE SERIESCASE SERIES
• Document unusual occurrences ofDocument unusual occurrences of
outcomesoutcomes
• First clues of a new diseases or adverseFirst clues of a new diseases or adverse
effects of exposureeffects of exposure
• Case series are an extension of caseCase series are an extension of case
reportsreports

Step 3Step 3
• Appraising the Evidence for validity and itsAppraising the Evidence for validity and its
applicability in your patientapplicability in your patient
CATCAT (critically appraised topic) a practical(critically appraised topic) a practical
approach.approach.

Step 4Step 4
Applying the evidence to one’s ownApplying the evidence to one’s own
patients, based uponpatients, based upon
• clinical judgement,clinical judgement,
• experienceexperience
• patient’s expectations and values.patient’s expectations and values.

Step 5Step 5
• Assessing the outcome of applyingAssessing the outcome of applying
the evidence in your patients.the evidence in your patients.

Step 6Step 6
• Summarizing and storing recordsSummarizing and storing records
for future reference.for future reference.

EBO ADVANTAGESEBO ADVANTAGES
• DEALS DIRECTLY WITH THEDEALS DIRECTLY WITH THE
UNCERTAINITIES OF CLINICALUNCERTAINITIES OF CLINICAL
PRACTICEPRACTICE
• INTEGRATES EDUCATION WITHINTEGRATES EDUCATION WITH
CLINICAL PRACTICECLINICAL PRACTICE
• APPLICATION FORAPPLICATION FOR
STUDENT,TEACHER,CLINICIANSTUDENT,TEACHER,CLINICIAN
AND PATIENTAND PATIENT

EBO DISADVANTAGESEBO DISADVANTAGES
• TIME TO PRACTICE AND LEARNTIME TO PRACTICE AND LEARN
• MINIMAL INFRASTRUCTUREMINIMAL INFRASTRUCTURE
MANDATORYMANDATORY
• EXPOSES GAPS IN EVIDENCEEXPOSES GAPS IN EVIDENCE
• INCREASING AVAILABILITY OFINCREASING AVAILABILITY OF
DATABASESDATABASES

LimitationsLimitations
• Authoritarian clinicians and teachersAuthoritarian clinicians and teachers
percieve it as a threatpercieve it as a threat
• Access to information is limitedAccess to information is limited
• Suitable evidence may not be availableSuitable evidence may not be available
• Some of tools of EBO are time consumingSome of tools of EBO are time consuming
and difficult to master.and difficult to master.
• Evidence based practice may increaseEvidence based practice may increase
rather than reducing the cost of treatmentrather than reducing the cost of treatment

Clinical ImplicationsClinical Implications

Functional appliances inFunctional appliances in
Class II treatmentClass II treatment
The author reviewed the findings of 26 articles dealing with results ofThe author reviewed the findings of 26 articles dealing with results of
Andresen and Frankel appliances from cephalometric radiographs.Andresen and Frankel appliances from cephalometric radiographs.
The author combined the means and the standard deviations of theThe author combined the means and the standard deviations of the
primary studies, using the Studentprimary studies, using the Student tt test for the figures and thetest for the figures and the
Mann-Whitney U test for the annual measurements, andMann-Whitney U test for the annual measurements, and
concluded thatconcluded that
(1)(1)there was no appreciable restraining effect on the forward growth ofthere was no appreciable restraining effect on the forward growth of
the maxilla in either group (functional appliances and control); (2) athe maxilla in either group (functional appliances and control); (2) a
slight mean increase in mandibular growth could be observed,slight mean increase in mandibular growth could be observed,
mainly in a vertical direction; (3) no change in the position of themainly in a vertical direction; (3) no change in the position of the
glenoid fossa was evident; and (4) there were wide individualglenoid fossa was evident; and (4) there were wide individual
responses, and average changes were rarely observed in a patient.responses, and average changes were rarely observed in a patient.
Mills JR. The effect of functional appliances on the skeletal pattern. BrMills JR. The effect of functional appliances on the skeletal pattern. Br
J Orthod 1991;18:267-75.J Orthod 1991;18:267-75.www.indiandentalacademy.comwww.indiandentalacademy.com

