STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS Abdolreza… [629682]

Stomatology Edu Journal
Review Articles ORTHODONTICS
STABILITY OF SKELETAL CLASS III MALOCCLUSION
AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND
META-ANALYSIS
Abdolreza Jamilian1a*, Ludovica Nucci2b, Ali Fateh3c, Mitra Toliat4d, Alireza Darnahal5e, Madi Alassadi6f,
Chin Wei Wang7g
1Department of orthodontics, Faculty of dentistry, Cranio maxillofacial Research center, Islamic Azad University, Tehran medical sciences, Tehran, Iran
2Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
3Cranio maxillofacial Research center, Islamic Azad University, Tehran medical sciences, Tehran, Iran
4Cranio maxillofacial Research center, Islamic Azad University, Tehran medical sciences, Tehran, Iran
5Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Michigan, USA
6 Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Michigan, USA
7 Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Michigan, USA
aDDS, MSc, OMFS, Professor
bUndergraduate Dental Student: [anonimizat], Executive Manager
dResearcher
ePost Doctorate Student: [anonimizat], Clinical Assistant Professor, Director, Predoctoral Periodontics
ABSTRACT
OPEN ACCESS This is an Open Access article
under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Jamilian A, Nucci L, Fateh A,
Toliat M, Darnahal A, Alassadi M, Wang CW.
Stability of skeletal Class III malocclusion
after orthognathic surgery and orthodontic
treatment: a systematic review and meta-
analysis.
Stoma Edu J. 2020;7(1):xxx-xxx
Received: February 06, 2020
Revised: February 13, 2020
Accepted: February 14, 2020
Published: February xx, 2020
Corresponding author:
Professor Abdolreza Jamilian
Department of orthodontics, Faculty of dentistry, Cranio
maxillofacial Research center, Islamic Azad University,
Tehran medical sciences, Tehran, Iran. No 14, Pesiyan Ave.,
Vali Asr St., Tehran, 1986944768, Iran
Tel/Fax: 00982122011892, e-mail: [anonimizat]
Copyright: © 2020 the Editorial Council
for the Stomatology Edu Journal.
Background: Relapse is one of the major concerns in the correction of skeletal
class III malocclusion
Objective: The purpose of this systemic review was to evaluate the degree
of relapse on skeletal class III patients who received bimaxillary surgery or
mandibular setback with orthodontic treatment.
Data Sources: A search of the literature was performed in the databases
of PubMed, Google Scholar Beta, Scopus, Web of Science, and the Cochrane
Library.
Study Selection: Out of the 165 articles identified, 73 studies were obtained,
once duplicated articles were excluded. Then, 40 other records were excluded
due to titles and abstracts, and 20 were removed for not fulfilling exclusion/
inclusion criteria. 11 studies met the final inclusion criteria. Some cephalometric
data during T1–T2–T3 were measured.
Data Extraction: SNA did not have any significant changes within less than 2
years but it increased significantly after 2 years. SNB did not have any significant
changes in more than 2 years’ follow-up, while it rose significantly in less than
2 years. Overjet decreased significantly after 2 years but not earlier than this
duration. Overbite intensified significantly in more than 2 years and not earlier.
Data Synthesis: SNA and overbite increased significantly after 2 years. SNB
increased significantly before 2 years and did not have any changes after it.
Overjet was significantly reduced after 2 years.
Keywords: Class III; Skeletal and Dental Changes; Stability; Bimaxillary Surgery
or mandibular setback; Systematic review and meta-analysis
1. Introduction
Moderate to severe skeletal class III patients often
require a combined orthodontic and surgical
approach for treatment. It has been reported that
skeletal class III malocclusion is the most frequent
deformity corrected by combined orthognathic
surgery and orthodontic treatment [1-4]. However,
bimaxillary surgery has gradually become more
popular to correct class III malocclusion [5-7]. It has been estimated that 20% to 25% of all Class III cases
have true mandibular prognathism suggesting that
at least 75% of all class III malocclusions have some
degree of maxillary retrusion. Given this scenario,
the surgical treatment has been regarded as the best
approach to achieve the best results in adult cases[8].
Post-surgical relapse is one of the major concerns
in the correction of skeletal class III malocclusion.
It has been shown that there is a greater tendency
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Stoma Edu J. 2020;7(1): http://www.stomaeduj.comSTABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Figure 1. PRISMA flowchart of article
retrieval.Review Articles
for relapse after bimaxillary osteotomy [9]. Similarly,
LaBanc et al. [10] reported that due to increased
incidence of relapse, bimaxillary surgery should only
be performed for specific indications; for example
two-jaw surgery has greater relapse than single-
jaw surgery. On the contrary, Proffit et al [11]. found
that better stability and predictable results can be
obtained after two-jaw surgery. Immediate relapse
can be identified after surgery which may occur due
to intraoperative error such as imprecise planning,
inaccurate osteosynthesis, or failure to fix the joint.
On the other hand, late relapse can be detected
once a considerable period has elapsed since the
day of the surgical procedure. Late relapse may
occur due to unstable occlusal relationships, growth
spurts, absence of myofunctional adaptation,
or persistent tongue or orofacial muscle habits
[12]. A study revealed that the rate of short-term
relapse of bilateral sagittal split osteotomy setback
surgery is 9.9%-62.1%, and long-term relapse is
between 14.9% and 28.0%, at point B. To the best
of our knowledge, there has been no meta-analysis
evaluating the stability of skeletal changes after a
combined orthodontic and surgical procedure for
treatment of skeletal Class III patients in short- and
long-term follow ups. The question is: “How much of the treatment effects remains stable by the end of
follow-up?”
