SYSTEMATIC REVIEW

Intraoral distalizer effects with conventional and

skeletal anchorage: A meta-analysis
Roberto Henrique da Costa Grec,a Guilherme Janson,b Nuria Castello Branco,a Patr
cia Garcia Moura-Grec,c

Fernando Castanha Henriquesb
Mayara Paim Patel,a and Jose
Bauru, S~ao Paulo, Brazil

Introduction: The aims of this meta-analysis were to quantify and to compare the amounts of distalization and
anchorage loss of conventional and skeletal anchorage methods in the correction of Class II malocclusion with
intraoral distalizers. Methods: The literature was searched through 5 electronic databases, and inclusion criteria
were applied. Articles that presented pretreatment and posttreatment cephalometric values were preferred.
Quality assessments of the studies were performed. The averages and standard deviations of molar and premolar effects were extracted from the studies to perform a meta-analysis. Results: After applying the inclusion and
exclusion criteria, 40 studies were included in the systematic review. After the quality analysis, 2 articles were
classied as high quality, 27 as medium quality, and 11 as low quality. For the meta-analysis, 6 studies were
included, and they showed average molar distalization amounts of 3.34 mm with conventional anchorage and
5.10 mm with skeletal anchorage. The meta-analysis of premolar movement showed estimates of combined
effects of 2.30 mm (mesialization) in studies with conventional anchorage and 4.01 mm (distalization) in
studies with skeletal anchorage. Conclusions: There was scientic evidence that both anchorage systems
are effective for distalization; however, with skeletal anchorage, there was no anchorage loss when direct anchorage was used. (Am J Orthod Dentofacial Orthop 2013;143:602-15)

or Class II malocclusion, several forms of

correction produce different dental and skeletal
effects depending on the type of treatment.1
When the problems of this malocclusion are predominantly skeletal, it is likely to be corrected by functional
or mechanical orthopedic appliances. However, to
achieve satisfactory results, these protocols usually
require patient compliance in using the appliances.2-4
Lack of compliance can increase treatment time and
create an uneasy relationship between parents, patient,
and doctor, thus compromising the nal treatment
result.3 When the problems of Class II malocclusions
are predominantly dental, these malocclusions can be
corrected by extractions in at least 1 dental arch,5,6
without extractions by using intermaxillary elastics,7,8
From Bauru Dental School, University of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
a
Postgraduate student, Department of Orthodontics.
b
Professor, Department of Orthodontics.
c
Postgraduate student, Department of Public Health.
The authors report no commercial, proprietary, or nancial interest in the
producets or companies described in this article.
Reprint requests to: Roberto Henrique da Costa Grec, Department of Orthodontics, Bauru Dental School, University of S~ao Paulo, Alameda Oct
avio Pinheiro
Brisolla 9-75, Bauru, SP 17012-901, Brazil; e-mail, robertogrec@usp.br.
Submitted, June 2012; revised and accepted, November 2012.
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2012.11.024

602

or by distalizing the maxillary molars to create a Class I

relationship.9
For several years, the extraoral appliance was the most
widely used distalizing device, but it is no longer esthetically acceptable. Also, it is removable and depends on patient compliance, which can compromise the results.2-4
Therefore, as alternatives to compliance-dependent
headgear, many intraoral methods to distalize the maxillary molars have been proposed, such as repelling magnets,10 distal jet appliance,11 Jones jig appliance,12
nickel-titanium coil springs,13 pendulum and pendex appliances,14,15 Wilson bimetric distalizing arch system
(Rocky Mountain Orthodontics, Denver, Colo),16 rst class
appliance (Leone, Firenze, Italy),17 and others, giving
clinicians a wide variety of treatment options.
Intraoral appliances have proven to be effective for
maxillary molar distalization independently of patient
compliance.3 However, distalizers generally use the
Nance button as anchorage, but it is not enough
to neutralize the side effects of anchorage loss,18
represented by maxillary anterior crowding, maxillary
incisor labial inclination increasing the overjet, and
tipping of premolars and canines.19-25
To prevent anchorage loss, mini-implants can be
used as an efcient skeletal anchorage unit for molar
distalization, decreasing the side effects with more

Grec et al

predictable results and less treatment time, and

consequently creating a new perspective in intraoral
distalizer appliances.26,27
Previously, 2 systematic reviews on the use of
noncompliance distalizing intramaxillary appliances
with conventional anchorage and skeletal anchorage
were performed.28,29 However, there is still no
comparison between the efciency of these 2
techniques of anchorage.
The aims of this meta-analysis were to quantify and
to compare the amounts of molar distalization and
anchorage loss of conventional and skeletal anchorage
methods in the correction of Class II malocclusion with
intraoral distalizers.
MATERIAL AND METHODS