Maxillary protraction in ClassMaxillary protraction in Class
III treatmentIII treatment
Kim et al evaluated the effectiveness of maxillary protraction withKim et al evaluated the effectiveness of maxillary protraction with
orthopedic appliances in Class III patients, aiming also to determineorthopedic appliances in Class III patients, aiming also to determine
a possible consensus regarding controversial issues such as thea possible consensus regarding controversial issues such as the
timing of treatment and the use of adjunctive intraoral appliances.timing of treatment and the use of adjunctive intraoral appliances.
Fourteen studies met the selection criteria. To combine the data ofFourteen studies met the selection criteria. To combine the data of
the primary articles, the means and the standard deviations of thethe primary articles, the means and the standard deviations of the
primary data were summarizedsummarized,and the correspondingprimary data were summarizedsummarized,and the corresponding
results were graphically represented.results were graphically represented.
The results indicated that protraction facemask therapy is effective inThe results indicated that protraction facemask therapy is effective in
growing patients, but to a lesser degree in those older than 10growing patients, but to a lesser degree in those older than 10
years, and that protraction combined with an initial period ofyears, and that protraction combined with an initial period of
expansion might provide more significant skeletal effects.expansion might provide more significant skeletal effects.
Kim JH, Viana MA, Graber TM, Omerza FF, BeGole EA. TheKim JH, Viana MA, Graber TM, Omerza FF, BeGole EA. The
effectiveness of protraction face mask therapy: a meta-analysis. Ameffectiveness of protraction face mask therapy: a meta-analysis. Am
J Orthod Dentofacial Orthop 1999;115:675-85.J Orthod Dentofacial Orthop 1999;115:675-85.

Treatment of transverseTreatment of transverse
problemsproblems
Burke et al evaluated changes in mandibularBurke et al evaluated changes in mandibular
intercanine width during and after treatment andintercanine width during and after treatment and
postretention. Twenty-six studies that assessedpostretention. Twenty-six studies that assessed
the longitudinal stability of postretentionthe longitudinal stability of postretention
mandibular intercanine width were evaluated.mandibular intercanine width were evaluated.
For the statistical analysis, weighted averagesFor the statistical analysis, weighted averages
and standard deviations for the means wereand standard deviations for the means were
compared for linear changes in intercaninecompared for linear changes in intercanine
transverse dimensions during treatment (T1),transverse dimensions during treatment (T1),
immediately after treatment (T2), and afterimmediately after treatment (T2), and after
removal of all retention (T3). Paired 2-tailremoval of all retention (T3). Paired 2-tail tt teststests
were performed between the T3 and T1 meanswere performed between the T3 and T1 means
on all groups, and 95% confidence intervalson all groups, and 95% confidence intervals
were computed.were computed.

The authors made the following conclusions. (1) Regardless of patientThe authors made the following conclusions. (1) Regardless of patient
diagnostic and treatment modalities or whether treatment wasdiagnostic and treatment modalities or whether treatment was
extraction or nonextraction, mandibular intercanine width tends toextraction or nonextraction, mandibular intercanine width tends to
increase during treatment by about 1 to 2 mm, to decrease atincrease during treatment by about 1 to 2 mm, to decrease at
postretention to approximately the original dimension, and to show apostretention to approximately the original dimension, and to show a
net change after postretention between 0.5 and –0.6 mm. (2)net change after postretention between 0.5 and –0.6 mm. (2)
Although statistically significant differences could be demonstratedAlthough statistically significant differences could be demonstrated
in various groups, the magnitudes of these differences were notin various groups, the magnitudes of these differences were not
considered clinically important. (3) The net change in mandibularconsidered clinically important. (3) The net change in mandibular
intercanine width of approximately zero supports the concept ofintercanine width of approximately zero supports the concept of
maintenance of the initial intercanine width in orthodontic treatment.maintenance of the initial intercanine width in orthodontic treatment.
Burke SP, Silveira AM, Goldsmith LJ, Yancey JM, Van Stewart A,Burke SP, Silveira AM, Goldsmith LJ, Yancey JM, Van Stewart A,
Scarfe WC. A meta-analysis of mandibular intercanine width inScarfe WC. A meta-analysis of mandibular intercanine width in
treatment and post-retention. Angle Orthod 1998;68:53-60.treatment and post-retention. Angle Orthod 1998;68:53-60.