Objectives: The aim of this study was a meta-analysis
of the literature on the stability of skeletal class III
malocclusion. Patients often require a combined
orthodontic and surgical approach after bimaxillary
surgery. This meta-analysis was undertaken to
explore the parameters related to the skeletal
stability in surgical correction of skeletal Class III
malocclusion.
2. Materials and methods
2.1. Protocol and registration
This systematic review was based on a specific
protocol developed and piloted following the
guidelines outlined in the PRISMA-P statement [13].
Furthermore, the procedure and reporting followed
the guidelines of the Cochrane Handbook for
Systematic Reviews of Interventions [14] and the
PRISMA statement, [15] respectively:
2.2. Information sources, search strategy, and study
selection
A literature search was performed using PubMed,
Google Scholar Beta, Scopus, Web of Science, and
the Cochrane Library to identify articles reporting
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Stomatology Edu JournalSTABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Review Articles Figure 2a. Before surgery T1 – After
surgery T2, (T1-T2) SNA.
Figure 2b. After surgery T2 – Last
follow-up T3, (T2-T3) SNA
Figure 2c. Subgroup analysis according
to the follow-up period (SNA).
1. Less than 2 years. ; 2. More than 2 years.
a
b
c
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Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Figure 3a. Before surgery T1 – After
surgery T2, (T1-T2) SNB.
Figure 3b. After surgery T2 – Last
follow-up T3, (T2-T3) SNB.
Figure 3c. Subgroup analysis according
to the follow-up period (SNB).
1. Less than 2 years. ; 2. More than 2 years.
a
b
c
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Stomatology Edu Journal
Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
combined orthodontic and surgical approach
for treatment of skeletal class III malocclusion in
non-growing patients. The search process was
conducted independently by two coauthors (AJ
and AD) for articles published up to December
2018. All titles and abstracts were evaluated, and
duplicate studies were removed.
2.3. Eligibility criteria
The inclusion and exclusion criteria were established
prior to the search according to Table 1. Each
keyword was carefully selected and revised for
each database. All keywords used in the search
are detailed in Table 2. This systematic review and
meta-analysis was conducted based on the PRISMA
(Preferred Reporting Items for Systematic reviews
and Meta-Analyses) guidelines [16]. Title-abstract-
full text of each article was checked independently
by two coauthors based on the PRISMA chart.
2.4. Data collection and data items
Two authors (AJ and AD) used pre-defined
electronic sheets to extract study characteristics
independently. Three time points were defined:
T1 (before surgery), T2 (after surgery), and T3 (the
end of the follow-up). The findings were obtained
on the following items: Name of first author, year
of publication, country, number and mean age
of patients, gender, type of surgery (Mandibular
setback including BSSO or vertical osteotomy)
or (Bimaxillary surgery including Lefort 1 + BSSO
or Lefort 1 + vertical), type of fixation including
Rigid Internal Fixation (RIF) or Maxillomandibular
Fixation (MMF), follow-up after surgery until 2 years,
follow-up after surgery until 5 years, SNA, SNB, ANB,
overjet, overbite, incisor mandibular plane angle
(IMPA), upper incisor to SN (U1/SN) angle, during
T1–T2 (surgical effects), T2–T3 (posttreatment
changes) were recorded. In order to identify the
correlation between relapse and cephalometric
landmarks, meta-analyses were conducted
between cephalometric landmarks and different
variables such as type of surgery (mandibular
setback including BSSO or vertical osteotomy)
or (bimaxillary surgery including Lefort 1 + BSSO
or Lefort 1 + vertical), type of fixation including
Rigid Internal Fixation (RIF) or Maxillomandibular
Fixation (MMF), follow-up after surgery within 2
years, follow-up after surgery within 5years.
The cutoff value of less than 2 years was chosen to
separate short-term from long-term studies.
2.5. Statistical analysis
All statistical tests were conducted using the STATA
14 (StataCorp LP , College Station, USA). The effects
of bimaxillary surgery or mandibular setback on
SNA, SNB, ANB, overjet, overbite, incisor mandibular
plane angle (IMPA) and upper incisor to SN (U1/
SN) angle, before and after surgery as well as the
last follow-up were measured by weighted mean difference (WMD) and the 95% confidence intervals
(CI). The standard error (SE) of the mean difference
(MD) for non-reported studies was calculated by the
following formula: SD2 baseline + SD2 final – (2 R* SD
baseline + SD final) and SD=SE*sq(n). Heterogeneity
across studies was assessed using the I-squared and
the alpha of 0.05 for statistical significance.
The subgroup analysis was based on the time of
follow-up to identify the source of heterogeneities.
To identify the source of clinical heterogeneity,
susceptible variables including treatment plan,
gender, country, treatment time, type of surgery,
type of fixation, and follow-up time were introduced
into a meta-regression model. WMD with 95% CI was
calculated for all variables.