This systematic review/meta-analysis was based on

the PRISMA guidelines, and the main question was
dened with the PICO format (Table I).30 Using
the main terms distalizers, distalization appliance,
orthodontic distalization, noncompliance appliances,
rst molar distalization, upper molar distalization,
and maxillary molar distalization, an electronic search
was conducted from 1970 to September 2010 in the
following databases: PubMed, Embase, Web of Science,
Scopus, and Cochrane Library (Table II).
To identify potential articles, the initial search was
performed by title and abstract. Initially, the selected
articles were preferred to have the following inclusion
criteria: published in English, human clinical trial, regarding the correction of Class II malocclusion with noncompliance molar distalization appliances, no reviews or
opinion articles, no annals, and no theses. Duplicate
studies were eliminated. The selection process was
independently conducted by 2 researchers (R.H.C.G.
and M.P.P.), and their results were compared to identify
discrepancies.
When the abstract did not provide enough information to make a decision, the article was completely
analyzed. Interexaminer conicts were resolved by
discussion of each article to reach a consensus regarding
all selection criteria. Furthermore, hand searches of the
reference lists of the selected articles were conducted.
At this stage, the previously selected articles were
rescreened according to the following additional
inclusion criteria: correction of Class II malocclusion
with a noncompliance molar distalization appliance
without concomitant use of other appliances, description of measurable pretreatment and posttreatment
cephalometric variables, measurement of the amount
of rst or second premolar anchorage loss (mesial
movement), minimum of 10 patients in each sample
group, no case reports, and growing patients.

603

Table I. PICO format

Population
Intervention
Comparison
Outcome

Subjects with Class II malocclusion

Intraoral distalizers with conventional anchorage
Intraoral distalizers with skeletal anchorage
Efciency in the correction of Class II malocclusion

The quality of each article was scored by using an

adapted version of 3 methods previously used by Fudalej
and Antoszewska,29 Cozza et al,31 and Chen et al.32 The
following characteristics were evaluated: study design,
sample size, sample description, error analysis, and
statistical analysis. Each characteristic received a score
according to the criteria described in Table III. The
quality of each study was categorized as high (7-9
points), medium (4-6 points), or low (0-3 points).
The data from the selected articles were divided into 2
groups according to the type of anchorage used:
conventional or skeletal. There was no distinction
between the different types of distalizers.
A meta-analysis was performed according to
a method proposed by Antonarakis and Kiliaridis28 and
Perillo et al.33 Data from each group (conventional and
skeletal anchorage) were individually compared with
a control group in which the average was zero. Among
untreated subjects, these variables are about zero
because of the short time of distalization.28 The standard
deviation is equal to the method error in the corresponding study. In studies that did not mention the method
error, the mean error from studies that gave the data
was used. Only articles of medium and high quality
were included in the meta-analysis. The averages and
standard deviations of molar and premolar movements
were extracted from the articles and subsequently
entered into RevMan software (version 5.0 for Windows;
Nordic Cochrane Centre, Copenhagen, Denmark) to
perform the meta-analysis.
Heterogeneity was assessed by calculating the I2
index. If there was evidence of heterogeneity, the
random effects model should be used.33-35 Forest plots
were drawn, mean and condence interval values were
calculated (95% condence interval), and signicance
tests were carried out (to calculate P values).
RESULTS

After the electronic database search, 947 studies were

retrieved from PubMed, 138 from Embase, 151 from
Web of Science, and 185 from Scopus. No studies were
identied from the Cochrane Library (Fig 1). After application of the initial inclusion and exclusion criteria and
elimination of studies indexed in more than 1 database,
178 were retrieved. The full texts were accessed, and all
articles with adult patients (age, $18 years), sample size

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604

Table II. Search strategy

Database
PubMed

Embase

Web of Science

Scopus

Cochrane Library

Key words
Distalizers OR distalization appliance OR orthodontic distalization
OR noncompliance appliances OR rst molar distalization OR
upper molar distalization OR maxillary molar distalization
Distalizers OR distalization appliance OR orthodontic distalization
OR noncompliance appliances OR rst molar distalization OR
upper molar distalization OR maxillary molar distalization
Distalizers OR distalization appliance OR orthodontic distalization
OR noncompliance appliances OR rst molar distalization OR
upper molar distalization OR maxillary molar distalization
Distalizers OR distalization appliance OR orthodontic distalization
OR noncompliance appliances OR rst molar distalization OR
upper molar distalization OR maxillary molar distalization
Distalizers; distalization and appliance; orthodontic and
distalization; noncompliance and appliances, rst and molar and
distalization; upper and molar and distalization; maxillary and
molar and distalization

Table III. Methodologic quality scoring protocol

(maximum score, 9 points)