Orthodontics andOrthodontics and
temporomandibular disorderstemporomandibular disorders
The subject of the study of Kim et al was the relationship betweenThe subject of the study of Kim et al was the relationship between
orthodontic treatment and temporomandibular disorders (TMDs) inorthodontic treatment and temporomandibular disorders (TMDs) in
patients after orthodontic therapy. The authors divided andpatients after orthodontic therapy. The authors divided and
extracted data from 31 articles according to study designs,extracted data from 31 articles according to study designs,
symptoms, signs, and indexes.symptoms, signs, and indexes.
A statistical test for the hypothesis of parametric homogeneity wasA statistical test for the hypothesis of parametric homogeneity was
conducted. In addition, probabilities of homogeneity and odds ofconducted. In addition, probabilities of homogeneity and odds of
parametric homogeneity were calculated.parametric homogeneity were calculated.
This MA provided no evidence about the relationships between TMDsThis MA provided no evidence about the relationships between TMDs
and orthodontic treatment.and orthodontic treatment.
Kim MR, Graber TM, Viana MA. Orthodontics and temporomandibularKim MR, Graber TM, Viana MA. Orthodontics and temporomandibular
disorder: a meta-analysis. Am J Orthod Dentofacial Orthopdisorder: a meta-analysis. Am J Orthod Dentofacial Orthop
2002;121:438-462002;121:438-46..

Cephalometric landmarkCephalometric landmark
identificationidentification
In their MA, Trpkova et al tried to assess the magnitude of lateralIn their MA, Trpkova et al tried to assess the magnitude of lateral
cephalometric landmark identification error for 15 landmarks. Thecephalometric landmark identification error for 15 landmarks. The
statistical analysis of the data of the 6 primary studies includedstatistical analysis of the data of the 6 primary studies included
weighted averages of the estimates to combine the studies reportingweighted averages of the estimates to combine the studies reporting
means and standard errors, and 1-way analysis of covariance tomeans and standard errors, and 1-way analysis of covariance to
combine the studies reporting standard deviations.combine the studies reporting standard deviations.
The authors concluded that 0.59 mm of total error for the x-coordinateThe authors concluded that 0.59 mm of total error for the x-coordinate
and 0.56 mm for the y-coordinate are acceptable levels of accuracy,and 0.56 mm for the y-coordinate are acceptable levels of accuracy,
and only the landmarks B, A, Ptm, S, and Go on the x-coordinate,and only the landmarks B, A, Ptm, S, and Go on the x-coordinate,
and Ptm, A, and S on they-coordinate had insignificant mean errorsand Ptm, A, and S on they-coordinate had insignificant mean errors
and small values for total errors. Therefore, these landmarks can beand small values for total errors. Therefore, these landmarks can be
considered reliable for cephalometric analysis of lateral radiographs.considered reliable for cephalometric analysis of lateral radiographs.
Trpkova B, Major P, Prasad N, Nebbe B. Cephalometric landmarksTrpkova B, Major P, Prasad N, Nebbe B. Cephalometric landmarks
identification and reproducibility: a meta analysis. Am J Orthodidentification and reproducibility: a meta analysis. Am J Orthod
Dentofacial Orthop 1997;112:165-70.Dentofacial Orthop 1997;112:165-70.