The publication bias was determined using Begg
tests. The p-value of 0.05 was regarded for statistical
significance. The changes in seven variables (SNA,
SNB, ANB, IMPA, overjet, U1/SN, and L1/MP) during
three time periods [Before surgery (T1), after
surgery (T2) and last follow-up (T3)] were compared
between the studies. The summarized data of
included studies and cephalometric measurements
of the included studies are seen in Tables 3 and 4
respectively. The results of the statistical analysis for
heterogeneity and the funnel plots are displayed in
Figures 2, 3, 4, 5, 6, 7, and 8.
3. Results
3.1. Study selection and characteristics
Of the 165 records resulting from the search
strategies, 73 studies were obtained once duplicated
articles were excluded. Then, 40 papers were
removed because of their titles and abstracts. In
addition, 20 more were further excluded for not
meeting the exclusion/inclusion criteria. Ultimately,
13 papers met the final selected criteria and were
selected to conduct the systematic review and
meta-analysis. The manual search did not yield
any additional material. In case of disagreement,
the authors discussed the controversy until an
agreement was reached.
Of the 13 studies, 2 of them did not provide us
with enough data for the meta-analysis and were
excluded from the study. Performing meta-analysis
was only feasible for 11 studies, and these studies
were included in our study. These studies include
non-growing patients with Class III malocclusion
with Follow-up of 6 months or longer. The level
of inter-examiner agreement of data extraction
was measured using kappa statistics. The level of
agreement between the two examiners was assessed
using the Cohen kappa scores. The kappa score for
study selection was 0.978, indicating an excellent
level of agreement. The PRISMA flow diagram of
study selection is outlined in Fig. 1
Before surgery T1– After surgery T2, (T1–T2) Figures
2a, 3a, 4a, 5a, 6a, 7a, and 8a
Short-term treatment effects included significant
increase in SNA (WMD 1.78, 95%CI:1.42, 2.12),
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Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Figure 4a. Before surgery T1 – After
surgery T2, (T1-T2) ANB.
Figure 4b. After surgery T2 – Last
follow-up T3, (T2-T3) ANB.
Figure 4c. Subgroup analysis according
to the follow-up period (ANB).
1. Less than 2 years. ; 2. More than 2 years.
a
b
c
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Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Figure 5a. Before surgery T1 – After
surgery T2, (T1-T2) Overjet.
Figure 5b. After surgery T2 – Last
follow-up T3, (T2-T3) Overjet.
Figure 5c. Subgroup analysis according
to the follow-up period (Overjet).
1. Less than 2 years. ; 2. More than 2 years.
a
b
c
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Stoma Edu J. 2020;7(1): http://www.stomaeduj.com
Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Figure 6a. Before surgery T1 – After
surgery T2, (T1-T2) Overbite.
Figure 6b. After surgery T2 – Last
fallow-up T3, (T2-T3) Overbite.
Figure 6c. Subgroup analysis according
to the follow-up period (Overbite).
a
b
c
1. Less than 2 years. ; 2. More than 2 years.
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Stomatology Edu Journal
Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS,
Table 1: Eligibility criteria used for the study selection

Category Inclusion criteria Exclusion criteria
Study design Randomized
controlled trials
Controlled clinical
trials
Cohort studies
Experimental studies,
prospective and
retrospective studies
comparing at least
two surgical
treatment strategies
Articles written in the
English language Case reports Commentaries
Systematic reviews or meta -analyses
descriptive studies, opinion articles, or
abstracts

Participants Non-growing patients
with Class III
malocclusion
Follow -up of 6
months or longer
Patients with cleft lip palate and/or
craniofacial
syndromes or genetic problems
Patients with temporomandibular joint
disorders
Treatment in growing patients
Intervention Mandibular set back
Bimaxil lary surgery:
(including maxillary
advancement and
mandibular set back)
Surgery first Maxillary advancement
Patients treated with orthodontic or
orthopedic
appliances
Studies not concerning surgical long –
term stability
Outcome Skeletal and
dentoalveolar
variables measured
by lateral
cephalometric
radiographs Studies providing no cephalometric
measurements
Average time of
follow -up Studies with an
average follow -up at
least 2 years after
surgery Studies with no follow -up Table 1. Eligibility criteria used for the study selection.
significant reduction in SNB (WMD -3.95, 95%CI:-
4.50, -3.40), significant rise in ANB (WMD 6.36,
95%CI:5.59, 7.13), significant growth in overjet
(WMD 8.24, 95%CI: 6.56, 9.92), significant elevation
in overbite (WMD 1.57, 95%CI: 0.30,2.84), while U1/
SN (WMD -2.34, 95%CI, -6.27, 1.58) and L1/MP (WMD
2.12, 95%CI:0.43, 3.82) did not show any significant changes. After surgery T2– Last follow upT3, (T2–T3)
Figures. 2b, 3b, 4b, 5b, 6b, 7b, and 8b.
The last follow-up showed no significant changes
in SNA (WMD 0.06, 95%CI:-.05, 0.16), ANB (WMD
0.19,95%CI:-0.43 ,0.82), overjet (WMD -0.53, 95%CI:
-1.36, 0.30), overbite (WMD 0.20, 95%CI:-0.17, 0.57),
L1/MP (WMD -0.38, 95%CI:-1.67, 0.92), while there
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Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
was a significant change in SNB and U1/SN (WMD
0.38, 95%CI:0.24, 0.51) and (WMD 2.12, 95%CI:0.43,
3.82) respectively.