Study design
3 points: randomized clinical trial
2 points: if randomization process was not well described,
or if it was a controlled prospective study
1 point: uncontrolled prospective study
0 point: retrospective study or not mentioned
Sample size
1 point: larger than or equal to 15 subjects or prior
estimate of sample size
0 point: less than 15 subjects and no prior estimate
of sample size
Sample description
2 points: description of all 3 items (age, sex, Class II
malocclusion severity)
1 point: only 2 items described
0 point: only 1 item described
Error analysis
1 point: error analysis value cited
0 point: error analysis value not cited, or error analysis not
performed
Statistical analysis
2 points: adequate
1 point: partially adequate
0 point: no statistical tests conducted

Only English; humans, 1970 to September 2010

English language; only articles (not reviews, letters,

abstracts, meetings, and editorials);1970 to
September 2010
English language; only articles (not reviews, letters,
abstracts, meetings, and editorials);1970 to
September 2010

treatment time, and amounts of molar and premolar

distalization and tipping.
Molar distalization with conventional anchorage was
evaluated in 36 studies, and with skeletal anchorage in 6.
Two studies evaluated both types of anchorage and were
therefore subdivided and separately inserted in the
table.36,37 The summarized data of the 40 articles
included in the review are shown in Table IV.
Quality assessment

less than 10 in at least 1 group, no evaluation of anchorage loss through premolar mesial movement and of
lateral cephalometric radiographs taken immediately
after molar distalization, and measurements of only
dental casts were excluded. Therefore, 40 studies fullling all inclusion and exclusion criteria were included in
this systematic review (Fig 1).
From the remaining articles, we independently
extracted the following data: author names, year of
publication, anchorage method, type of distalizing
appliances, sample size, mean age of groups, distalizer

May 2013  Vol 143  Issue 5

Limits
English language; humans, 1970 to September
2010

After quality analysis, 2 articles were classied as high

quality, 27 as medium quality, and 11 as low quality
(Table V).
Among the high-quality articles, only that by
Papadopoulos et al9 received a full score. These authors
evaluated the treatment effects of the rst class
appliance in patients with Class II malocclusion in the
mixed dentition. The study was a randomized clinical
trial with a sample of 15 treated children (mean age,
9.2 years). Another 11 subjects served as the control
group (mean age, 9.7 years). The rst class appliance
was placed on the 2 maxillary rst molars and the second
deciduous molars or the second premolars. A modied
Nance buttery-shaped button was used as anchorage.
The mean molar distal movement was 4 mm with distal
tipping of 8.56 in 4.01 months. The mean premolar or
rst deciduous molar mesial movement was 1.86 mm
(31.84% of anchorage loss) with 1.85 of tipping. The
control group showed distal molar movement of 0.04
mm in the same period.9
The other study classied as high quality compared
the dentoalveolar changes of Class II patients treated
with the Jones jig and the pendulum appliances.25 Forty
Class II malocclusion patients were divided into 2 groups
of 20. Group 1 (11 boys, 9 girls), with a mean

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605

Fig 1. PRISMA ow diagram.

pretreatment age of 13.17 years, was treated with the

Jones jig appliance for 0.91 years, and group 2 comprised 20 patients (8 boys, 12 girls) with a mean pretreatment age of 13.98 years, treated with the pendulum
appliance for 1.18 years. The maxillary second premolars
showed greater mesial tipping and extrusion in the Jones
jig group, indicating more anchorage loss during molar
distalization with this appliance. The amounts and the
monthly rates of molar distalization were similar in
both groups.
According to each criterion for quality analysis, the
following results were obtained.
Study design: only 2 studies were randomized clinical
trials with the randomization process described in detail.9,38
Sample size: the authors of 30 studies performed
sample-size calculation or had sample sizes larger than
or equal to 15 patients.
Selection description: 7 studies mentioned the
severity of the malocclusions.9,19,23,25,39-41 One article

did not mention the mean age,36 and 2 articles did not
mention the sex of the sample.24,42
Error analysis: the authors of 24 studies performed
and described the method error results. Some studies
stated that the error of the method was performed but
did not present the results.3,20-22,24,36,38,43-45
Statistical analyses: the authors of 4 studies
performed only a descriptive analysis.3,18,24,46
Maxillary molar distalization appliances with
conventional anchorage

Treatment effects of distalizers with conventional

anchorage were analyzed in 43 groups assessed in 36
studies (Table IV).
Fourteen distalizers were used: rst class, pendulum, distal jet, Jones jig, dual force, Keles slider,
greeneld, jig appliance modied, pendex, 3dimensional bimetric maxillary distalizing arch
(3D-BMDA), intraoral bodily molar distalizer (IBMD),

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606

Table IV. Characteristics of included studies

Number
Study
Conventional anchorage
Papadopoulos et al,9 2010
1
2
Acar et al,47 2010
3
Haq et al,78 2010
4
Patel et al,25 2009
5
Patel et al,25 2009
6
Polat-Ozsoy et al,37 2008
7
Sch
utze et al,79 2007