Overjet size in relation toOverjet size in relation to
traumatic dental injuriestraumatic dental injuries
In the only study of this category, Nguyen et al investigated the risk of traumaticIn the only study of this category, Nguyen et al investigated the risk of traumatic
dental injuries of the anterior teeth due to overjet. To qualitatively assess thedental injuries of the anterior teeth due to overjet. To qualitatively assess the
11 articles finally included in the investigation, a methodologic checklist for11 articles finally included in the investigation, a methodologic checklist for
observational studies was developed. For each primary study, the oddsobservational studies was developed. For each primary study, the odds
ratios and their 95% confidence intervals were computed, and then theseratios and their 95% confidence intervals were computed, and then these
odds ratios were pooled across the studies.odds ratios were pooled across the studies.
According to this evaluation, the authors concluded that (1) children withAccording to this evaluation, the authors concluded that (1) children with
overjets larger than 3 mm are approximately twice as much at risk ofoverjets larger than 3 mm are approximately twice as much at risk of
traumatic dental injuries on anterior teeth than children with overjets lesstraumatic dental injuries on anterior teeth than children with overjets less
than 3 mm, (2) the effect of overjet on the risk of dental injury is less in boysthan 3 mm, (2) the effect of overjet on the risk of dental injury is less in boys
than in girls of the same overjet group, and (3) the risk of anterior tooththan in girls of the same overjet group, and (3) the risk of anterior tooth
injuries tends to increase with increasing overjet size.injuries tends to increase with increasing overjet size.
Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review ofNguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of
the relationship between overjet size and traumatic dental injuries. Eur Jthe relationship between overjet size and traumatic dental injuries. Eur J
Orthod 1999;21:503-15.Orthod 1999;21:503-15.

Obstructive sleep apneaObstructive sleep apnea
syndromesyndrome
The subject of an MA conducted by Miles et al was theThe subject of an MA conducted by Miles et al was the
possible significant differences between thepossible significant differences between the
cephalometric variables describing the craniofacialcephalometric variables describing the craniofacial
skeletal or soft-tissue morphology of patients with andskeletal or soft-tissue morphology of patients with and
without obstructive sleep apnea syndrome (OSAS). Thewithout obstructive sleep apnea syndrome (OSAS). The
MAPs used in this study included combined means andMAPs used in this study included combined means and
standard deviations for the OSAS and control groups,standard deviations for the OSAS and control groups,
plots of effect size to examine the distribution andplots of effect size to examine the distribution and
consistency of outcomes across studies, Z-scores forconsistency of outcomes across studies, Z-scores for
statistical significance testing between groups, andstatistical significance testing between groups, and
receiver operating characteristic curves.receiver operating characteristic curves.

The authors made the following conclusions.(1) The literature hasThe authors made the following conclusions.(1) The literature has
several methodologic deficiencies and therefore is equivocalseveral methodologic deficiencies and therefore is equivocal
regarding causal associations between craniofacial structures andregarding causal associations between craniofacial structures and
OSAS. (2) Evidence for a direct causal relationship betweenOSAS. (2) Evidence for a direct causal relationship between
craniofacial structure and OSAS is unsupported by the literature,craniofacial structure and OSAS is unsupported by the literature,
both qualitatively and quantitatively. (3) The rationale for OSASboth qualitatively and quantitatively. (3) The rationale for OSAS
treatments based on morphologic criteria remains unsubstantiated.treatments based on morphologic criteria remains unsubstantiated.
(4) The 2 most consistent, strong effect sizes with the highest(4) The 2 most consistent, strong effect sizes with the highest
diagnostic accuracies had variables related to mandibular structuresdiagnostic accuracies had variables related to mandibular structures
(Sn/MPA, Go-Gn). (5) Although mandibular body length (Go-Gn)(Sn/MPA, Go-Gn). (5) Although mandibular body length (Go-Gn)
appears to be an associated factor, this does not support causality.appears to be an associated factor, this does not support causality.
(6) More standardization of research methods and data presentation(6) More standardization of research methods and data presentation
is required.is required.
Miles PG, Vig PS, Weyant RJ, Forrest TD, Rockette HE Jr. CraniofacialMiles PG, Vig PS, Weyant RJ, Forrest TD, Rockette HE Jr. Craniofacial
structure and obstructive sleep apnea syndrome—a qualitativestructure and obstructive sleep apnea syndrome—a qualitative
analysis and meta-analysis of the literature. Am J Orthodanalysis and meta-analysis of the literature. Am J Orthod