3.2. Subgroup analysis
A subgroup analysis based on the duration of follow-
up: less than 2 years (group 1) and more than 2 years
(group 2) was conducted to identify the source of
the high heterogeneity and the influence of the
follow-up duration.
SNA increased significantly after a 2 year-follow-up
[WMD 0.07, 95%CI: 0.03, 0.11)] but no significant
changes were noted in less than 2 year-follow-up
[WMD -0.02, (95%CI: -0.23, 0.19)].
SNB did not have any significant changes in more
than 2 year-follow-up [WMD 0.03 (95%CI: – 0.11,
0.18)]; however, it increased significantly in group 1
[WMD 0.76 (95%CI: 0.49, 1.03)].
There were no significant changes in ANB in both
group 2 durations [WMD .047 (95%CI:-0.26,1.20)] or
group 1 [WMD-0.49 (95%CI:-1.72,0.74)] durations. For overjet, it decreased significantly after a 2 year-
follow-up [WMD -0.80 (95%CI: -1.23, -0.36)], but not
in less than a 2 year-follow-up [WMD -0.49 (95%CI:
-1.38, 0.41)]. Overbite grew significantly in group 2
[WMD 0.50 (95%CI:0.01, 0.98)] and not in group 1
[WMD 0.03.
(95%CI: -0.36, 0.41)]. Only a few studies measured
U1/SN and L1/MP; hence, the heterogeneity could
not be measured due to the small sample size. The
results of the statistical testing for heterogeneity
and the corresponding funnel plots are given in
Figures. 2c, 3c, 4c, 5c, and 6c.
3.3. Risk of bias within studies /publication bias
No publication bias was determined by using the
Begg’s test (in STATA 14 (StataCorp LP , College
Station, USA)). The results of the Begg’s test for the
analysis of small study effect (publication bias) for the
measurements of SNA, SNB, ANB, overjet, overbite,
U1/SN, and L1/MP are as follows, respectively: 0.78,
0.33, 0.95, 0.08, 0.45, 0.98, and 0.34.Table 2 : Keywords used for each data base search
Pubmed Web of science Scopus Embase Cochrane
50 7 63 42 3
(((((("Malocclusion,
Angle Class III"[Mesh]
OR
"class3"[Title/Abstract])
OR "class
III"[Title/Abstract]) OR
"Maxillary
Deficiency"[Title/Abstra
ct]) OR "mandibular
protrusion"[Title/Abstra
ct]) OR "Maxillary
retrusion"[Title/Abstract
]) AND (((("Mandibular
Osteotomy"[Mesh] OR
"mandibular
surgery"[Title/Ab stract])
OR "bimaxillary
surgery"[Title/Abstract])
OR "surgical
orthodontics"[Title/Abst
ract]) OR "mandibular
set
back"[Title/Abstract]))
AND
(stability[Title/Abstract]
OR
relapse[Title/Abstract]) TI=("Malocclusi
on, Angle Class
III" OR "class3"
OR "class I II"
OR "Maxillary
Deficiency" OR
"mandibular
protrusion" OR
"Maxillary
retrusion") AND
TI=("Mandibula
r Osteotomy"
OR "mandibular
surgery" OR
"bimaxillary
surgery" OR
"surgical
orthodontics"
OR "mandibular
set back") AND
TI=(stability OR
relapse)

( ( TITL E-ABS –
KEY ( "Malocclusion,
Angle Class
III" ) OR TITLE -ABS –
KEY ( "class3" ) OR TI
TLE-ABS -KEY ( "class
III" ) OR TITLE -ABS –
KEY ( "Maxillary
Deficiency" ) OR TITL
E-ABS –
KEY ( "mandibular
protrusion" ) OR TITL
E-ABS –
KEY ( "Maxillary
retrusion" ) ) ) AND ( (
TITLE -ABS –
KEY ( "Mandibular
Osteotomy" ) OR TITL
E-ABS –
KEY ( "mandibular
surgery" ) OR TITLE –
ABS -KEY ( "bimaxillary
surgery" ) OR TITLE –
ABS -KEY ( "surgical
orthodontics" ) OR TIT
LE-ABS –
KEY ( "mandibular set
back" ) ) ) AND ( ( TIT
LE-ABS –
KEY ( stability ) OR TI
TLE-ABS –
KEY ( relapse ) ) ) 'malocclusion
angle class
iii':ab,ti OR
'class3':ab,ti
OR 'class
iii':ab,ti OR
'maxillary
deficiency':ab,t
i OR 'maxillary
retrusion':ab,ti
and
'mandibular
osteotomy':ab,t
i OR
'mandibular
surgery':ab,ti
OR
'bimaxillary
surgery':ab,ti
OR 'surgical
orthodontics':a
b,ti OR
'mandibular set
back':ab,ti and
'stability':ab,ti
OR
'relapse':ab,ti ("Malocclusion,
Angle Class III" OR
"class3" OR "class
III" OR "Maxillary
Deficiency" OR
"mandibular
protrusion" OR
"Maxi llary
retrusion") AND
("Mandibular
Osteotomy" OR
"mandibular
surgery" OR
"bimaxillary
surgery" OR
"surgical
orthodontics" OR
"mandibular set
back") AND
(stability OR
relapse)

Table 2. Keywords used for each data base search.