8
Onca
g et al,36 2007
9
Angelieri et al,19 2006
10
Fuziy et al,23 2006
11
Mavropoulos et al,46 2006
12
Sayinsu et al,80 2006
13
Chiu et al,22 2005
14
Chiu et al,22 2005
15
Kinzinger et al,73 2005
16
Kinzinger et al,73 2005
17
Kinzinger et al,73 2005
18
Mavropoulos et al,18 2005
19
Ferguson et al,81 2005
20
Ferguson et al,81 2005
21
Fortini et al,82 2004
22
Papadopoulos et al,40 2004
23
Taner et al,83 2003
24
Bolla et al,84 2002
25
Paul et al,38 2002
26
Nishii et al,85 2002
27
Chaqu
es-Asensi and Kalra,86 2001
28
Ngantung et al,39 2001
29
Keles,43 2001
30
Toroglu et al,48 2001
31
Toro
glu et al,48 2001
32
Bussick and McNamara,21 2000
em et al,41 2000
33
Uc
34
Brickman et al,20 2000
24

2000
35
Haydar and Uner,
36
Keles and Sayinsu,3 2000
37
Bondemark,87 2000
38
Bondemark,87 2000
39
Runge et al,45 1999
40
Gulati et al,42 1998
41
Byloff and Darendeliler,57 1997
42
Byloff et al,88 1997
43
Ghosh and Nanda,58 1996
Skeletal anchorage
1
Kinzinger et al,44 2009
2
Oberti et al,51 2009
3
4
5
6

Polat-Ozsoy et al,37 2008

a
Onc
g et al,36 2007
Escobar et al,49 2007
Kircelli et al,50 2006

Appliance
First class
Pendulum
Distal jet
Jones jig
Pendulum
Pendulum
Pendulum
Pendulum
Pendulum
Pendulum
Keles slider
Keles slider
Pendulum
Distal jet
Pendulum
Pendulum
Pendulum
Jones jig
Distal jet
Greeneld
First class
Jig appliance modied
Pendex
Distal jet
Jones jig
Distal jet
Pendulum
Distal jet
Keles slider
Pendulum
Pendulum
Pendulum
3D-BMDA
Jones jig
Jones jig
IBMD
Nickel-titanium coil
Repelling magnets
Jones jig
Sectional jig assembly
Pendulum
Pendulum
Pendulum

Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Enlarged acrylic Nance button
Enlarged acrylic Nance button
Modied acrylic Nance button
Modied acrylic Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button with an anterior bite plane
Nance button
Nance button
Nance button
Intermaxillary elastic system
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button
Nance button

Distal jet
Dual force

2 mini-implants
2 mini-implants used in maxillofacial
surgery for osteosynthesis 1 Nance button
1 or 2 mini-implants 1 Nance button
1 implant
2 mini-implants 1 Nance button
1 or 2 mini-implants 1 Nance button

Pendulum
Pendulum
Pendulum
Pendulum

nickel-titanium coil, magnets, and sectional jig

assembly. The pendulum appliance was the most
used (22 articles), followed by the distal jet (7 articles)

May 2013  Vol 143  Issue 5

Anchorage

n
15
15
30
20
20
17
15
15
22
31
20
17
32
32
10
10
10
10
25
25
17
14
13
20
11
15
26
33
15
14
16
101
14
72
10
15
21
21
13
10
13
20
41
10
16
22
15
15
10

and the Jones jig (6 articles). The most used anchorage

reinforcement appliance was the Nance button and its
variations (Table IV).

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607

Table IV. Continued

Distalization
Average age (y)
treatment time (mo)
Conventional anchorage
4.3
9.2
15.0
3
12.8
7.11
13.2
10.92
13.9
14.16
13.6
5.1
12.6
8.46

7.25
14.5
5.85
14.6
5.87
13.1
4.37
13.5

12.5
7
12.3
10
9.9
6.22
11.6
4.45
12.6
5.95
13.2
4.37
12.5
7.87
11.5
10.4
13.4
2.4
13.4
4.12
10.6
7.31
12.6
5
14.8
6
14.6
6.4
11.2
6.5
12.8
6.7
13.3
6.1
13.1
5.7
12.9
5.03
12.0
7
12.2
1.5
13.7
6.35
10.7
2.5
13.5
7.5
14.4
6.5
13.9
5.8
14.5
6.5
12-15
4
11.1
4.15
13.1
6.81
12.4
6.2
Skeletal anchorage
12.1
6.7
14.3
5
13.6

13.0
13.5

6.8
6.75
7.8
7

Molar
distalization (mm)

Molar tipping ( )

Premolar
movement (mm)

Premolar
tipping ( )

4
4.53
2.93
3.12
3.51
2.7
3.83
5.03
2
4.6
3.1
2.85
6.1
2.8
3.93
3.43
4.20
1.9
3.4
3.9
4.0
1.4
3.81
3.2
1.17
2.4
5.3
2.12
4.92
5.9
4.1
5.7
3.5
2.51
2.80
5.23
2.5
2.6
2.23
2.95
3.39
4.14
3.37