Frequency of severe occlusalFrequency of severe occlusal
problemsproblems
Frazao et al investigated the prevalence of severe occlusal problems in theFrazao et al investigated the prevalence of severe occlusal problems in the
permanent and deciduous dentitions. The authors evaluated the primarypermanent and deciduous dentitions. The authors evaluated the primary
data of 7 articles by calculating the weighted odds ratios and theirdata of 7 articles by calculating the weighted odds ratios and their
corresponding 95% confidence intervals, using the fixed effect analysis,corresponding 95% confidence intervals, using the fixed effect analysis,
after checking for data homogeneity with the chi-square test and the Yatesafter checking for data homogeneity with the chi-square test and the Yates
correction.correction.
The statistical analysis showed that the prevalence of occlusal problems wasThe statistical analysis showed that the prevalence of occlusal problems was
almost twice as large in patients in the permanent rather than the deciduousalmost twice as large in patients in the permanent rather than the deciduous
dentition (71.3% and 49.0%, respectively). Furthermore, from the examineddentition (71.3% and 49.0%, respectively). Furthermore, from the examined
variables (including sex, type of school, and ethnic group), thevariables (including sex, type of school, and ethnic group), the
developmental stage of the dentition was the only variable significantlydevelopmental stage of the dentition was the only variable significantly
associated with the severity of malocclusion.associated with the severity of malocclusion.
Frazao P, Narvai PC, Latorre Mdo R, Castellanos RA. Are severe occlusalFrazao P, Narvai PC, Latorre Mdo R, Castellanos RA. Are severe occlusal
problems more frequent in permanent than deciduous dentition? Rev Saudeproblems more frequent in permanent than deciduous dentition? Rev Saude
Publica 2004;38:247-54.Publica 2004;38:247-54.

External apical rootExternal apical root
resorptionresorption
The treatment-related factors of external apical root resorption were alsoThe treatment-related factors of external apical root resorption were also
among the subjects recently investigated with MAPs.Clinical trials in Englishamong the subjects recently investigated with MAPs.Clinical trials in English
with sample sizes of more than 10 subjects who received orthodonticwith sample sizes of more than 10 subjects who received orthodontic
treatment with fixed appliances, with available preoperative andtreatment with fixed appliances, with available preoperative and
postoperative radiographs, and measurements of external apical rootpostoperative radiographs, and measurements of external apical root
resorption mainly in the maxillary incisors were included in this study.resorption mainly in the maxillary incisors were included in this study.
To access the methodologic soundness of each study, coding variables wereTo access the methodologic soundness of each study, coding variables were
determined along with a grading system, and a cumulative “meta-analysisdetermined along with a grading system, and a cumulative “meta-analysis
factor” was computed for each study.factor” was computed for each study.
Authors concluded that treatment-related causes of external apical rootAuthors concluded that treatment-related causes of external apical root
resorption seem to be the total distance the apex had moved and the time itresorption seem to be the total distance the apex had moved and the time it
took. Consequently, factors associated with the duration of active treatmenttook. Consequently, factors associated with the duration of active treatment
might result in greater apical root resorption in predisposed patients.might result in greater apical root resorption in predisposed patients.
Segal GR, Schiffman PH, Tuncay OC. Meta-analysis of the treatment-relatedSegal GR, Schiffman PH, Tuncay OC. Meta-analysis of the treatment-related
factors of external apical root resorption. Orthod Craniofac Res 2004;7:71-8.factors of external apical root resorption. Orthod Craniofac Res 2004;7:71-8.