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Stomatology Edu Journal
Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Figure 7a. Before surgery T1 – After
surgery T2, (T1-T2) U1/SN.
Figure 7b. After surgery T2 – Last
follow-up T3, (T2-T3) U1/SN.
a
b
4. Discussion
4.1. Summary of evidence
This meta-analysis showed some significant relapse
in skeletal and dental variables during the follow-
up period. SNA and overbite increased significantly
after a 2 year-follow-up. On the contrary, SNB
increased significantly before a 2 year-follow-up.
Overjet was significantly reduced after a 2 year-
follow-up . To the best of our knowledge, this is the
first meta-analysis reviewing the stability of skeletal
class III malocclusion after bimaxillary surgery or
mandibular setback.
Data from this study revealed that the main relapse
in SNA occurred after a 2 year-follow-up but not in
less than 2 years. This suggested that SNA relapse
often happened after a 2 year-follow-up and was
largely associated with the growth of maxilla that is
a common finding in class III malocclusion.
For SNB, a significant increase was noted before a
2 year-follow-up and not after a 2 year-follow-up.
This relapse in the short-term is due to the growth
of mandible which reportedly can continue even
after 18 years of age [17]. Hence, it is important
to consider the patient’s age and their related growth pattern before bimaxillary surgery and/or
mandibular setback treatment.Overjet was reduced
significantly in more than a 2 year-follow-up ; this
relapse is due to an increase in SNB. However, the
extent of overbite increased significantly after 2
years. Pre-surgical orthodontic treatment aims to
decompensate incisor inclination toward normal
values. Orthodontic decompensation allows a
greater surgical correction, and this may be a more
important factor in the relapse We should keep in
mind that skeletal relapse is masked frequently by
compensatory changes in the axial inclination of the
teeth [18-21].
Relapse varies considerably between patients and
surgeons without any known reason. It is clear that
good surgical training, profound experience in
orthognathic surgery, and technical refinements by
the surgeon are required to have perfect surgical
outcomes with regards to esthetics and stability.
The orthodontist should prepare the patient before
surgery for a perfect coordination and leveling and
alignment of both dental arches in transverse width,
correct decompensation of the incisors, control of
the surgical splint, and its newly defined occlusion
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Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Table 3. Characteristics of the studies included in the systematic review.Table 3. Characteristic sof the included studies in the systematic review .
PublicationObservation
periodGroup(s)Participants (Number, sex,
age)Type of Surgery Type of fixation Country
Jeong et al[1],
20182 yearsconventional
bimaxillary surgery14 (7M, 7F) / Mean age (21.5
± 2.5)Le Fort I
Osteotomy &
Bilateral IVRO*Rigid
South Korea
surgery first17 (9M, 8F) / Mean age (20.3
± 2.2)Wire
Choi et al[2],
20162 yearsIVRO15 (7M, 8F) / Mean age (22.1
± 2.3)IVROIntermaxillary
FixationSouth Korea
IVRO + Lefort 115 (7M, 8F) / Mean age (24.1
±4.3)IVRO + Lefort 1 Rigid
Park et al [3], 2016 6 monthsConventional
bimaxillary surgery20 (13M, 7F) / Mean age
(25.3) Lefort 1 &
BSSO**Rigid South Korea
Surgery -first20 (12M, 8F) / Mean age
(22.6)
Aydemir et al [4],
20155 yearsBSSO with Semi
Rigid Fixation and
Lefort 1 with Rigid
Fixation26 /
Mean age (17 -29)Lefort 1 &
BSSO**Semi Rigid and
Rigid FixationTurkey
Kim et al [5],
20141 yearBimaxillary Surgery