8.56
5.13
3.41
9.54
10
5.3
6.45
6
9.4
18.5
4
2.56
10.7
5
6.35
5.05
2.55
6.8
3.2
6.5
4.6
6.8
11.77
3.1
4.56
1.9
13.06
3.26
0.89
14.9
13.4
10.6
1.8
7.53
7.85
1.15
2.2
8.8
4
3.5
14.5
6.07
8.36

1.86
0.27
0.95
2.55
2.23
2.3
1.18
2.16
3.6
2.65
3.2
2
1.4
2.6
1.05
1.4
0.8
2.08
1
2.9
1.7
2.6
0.73
1.3
0.18
1.4
2.21
2.6
1.31
4.8
6.6
1.8
2.1
2
3.35
4.33
1.2
1.8
2.23
1.05
1.63
2.22
2.55

1.85
2.2
7.33
9.29
2.37
3.8
1.94
2.98
6.6
2.5
6.1
2.21
1.7
0.3
0.7
0.4
1.8
7.5
3.1
0.2
2.2
8.1
4.08
2.8

4.84
4.33
1.25
3.9
5.9
1.5
1.4
4.76
6.05
2.73
2.1
6.7
9.47
2.6

1.29

3.92
5.9

3
5.68

0.72
4.26

0.79
5.43

4.8
3.95
6.00
6.4

9.1
12.2
11.31
10.9

4.1
3.1
4.85
5.4

9.9
6.795
8.62
16.3

The included studies evaluated patients during the

growth period, and the mean initial chronologic age

ranged from 9.29 to 1547 years. Treatment times were

1.50 to 14.16 months.

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608

Molars demonstrated distal movements from 1.17 to

6.10 mm with conventional anchorage. The pendulum
appliance showed the greatest distalization in 7
months.22 The least distalization was obtained with
the Jones jig in 6 months.38 The greatest molar distal
tipping was 18.5 ,23 and the least was 0.89 .43
Anchorage loss could be identied in the studies with
conventional anchorage through premolar movement,
which showed positive values indicating mesial
movement. These values ranged from 0.27 mm in 3
months47 to 6.6 mm in 5 months48 with the pendulum
appliance. The greatest premolar mesial tipping was
9.47 observed in the study of Runge et al.45
Maxillary molar distalization appliances with
skeletal anchorage

In 6 studies, the treatment effects of distalizers with

skeletal anchorage were analyzed. Four studies used the
pendulum appliance to distalize the maxillary
molars,36,37,49,50 one used the distal jet,44 and the other
used the dual force.51 One36,37,50 or 237,44,49,51 implants
or mini-implants were used in the paramedian region of
the midpalatal suture as anchorage. The screw was
connected to an acrylic plate37,49-51 except in the
a
g et al36 (Table IV).
studies of Kinzinger et al44 and Onc
The mean initial chronologic age ranged from 12.144
to 14.351 years. One study did not report the mean initial
age.36 Treatment time ranged from 5.051 to 7.849
months.
The mean molar distal movement ranged from 3.944 to
50
6.4 mm, and the mean molar distal tipping ranged from
3.0 44 to 12.2 .39 The greatest distalization was obtained
with the pendulum and the smallest with the distal jet.
Studies with mini-implant anchorage showed
negative values for premolar movement ( 3.1 to 5.4
mm) indicating distal movement of these teeth and no
anchorage loss. Only the study of Kinzinger et al44
showed mesial movement (0.72 mm) and mesial tipping
(0.79 ) of premolars, indicating anchorage loss even
when associated with mini-implants.
No article with skeletal anchorage was classied as
high quality, 4 were classied as medium quality, and
2 had low quality (Table V).
Meta-analysis

After we assessed the quality of the 36 studies with

conventional anchorage included in the systematic
review, 34 were rejected because of low or medium
quality. Thus, the meta-analysis was conducted with 2
high-quality studies with no heterogeneity (I2 5 0%).
However, in the group with skeletal anchorage, no study
had high quality, and 2 articles with low quality were

May 2013  Vol 143  Issue 5

excluded. The meta-analysis was conducted with 4

studies of medium quality, with heterogeneity of I2 of
82% in the analysis of molar distalization, and of I2 of
69% in the analysis of premolars.
One study with more than 1 group was subdivided
according to the number of groups and separately
included in the meta-analysis.25 Therefore, 3 items
were analyzed with conventional anchorage and 4 items
with skeletal anchorage.
The meta-analysis of molar distal movement had
estimated combined effects of 3.34 mm in studies with
conventional anchorage and 5.10 mm in studies with
skeletal anchorage (Figs 2 and 3).
As for the premolars, the meta-analysis showed average
mesial movements of 2.30 mm in studies with conventional anchorage and 4.01 mm of distal movement in
studies with skeletal anchorage (Figs 4 and 5).
DISCUSSION