Methods of mixed dentitionMethods of mixed dentition
analysisanalysis
Moyer’s method of mixed dentition analysis was the subject of an MAMoyer’s method of mixed dentition analysis was the subject of an MA
performed by Buwembo and Luboga35 to assess its applicability inperformed by Buwembo and Luboga35 to assess its applicability in
various ethnic groups. The authors pooled the correlationvarious ethnic groups. The authors pooled the correlation
coefficients of the 7 primary studies and calculated the weightedcoefficients of the 7 primary studies and calculated the weighted
mean correlations, their variances, and the variances in themean correlations, their variances, and the variances in the
population correlation, and they also performed a chi-square test forpopulation correlation, and they also performed a chi-square test for
the population correlation coefficients.the population correlation coefficients.
Consequently, the authors concluded that Moyer’s method of mixedConsequently, the authors concluded that Moyer’s method of mixed
dentition analysis can show population variations, and theydentition analysis can show population variations, and they
proposed the development of prediction tables for specificproposed the development of prediction tables for specific
populations.populations.
Buwembo W, Luboga S. Moyer’s method of mixed dentition analysis: aBuwembo W, Luboga S. Moyer’s method of mixed dentition analysis: a
meta-analysis. Afr Health Sci 2004;4:63-6.meta-analysis. Afr Health Sci 2004;4:63-6.

Incisor intrusionIncisor intrusion
The quantification of the amount of true incisor intrusion attained duringThe quantification of the amount of true incisor intrusion attained during
orthodontic treatment was the subject of another MA by Ng et al. Aorthodontic treatment was the subject of another MA by Ng et al. A
fixed-effects MA for these 2 studies was performed to evaluate thefixed-effects MA for these 2 studies was performed to evaluate the
amount of incisor intrusion attained with the segmented archamount of incisor intrusion attained with the segmented arch
technique (SAT).technique (SAT).
The results indicated that true incisor intrusion was feasible in bothThe results indicated that true incisor intrusion was feasible in both
arches by using the SAT, but the clinical significance of the amountarches by using the SAT, but the clinical significance of the amount
of true intrusion as an exclusive treatment option is questionable forof true intrusion as an exclusive treatment option is questionable for
patients with severe deep bites. Furthermore, the SAT couldpatients with severe deep bites. Furthermore, the SAT could
achieve 1.5 mm of maxillary incisor intrusion and 1.9 mm ofachieve 1.5 mm of maxillary incisor intrusion and 1.9 mm of
mandibular incisor intrusion when used in nongrowing patients.mandibular incisor intrusion when used in nongrowing patients.
Ng J, Major PW, Heo G, Flores-Mir C. True incisor intrusion attainedNg J, Major PW, Heo G, Flores-Mir C. True incisor intrusion attained
during orthodontic treatment: a systematic review and meta-during orthodontic treatment: a systematic review and meta-
analysis. Am J Orthod Dentofacial Orthop 2005;128:212-9.analysis. Am J Orthod Dentofacial Orthop 2005;128:212-9.

Prevalence of dentalPrevalence of dental
agenesisagenesis
The prevalence of dental agenesis of theThe prevalence of dental agenesis of the
permanent teeth was the subject of the MA ofpermanent teeth was the subject of the MA of
Polder et al, aiming to increase insight into thisPolder et al, aiming to increase insight into this
problem and its implications for dentalproblem and its implications for dental
consumption in communities. Multiple regressionconsumption in communities. Multiple regression
analysis (weighted least squares) was used inanalysis (weighted least squares) was used in
28 primary studies to evaluate the possible28 primary studies to evaluate the possible
influence of chronologic age, sample size,influence of chronologic age, sample size,
continent, and year of publication. Thecontinent, and year of publication. The
prevalence of agenesis by tooth type, affectedprevalence of agenesis by tooth type, affected
patients, and numbers of missing teeth perpatients, and numbers of missing teeth per
patient were calculated from the articles.patient were calculated from the articles.