Le Fort 1 and IVRO37(20M,17F) / Mean age
(23±4)Lefort 1 & IVRO Wire South Korea
Kim et al [6],
201422 monthsConventional -BSSO23 (14M, 9F)/
Mean age (23 ±6.3)SF*** Rigid
South Korea
Surgery first38 (19M,19F)/
Mean age (21.6 ±3.5)BSSO Rigid
Ko et al [7],
20131 year45(19M, 26F) /
Mean age (23.2)Lefort I &
bilateral sagittal
split osteotomyMonocortical plates
and screws in each
side of the mandible
and miniplates in
each side of
the maxillaTaiwan
Jakobsone et al [8],
20113 years Lefort 1 + BSSO81 (55M, 26F) /
Mean age (25.8 ± 9.5)Lefort 1 + BSSO Rigid Norway
Abeltins et al [9],
20111 yearIVRO 21(6M,15F) / Mean age (20.2) Lefort 1 + BSSO
Wire Latvia
BSSO 30(7M,23F) / Mean age (19.4) Lefort 1 + IVRO
Iannetti et al [10],
20072 yearsLefort 1 N/A /
Mean age (18 -36)Bimaxillary
Rigid ItalyLefort 1 + BSSO Lefort 1
Costa et al [11],
20061 yearrigid titanium
21 / Mean age (N/A)Rigid resorbable
plateRigid resorbable
plateItaly
rigid resorbable plate Rigid titanium Rigid titanium
Kwon et al [12] ,
20007 months Lefort 1 and BSSO25 (13M, 12F) /
Mean age (24.1)Lefort 1 + BSSO Rigid Japan
McCance et 1 year Lefort 1 +BSSO 18 (N \A) / Lefort 1 + BSSO Wire England
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Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Age is reported in years; N/A, Not available; M, Male; F, Female
*IVRO, Intra-oral vertical ramus osteotomy; **BSSO, Bilateral sagittal split osteotomy; SF***, Surgery FirstKim et al [6],
201422 monthsConventional -BSSO23 (14M, 9F)/
Mean age (23 ±6.3)SF*** Rigid
South Korea
Surgery first38 (19M,19F)/
Mean age (21.6 ±3.5)BSSO Rigid
Ko et al [7],
20131 year45(19M, 26F) /
Mean age (23.2)Lefort I &
bilateral sagittal
split osteotomyMonocortical plates
and screws in each
side of the mandible
and miniplates in
each side of
the maxillaTaiwan
Jakobsone et al [8],
20113 years Lefort 1 + BSSO81 (55M, 26F) /
Mean age (25.8 ± 9.5)Lefort 1 + BSSO Rigid Norway
Abeltins et al [9],
20111 yearIVRO 21(6M,15F) / Mean age (20.2) Lefort 1 + BSSO
Wire Latvia
BSSO 30(7M,23F) / Mean age (19.4) Lefort 1 + IVRO
Iannetti et al [10],
20072 yearsLefort 1 N/A /
Mean age (18 -36)Bimaxillary
Rigid ItalyLefort 1 + BSSO Lefort 1
Costa et al [11],
20061 yearrigid titanium
21 / Mean age (N/A)Rigid resorbable
plateRigid resorbable
plateItaly
rigid resorbable plate Rigid titanium Rigid titanium
Kwon et al [12] ,
20007 months Lefort 1 and BSSO25 (13M, 12F) /
Mean age (24.1)Lefort 1 + BSSO Rigid Japan
McCance et 1 year Lefort 1 +BSSO 18 (N \A) / Lefort 1 + BSSO Wire England
al[13], 1992 Mean age (N\A)
Age is reported in years; N/A,Not available; M ,Male; F ,Female
*IVRO ,Intra -oral vertical ramus osteotomy ;**BSSO ,Bilateral sagittal split osteotomy ;SF
13

Stoma Edu J. 2020;7(1): http://www.stomaeduj.com
Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Table 4. Outcomes in terms of cephalometric measurements of the studies included in the quantitative meta-analysis.
Article & year Group Outcome
Before surgery
(T1) After surgery
(T2) T1-T2 Last Follow -up
(T3) T2-T3
Jeong et al[1], 2018 Conventional
bimaxillary surgery N/A N/A SNA: 0.4±2.3
SNB: -4.9±2. 1 N/A SNA: -0.1±1
surgery first N/A N/A SNA: 0.3±2.3
SNB: -5.7±2.6 N/A SNA:0.1±0.9
Park et al [3], 2016 Conventional
bimaxillary surgery N/A N/A SNA: – 2.8±1.9
SNB: -3.7±1.6 N/A SNA:0.3±1.4
SNB: 0.2±0.8
Surgery -first N/A N/A SNA: -2.5±2.3
SNB: -3.2±1.9 N/A SNA:0.4±1.3
SNB: 0.7±1.0
Aydemir et al [4],
2015 BSSO with Semi Rigid
Fixation and Lefort 1
with Rigid Fixation SNA: 78.9±
2.9
SNB: 83.1±
3.9
ANB:
24.2±3.1
OJ: 27.0± 3.5
OB: 22.3± 2.6 SNA: 82.9±2.5
SNB: 82.4±2.9
ANB: 0.5± 2.5
OJ: 2.6 ±3.4
OB: 1.3 ±1.7 SNA: 4.1±2.3
SNB: -1.4±2.6
ANB: 5.5±2.3
OJ: 9.6±3.7