Since the introduction of intraoral distalizers for

Class II malocclusion treatment, studies have been
conducted to evaluate their distalizing effects and
anchorage losses with their use.
One systematic review evaluated the effects of intraoral distalizers with conventional anchorage28 and the
other with skeletal anchorage.29 The purpose of this
meta-analysis was to compare the anchorage loss with
the use of these appliances with both types of anchorage.
There is no standardization regarding evaluation of
anchorage loss, which can be conducted by using the
premolars, incisors, and overjets as references. Because
anchorage loss can be underestimated by crowding of
the anterior teeth, the option was to determine loss of
anchorage by means of changes in premolar position.
Thus, studies that used the incisors and overjet as
references were excluded to decrease the variability
among the studies.
In a systematic review, it is important to evaluate the
quality of the articles and allow inclusion of betterquality articles in the meta-analysis to decrease the
heterogeneity among them, with the goal of presenting
more reliable data.52 In health eld investigations, which
involve patient treatments, signicant degrees of
clinical, methodological, and statistical heterogeneity
are expected because of the nature of these studies
and the different variables involved, and the entire systematic review project must address this issue.34
Various factors should be considered to explain
this heterogeneity. One is the degree of occlusal
severity of the Class II malocclusions; this has a direct inuence on the amounts of distalization and
anchorage loss after treatment. In other words, a complete

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609

Table V. Assessment of the study quality

Number
Study
Conventional anchorage
Papadopoulos et al,9 2010
1
2
Acar et al,47 2010
3
Haq et al,78 2010
4
Patel et al,25 2009
5
Polat-Ozsoy et al,37 2008*
6
Sch
utze et al,79 2007
a
7
Onc
g et al,36 2007*
8
Angelieri et al,19 2006
9
Fuziy et al,23 2006
10
Mavropoulos et al,46 2006
11
Sayinsu et al,80 2006
12
Chiu et al,22 2005
13
Kinzinger et al,73 2005
14
Mavropoulos et al,18 2005
15
Ferguson et al,81 2005
16
Fortini et al,82 2004
17
Papadopoulos et al,40 2004
18
Taner et al,83 2003
19
Bolla et al,84 2002
20
Paul et al,38 2002
21
Nishii et al,85 2002
22
Chaqu
es-Asensi and Kalra,86 2001
23
Ngantung et al,39 2001
24
Keles,43 2001
25
Toro
glu et al,48 2001
26
Bussick and McNamara,21 2000
em et al,41 2000
27
Uc
28
Brickman et al,20 2000
24

2000
29
Haydar and Uner,
30
Keles and Sayinsu,3 2000
31
Bondemark,87 2000
32
Runge et al,45 1999
33
Gulati et al,42 1998
34
Byloff and Darendeliler,57 1997
35
Byloff et al,88 1997
36
Ghosh and Nanda,58 1996
Skeletal anchorage
1
Kinzinger et al,44 2009
2
Oberti et al,51 2009
3
Polat-Ozsoy et al,37 2008*
a
4
Onc
g et al,36 2007*
5
Escobar et al,49 2007
6
Kircelli et al,50 2006

Study
design 0-3

Sample
size 0-1

Selection
description 0-2

Method
error
analysis 0-1

Adequacy of
statistical
analysis 0-1

Quality
Score 0-9

Judged
quality
standard

3
1
0
2
0
0
2
1
1
1
1
0
1
1
0
1
1
2
0
3
1
1
0
0
1
0
1
1
2
1
0
0
1
1
1
0

1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
1
0
0
1
1
1
1
1
1
1
1
0
1
0
1
1
0
0
0
1
1

2
1
1
2
1
1
0
2
2
1
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
2
1
0
1
1
1
0
1
1
1

1
1
1
1
1
1
0
1
1
1
1
0
1
1
1
1
1
1
1
0
1
1
1
0
0
0
1
0
0
0
1
0
1
0
0
1

2
1
1
2
1
2
1
1
1
0
1
1
1
0
1
1
2
1
1
1
1
1
1
1
1
1
1
1
0
0
1
1
1
1
1
1

9
5
4
8
4
5
4
6
6
4
5
3
5
3
4
5
6
5
4
6
5
5
5
3
4
3
5
4
2
3
4
2
3
3
4
4

High
Medium
Medium
High
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Low
Medium
Low
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Low
Medium
Low
Medium
Medium
Low
Low
Medium
Low
Low
Low
Medium
Medium

1
1
0
2
1
1

0
1
1
1
1
0

1
1
1
0
1
1

0
0
1
0
0
0

1
1
1
1
1
1

3
4
4
4
4
3

Low
Medium
Medium
Medium
Medium
Low

*Both studies compared the effects of the Pendulum on both anchorage types (conventional and skeletal).