After this evaluation, the authors concluded that agenesis differs byAfter this evaluation, the authors concluded that agenesis differs by
continent and sex; the prevalence of dental agenesis for both sexescontinent and sex; the prevalence of dental agenesis for both sexes
was higher in Europe (males, 4.6%; females, 6.3%) and Australiawas higher in Europe (males, 4.6%; females, 6.3%) and Australia
(males, 5.5%; females, 7.6%) than in North American whites (males,(males, 5.5%; females, 7.6%) than in North American whites (males,
3.2%; females, 4.6%). In addition, the prevalence of dental agenesis3.2%; females, 4.6%). In addition, the prevalence of dental agenesis
in females was 1.37 times higher than in males for all 3 continentsin females was 1.37 times higher than in males for all 3 continents
examined. Furthermore, the mandibular second premolars wereexamined. Furthermore, the mandibular second premolars were
affected most frequently, followed by agenesis of the maxillaryaffected most frequently, followed by agenesis of the maxillary
lateral incisors and the maxillary second premolars. Finally, bilaterallateral incisors and the maxillary second premolars. Finally, bilateral
agenesis of the maxillary lateral incisors was more frequent thanagenesis of the maxillary lateral incisors was more frequent than
unilateral agenesis, whereas the opposite was found for theunilateral agenesis, whereas the opposite was found for the
mandibular and maxillary second premolars, and the maxillary firstmandibular and maxillary second premolars, and the maxillary first
premolars.premolars.
Polder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers-Jagtman AM. APolder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers-Jagtman AM. A
meta-analysis of the prevalence of dental agenesis of permanentmeta-analysis of the prevalence of dental agenesis of permanent
teeth. Community Dent Oral Epidemiol 2004;32:217-26.teeth. Community Dent Oral Epidemiol 2004;32:217-26.

Is anchorage reinforcements withIs anchorage reinforcements with
implants effective in orthodontics?implants effective in orthodontics?
• Study selection were Randomized clinical trialsStudy selection were Randomized clinical trials
involving surgically assisted means ofinvolving surgically assisted means of
anchorage reinforcement in orthodontic patientsanchorage reinforcement in orthodontic patients
• Authors have concluded that there is limitedAuthors have concluded that there is limited
evidence that osseo-integrated palatal implantsevidence that osseo-integrated palatal implants
are an acceptable means of reinforcingare an acceptable means of reinforcing
anchorage.anchorage.
Kalha ASKalha AS Evid Based Dent. 2008;9(1):13-4.Evid Based Dent. 2008;9(1):13-4.

ConclusionConclusion
• It is conceivable in 2008 that if a patient seeksIt is conceivable in 2008 that if a patient seeks
orthodontic opinions from 10 orthodontists, he ororthodontic opinions from 10 orthodontists, he or
she may receive 10 different treatment plans. Itshe may receive 10 different treatment plans. It
also is conceivable that all 10 treatment plansalso is conceivable that all 10 treatment plans
could achieve satisfactory results. However,could achieve satisfactory results. However,
when viewed in light of the principles ofwhen viewed in light of the principles of
effectiveness and efficiency, there might be onlyeffectiveness and efficiency, there might be only
one or two treatment alternatives that bestone or two treatment alternatives that best
satisfy the patient’s esthetic, functional andsatisfy the patient’s esthetic, functional and
psychosocial needs.psychosocial needs.

• The challenge facing orthodontists in theThe challenge facing orthodontists in the
21st century is the need to integrate the21st century is the need to integrate the
accrued scientific evidence into clinicalaccrued scientific evidence into clinical
orthodontic practice. Until this occurs,orthodontic practice. Until this occurs,
orthodontists will not be able to present aorthodontists will not be able to present a
forthright and accurate cost/benefitforthright and accurate cost/benefit
analysis to the patient and, therefore, notanalysis to the patient and, therefore, not
obtain truly informed consent.obtain truly informed consent.

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NumberNumber 55 Papadopoulos and GkiaourisPapadopoulos and Gkiaouris 599599

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