OB: 3.1±3.6 SNA:83.0 ±3.0
SNB:81.4± 3.6
ANB:1.6 ± 2.2
OJ: 3.0 ± 1.0
OB:1.4 ± 0.6 SNA: 1.1± 0.3
SNB: -1±0.4
ANB: 1.1±0.1
OJ: 0.4±5.9
OB: 0.1±1.2
Kim et al [5], 2014 Bimaxillary Surgery Le
Fort 1 and IVRO SNA: 81.4±2.7
SNB: 83.8±3.7
U1/SN:
115.1±5.5
IMPA:
84.9±6.7 SNA:
81.94±2.9
SNB: 79±3.2
U1/SN:
107.9±5.4
IMPA:
83.2±5.9 SNA: 0.6+_1.1
SNB: -4.9±2.4
U1/SN: –
7.2±3.7
IMPA: –
1.7±3.9 SNA: 82±3.1
SNB: 79.1±3.1
U1/SN: 106.3±7.2
IMPA: 84±5.9 SNA: 0.1±0.0
SNB: 0.1±0.0
U1/SN: 0.6±0
IMPA: 1.2±1.2
Kim et al [6], 2014 Conventional -BSSO SNA: 81±3.8
SNB: 83.5±4.3
ANB: -2.5±2.8
IMPA:
92.6±5.9
OJ: -6.2±3.4 N/A SNB: -4.7±1.9
IMPA: 0±0
OJ: 10.1±3.5
OB: 0.1±1.4 N/A SNB:0.9±0.8
IMPA: -8.9±5
OJ: -0.8±1.2
OB:0.2±0.6
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Stomatology Edu JournalSTABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
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Review Articles OB: 0.9±1.3
Surgery first SNA: 80.5±4.1
SNB: 83.5±4.1
ANB: -3±2
IMPA:
82.3±9.3
OJ: – 4.4±2.9
OB: 0.7±2 N/A SNB: -4.4±1.3
IMPA:0.7±2.2
OJ:9.3±4.4
OB: 0.8±2.1 N/A SNB: 1.1±0.7
IMPA: -0.6±5.7
OJ: -2.3±3.1
OB: -0.3±0.9
Jakobsone et al [8],
2011 Lefort 1 + BSSO SNA: 79.6±3.6
SNB: 84.7±5.5
ANB: -5.1±4.1
OJ: -7±5
OB: -1.8±3.8 N/A SNA: 3.3±2.1
SNB: -4±3
ANB: 7.3±3.4
OJ: 9.8±4.6
OB: 3.7±3.5 N/A SNA: -0.1±0.9
SNB: 1±1.2
ANB: -1±1.2
OJ: -0.8±2
OB: 0±0.7
Abeltins et al [9], 2011 IVRO SNA: 80.7±3.7
SNB: 84.9±4.9
ANB: -4.2±3.3 N/A N/A N/A N/A
BSSO SNA: 79.3±3
SNB: 83.6±3.7
ANB: -4.2±3 N/A N/A N/A N/A
Iannetti et al [10],
2007 Lefort 1 N/A N/A SNA: 0.1±0. 1 N/A SNA:0.1±0.1
SNB:0.1±0.1
ANB:01±0.2
Lefort1+BSSO N/A N/A SNA: 0.1±0.1 N/A SNA:0.1±0.1
SNB: -0.5±0.3
ANB: 0.6±0.3
Costa et al [11], 2006 Rigid titanium
SNA: 78.4±2.8
SNB: 81.9±3.8 SNA: 81.7±2.9
SNB: 80.7±3.7 SNA: 3.3±1.6
SNB: -2.2±2.9 N/A SNA: -0.1±0.6
SNB: 0.9±1.1
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Stoma Edu J. 2020;7(1): http://www.stomaeduj.com
Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
ANB: -3.5±2.7
U1/SN:
111.2±7.8
IMPA:
88.3±7.1
OJ: -4.6±3.8
OB: 1.1±21 ANB: 1±2.4
U1/SN:112.7±
8.4
IMPA:
87.7±7.8
OJ: 3.2±1.31
OB: 2.3±1.4 ANB: 5.5±2.8
U1/SN: –
2.3±3.5
IMPA: –
0.2±2.7
OJ: 7.9±3.5
OB: -0.4±2.1 ANB: -0.9±1.3
U1/SN: 3.9±5.4
IMPA: -0.4±4.1
OJ: -0.1±1.7
OB: 1.6±1.9
Rigid resorbable plate
SNA: 80±3.6
SNB: 82.9±3.3
ANB: -2.9±0.8
U1/SN:
105.8±7.1
IMPA:
85.6±5.6
OJ: -5.1±1.9
OB: 0.8±2.1 SNA: 82.4±3.9
SNB: 80.3±3.6
ANB: 2.1±1.9
U1/SN:
107.4±7.4
IMPA:
86.1±6.5
OJ: 2±1.0
OB: 2.8±0.8 SNA: 3±1.28
SNB: -3.6±1.5
ANB: 6.6±1.4
U1/SN:3.1±9
IMPA:2.4±3.3
OJ: 8.2±2.4
OB: 0.9±2.4 N/A SNA: -0.6±1.2
SNB: 1.1±0.6
ANB: -1.7±1.0
U1/SN: 1.4±3.3
IMPA: -1.9±2.9
OJ: -0.4±0.8
OB: 0.3±1.1
Kwon et al [12] , 2000 Lefort 1 and BSSO N/A N/A OJ: 9.1±4.6
OB: 2.5 -±3 N/A OJ: -0.6±1.4
OB: -0.1±2.0
McCance et al [13],
1992 Lefort 1 +BSSO SNA: 78.2±4.3
SNB: 83±4.4
ANB : -4.8±1.9
IMPA: 85±11
OJ: -4.1±3
OB: -6.3±3.8 SNA: 82.3±3.4
SNB: 81.4±2
ANB: 1.3±1.2
IMPA:
83.3±6.3
OJ: -0.9±1.1
OB: 2.4±1.2 SNA: 4.1±1
SNB: -2±2.0
ANB: 5.9±0.0
IMPA: -1±2.0
OJ: 2.4±4
OB: 3.2±3.6 N/A SNA: -0.1±0.0
SNB: 0.4±1
ANB: 0.2±0.4
IMPA: -0.5±0.5
OJ: 0.8±0.0
OB: -0.7±0.5
Data are presented as means ± standard deviations
OB, Over bite; OJ, Over Jet, BSSO, Bilateral sagittal split osteotomy; IVRO Intra -oral vertical ramus osteotomy, SF, Surgery -First Data are presented as means ± standard deviations
OB, Over bite; OJ, Over Jet, BSSO, Bilateral sagittal split osteotomy; IVRO Intra-oral vertical ramus osteotomy, SF, Surgery-First
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Stomatology Edu JournalSTABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Review Articles Figure 8a. Before surgery T1 – After
surgery T2, (T1-T2) L1/MP .