Class II molar relationship requires greater molar distalization and produces greater side effects on the anchorage
unit than does a quarter Class II molar relationship.8,53,54
Among the 40 studies included in the systematic
review, only 7 presented data regarding the initial occlusal severity of the Class II malocclusions.9,19,23,25,39-41
Ucem et al41 included only patients with a complete Class
II molar relationship; Papadopoulos et al40 included only
patients with over a half Class II molar relationship; and

Ngantung et al39 included only Class II up to 3 to 4 mm of

molar relationship discrepancy. The other articles included patients with various severities.9,19,23,25,41 It
would be ideal if all investigators had selected patients
with a similar occlusal malocclusion severity, since it
would have allowed better comparisons among the
studies. However, obtaining sufcient numbers of
patients with the same characteristics in a clinical study
is difcult.55

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610

Fig 2. Forest plots representing molar distalization with conventional anchorage.

Fig 3. Forest plots representing molar distalization with skeletal anchorage.

Another factor related to heterogeneity is the use of

different cephalometric reference points.28 Some studies
have used the buccal cusps of the maxillary teeth, which
are difcult to locate because of image superimposition;
these teeth move excessively with accentuated
angulation and do not reect actual molar and premolar
movements.56 Other studies were based on the center of
the clinical crown and the centroid point, which better
represent changes during treatment.20,39,45,57,58
Part of this heterogeneity is also related to the
different study designs (randomized clinical trials, case
control studies, and retrospective studies), lack of error
analyses, and different sample calculations with
consequent great variability in the numbers of patients
in the studies. In orthodontics, it is difcult to conduct
a randomized clinical trial on certain topics.31,59
Because there were only 2 randomized clinical trials,
we thought that other study designs that disclosed
important results on the effects of distalizers with
different anchorage systems should be included in this
systematic review. Therefore, quality assessment was

May 2013  Vol 143  Issue 5

used instead of a risk of bias assessment, which is

more rigid and specic for randomized clinical trials.
The number of patients in the sample is important to
be able to represent part of a population; therefore, it
was 1 criterion for quality analysis.60
Another important criterion is a statistical analysis of
the data because it provides a mathematic interpretation
of the data.61 In this systematic review, the quality of 4
articles was compromised because the authors gave only
descriptive analyses.3,18,24,46
In all the evaluated studies, the patients were in
the growth stage, in which natural skeletal and dentoalveolar changes must be differentiated from the
appliance-induced effects.62 The mean initial chronologic ages ranged from 9.29 to 1547 years. However,
craniofacial growth does not signicantly interfere
when 2 distalization modalities are compared because
distalization time is short.
The different types of distalizers used was also
a methodologic variable that must be considered. These
appliances have an active unit that applies a distalizing

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611

Fig 4. Forest plots representing premolar movement with conventional anchorage.

Fig 5. Forest plots representing premolar movement with skeletal anchorage.

force with various mechanisms. Because the intention

was to compare the changes in the 2 types of anchorage,
these differences would not play a signicant role, since
the anchorage units were similar (a Nance button
supported on the premolars), except for Kinzinger
et al,63 who used the deciduous molars for conventional
anchorage. In the skeletal type, the anchorage unit was
a mini-implant37,44,49-51 or an implant.36
These methodologic limitations were the reason for
considering 11 studies to be low quality, 29 medium
quality, and only 2 high quality. Of these 2 studies,
only one obtained the maximum score possible.9 Of
the 11 low-quality studies, 7 were published over 10
years ago. The 2 studies considered to be high quality
were from 2009 and 2010, indicating greater concern
with quality because of increasingly demanding
scientic methodologic criteria.
In this review, we observed that the most frequently
used distalizer was the pendulum and its variations.

This might be explained because this distalizer has

a low cost and is easy to fabricate, whereas with other
distalizers (distal jet, Jones jig, rst class), one needs to
buy a kit that requires more complex laboratory
fabrication.15 As anchorage, all used a Nance button,
em et al,41 who used intermaxillary elastics
except for Uc
as recommended for the 3D-BMDA appliance.64,65
The great variation in distalization time (1.50-14.16
months) in the studies might be the result of variations
in the amount of force applied by each type of appliance
and the different Class II malocclusion occlusal severities
of the samples, which demanded different amounts of
distalization ( 1.17 to 6.10 mm).
In the same way as in conventional anchorage, the
pendulum appliance was the most used in the studies
that used skeletal anchorage. Associated with skeletal
anchorage, most also opted for the Nance button. Use
of the Nance button might be a way to reduce possible
movement of the mini-implants.66

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612

Studies that associated intraoral distalizers with

skeletal anchorage in the palate used devices with
various diameters and lengths. However, these factors
do not interfere with the stability or the effectiveness
of the mini-implant to increase anchorage.67,68 All
devices used had diameters greater than 1.0 mm,
because thinner mini-implants can have considerable
failure rates.69
The majority of the studies used 1 or 2 mini-implants
inserted in the paramedian region; this is considered
better for mini-implants in growing patients because
the midpalatal suture consists of connective tissue,
and insertion in this suture could compromise retention.70-72
Differently from conventional anchorage, there were
fewer variations in treatment times (5.0-7.8 months),
amounts of distalization ( 3.9 to 6.4 mm), and
anchorage loss ( 3.1 to 5.4 mm). Although the studies
with skeletal anchorage did not mention the anteroposterior occlusal severity of the malocclusion, it is believed
that there is a tendency to select patients with greater
severity for treatment with this type of anchorage.
Mini-implants can be used as direct or indirect
anchorage. In direct skeletal anchorage, mini-implants
directly receive the force of reaction resulting from
movement, whereas in indirect anchorage, the force is
received on the anchor teeth that are supported by the
mini-implants.73 Of the 6 studies included in the systematic review, 5 that used direct anchorage showed
spontaneous distal movement of the premolars,
probably due to stretching of the interseptal
bers.36,37,49-51 In the study that used indirect
anchorage, loss of anchorage, although small, was
shown.44 This is because the reaction force, in conjunction with other factors, such as movement of the
mini-implants due to absence of osseointegration or
bone elasticity, exibility of the premolarmini-implant
connecting wire, or insufcient contact of the wire
with the mini-implant and the periodontal ligament,
might result in mesialization of premolars even when
associated with mini-implants.49,70
Kinzinger et al44 used the distal jet associated
with mini-implants in the palate, including the 2 rst
premolars instead of the second premolars. After
distalization of the molars, the second premolars
underwent spontaneous distalization of 1.87 mm;
however, there was no reduction in anterior crowding,
because the rst premolars that had indirect anchorage
showed mesialization of 0.72 mm.
To enable a meta-analysis, careful selection was
made, and only 2 studies in the group with conventional
anchorage were included because they were of high
quality. However, since there were no high-quality

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articles in the group with skeletal anchorage, the

meta-analysis was performed with medium-quality
articles; this resulted in high heterogeneity.
When there is heterogeneity, alternative analyses
such as meta-analysis in subgroups and metaregression could be considered to explain the variability
among the groups; however, these types of analyses
require many studies.52 When this is not the case, the
random-effects model is recommended.74 This can
also be used when the researcher combines various
studies with the same objective that were not conducted
in the same manner.34,74 This justies its use in this
study.
The clinical success of molar distalization and Class II
malocclusion correction was observed in both groups
(conventional and skeletal anchorage) evaluated in this
study. However, the meta-analysis showed a greater
mean distalization in the skeletal anchorage group,
similar to the results of Polat-Ozsoy et al.37 The
difference between the groups was 1.76 mm. The greater
distalization in the group with skeletal anchorage might
have been due to the tendency to include patients with
more severe Class II malocclusions, when greater
anchorage is desired.
The use of intraoral distalizing appliances with
conventional anchorage has shown anchorage loss,
which was conrmed in this meta-analysis.70,71,75 This
is because the Nance button and the anterior teeth
cannot resist the opposing forces of distalization
without moving in the opposite direction.36,44
Consequently, associating intraoral distalizers with
skeletal anchorage has been an approach to achieve total
anchorage during distalization.36,37,44,49-51,66,70 The 4
studies included in the meta-analysis used direct
anchorage, which explains the net distal movement of
the premolars.
Direct skeletal anchorage produces fewer side effects
resulting from distalization mechanics, due to spontaneous distal migration of the premolars; this
reduced anterior crowding, facilitating the xed
appliance treatment phase and decreased treatment
time.36,49,50,71
Even though the studies with direct anchorage
showed no anchorage loss, side effects of anterior
movement of mini-implants can occur, caused by the
reaction force from the molars.36,49 Skeletal anchorage
does not eliminate the reaction force during
orthodontic treatment but transfers it to the bone,
which has plasticity when subjected to forces and thus
allows movement of mini-implants.76,77
The efciency of intraoral distalizers in clinical
applications depends on a stable anchorage unit.75
Anchorage is a decisive factor for successful

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orthodontic treatment with these appliance types and

must be an initial concern of orthodontists in this type
of treatment.
CONCLUSIONS

Molar distalization was shown to be effective with

both anchorage systems. The amounts of distal molar
movement were 3.34 mm with conventional anchorage
and 5.10 mm with the skeletal anchorage system.
The conventional anchorage system showed anchorage loss, represented by premolar mesial movement of
4.01 mm. The skeletal anchorage system showed no
anchorage loss and spontaneous distal premolar
movement of 2.30 mm when direct anchorage was
used. Therefore, intraoral distalizers associated with
direct skeletal anchorage seem to be a viable method
to minimize the effects of anchorage loss in the
treatment of Class II malocclusions.
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American Journal of Orthodontics and Dentofacial Orthopedics

May 2013  Vol 143  Issue 5