Figure 8b. After surgery T2 – Last
follow-up T3, (T2-T3) L1/MP .
a
b
to allow correct placement of the mandible during
surgery. The etiology of relapse is multifactorial,
including, but not limited to: the proper seating of
the condyles, the extent of mandibular setback and
maxillary advancement, the soft tissue and muscles,
the mandibular plane angle, the remaining growth
and remodeling, the skill of the surgeon, and the
pre-operative age of the patient [8]. Proffit et al [22]
questioned the stability in orthognathic surgery
since the stability of the surgical repositioning of
the jaws varies considerablydepending on the
procedure. In their view, the order of importance
starts with the direction of movement, the type of
fixation used, and in the end, the surgical technique
that has been adopted.
4.2. Limitations
This meta-analysis might be considered a first
step in addressing the stability of skeletal class III
malocclusion after bimaxillary surgery or mandibular
setback. Although this study provided an overview
of the topic, there were several limitations. One main
limitation was the shortage of large and high-quality RCTs. The numbers of relevant research articles and
patients included in the meta-analysis were not
large enough. Furthermore, the sample sizes were
diluted due to too many study variables included (7
cephalometric variables at 3 different time points).
Hence, the quantitative.
analysis cannot accurately reflect real skeletal
and dental changes. Additionally, not every study
included looked at all variables further complicating
the analysis. Eventually, some studies proposed
surgery first which were deleted from the analysis;
however, whether the treatment effects of surgery
first can be stable remains unclear. Attention should
also be paid to the stability of the treatment effects
of surgery first. Therefore, future research in this area
is warranted.
5. Conclusions
On the basis of this review, we concluded the
following:
1. Surgical orthodontic improves sagittal skeletal
and dental relationships but significant relapse
during the follow-up period may happen.
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Review Articles STABILITY OF SKELETAL CLASS III MALOCCLUSION AFTER ORTHOGNATHIC SURGERY AND ORTHODONTIC
TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
2. SNA and overbite increased significantly after a 2
year-follow-up .
3. SNB increased significantly before a 2 year-follow-
up with no significant changes after this follow-up.
4. Overjet diminished significantly after a 2 year-
follow-up
Acknowledgments
The authors report no commercial, proprietary,
or financial interest in the products or companies
described in this article.
The author’s institutional affiliations where the
work was conducted
Department of orthodontics, Faculty of dentistry,
Cranio maxillofacial Research center, Tehran medical
sciences, Islamic Azad University, Tehran, Iran. And
Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Michigan,
USA
Conflict of interest and source of funding
The authors do not have any financial interests, either
directly or indirectly, in the products or information
listed in the paper. This manuscript was partially
supported by the University of Michigan Graduate
Research Fund.
Author Contributions
AJ: conceptualization, study design, study concept,
original writing and corresponding author. LN:
drafting, data interpretation, drawings and editing.
MT and AD: literature review, search design,
data gathering. AF and MA: software programs
and statistical analysis. CWW: drafting, data
interpretation, critical revision and final approval.
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[Full text links] [CrossRef] [PubMed] Google Scholar Scopus
CV
Professor Abdolreza Jamilian is a researcher and specialist in field of Orthodontics. He received his D.D.S (1991), MSc in
Orthodontics (1998), and Fellowship of Orthognathic Surgery & Craniofacial Syndroms (2010) from the Shahid Beheshti
University in Tehran, Iran. He obtained his European Board of Orthodontics in 2013. Now he is a professor at the Islamic Azad
University in Tehran. His practice is limited to orthodontics. He has lectured in several international congresses and has been
a consultant for various journals. He has published over 200 original, peer reviewed research and review articles, 15 book
chapters and more than 300 scientific communications. He holds 3 patents with the United States Patent and Trademark Office.
Research interests: (1) Class 3 malocclusion (2) Cleft lip and palate (3) Orthognathic surgery.
You can reach him through info@jamilian.net View his website at https://jamilian.net/en/Abdolreza JAMILIAN
DDS, PhD, Professor
Department of orthodontics
Faculty of dentistry
Cranio maxillofacial Research center
Tehran medical sciences, Islamic Azad University
Tehran, Iran
Questions
1. Which one is correct regarding stability after surgery.
qa. Single jaw surgery has greater relapse than two jaw surgery;
qb. Two jaw surgery has greater relapse than single jaw surgery;
qc. There is a controversy regarding the stability of single and two jaw surgery;
qd. None of them.
2. What are the causes of late relapse after orthognathic surgery?
qa. Unstable occlusal relationships;
qb. Absence of myofunctional adaptation;
qc. Persistent tongue or orofacial muscle habits;
qd. All of them.
3. How much of the Class III malocclusions have true mandibular prognathism?
qa. 5% to 10%;
qb. 20% to 25%;
qc. 30% to 50%;
qd. 50% to 70%.
4. How much of the of all class III malocclusions have some degree of maxillary retrusion?
qa. 15%;
qb. 25%;
qc. 50%;
qd. 75%.
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