Background: There are various treatment modalities in correcting the developing class III, of which the efficacy of removable mandibular retractor (RMR) in class III correction has not been discussed much in the literature. Available literature has compared various fixed and removable appliances for class III correction, which did not take RMR into inclusion. Hence, this systematic review focuses on the efficacy of the RMR appliance in bringing about favorable skeletal, dentoalveolar, and soft tissue changes in growing skeletal class III patients and patient acceptance of the appliance.
Objective: To assess the skeletal, dentoalveolar, and soft tissue effects of RMR appliance and acceptability of the appliance in growing skeletal class III patients.
Search methods: A systematic review of articles was performed using different electronic databases (PubMed, Cochrane Library, MEDLINE, Embase, Google Scholar, LILACS, and Web of Science) along with a manual search of orthodontic journals from 2011 to the year 2021.
Selection criteria: Search items consisted of “removable appliances” and “skeletal class III.” The selection criteria were set to include only randomized controlled trials (RCTs). Four RCTs were included in the systematic review that evaluated dental, skeletal, and soft tissue effects and patient acceptance of RMR appliances.
Data collection and analysis: Data regarding patient acceptance, skeletal, dentoalveolar, and soft tissue outcomes were extracted to collect study characteristics. Two separate authors independently extracted the data. Review manager (RevMan) version 5.1, Denmark, was the software used to analyze the data. After evaluating the risk of bias, standardized mean differences and 95% confidence intervals were calculated.
Results: Of the four RCTs included, two RCTs evaluated the dentoalveolar, skeletal, and soft tissue changes with bone-anchored mandibular protraction (BAMP) and RMR appliance, and two RCTs evaluated the patient compliance and acceptability of the appliance. The results of the study by Majanni and Hajeer in 2016 revealed that skeletal and soft tissue changes were more pronounced with BAMP and dental changes were more pronounced with RMR appliance. However, a study by Saleh et al. concluded that hard and soft tissue changes were pronounced with RMR appliances when compared with no treatment controls. Two RCTs that evaluated patient compliance revealed that compared to RMR, bone-anchored intermaxillary traction (BAIMT) produced more pain, pressure, and tension of soft tissues that gradually reduced over time, and speech difficulty and social avoidance were noted in patients wearing RMR, which decreased gradually in time.
Conclusion: Studies reviewed provide insufficient evidence to form a conclusion regarding the effects of the use of MR appliances. The available evidence suggests that the use of MR produces predominant dental changes and causes speech difficulty and social avoidance for the patients. More trials are needed to produce stable results on the use of RMR appliances.
Ngan P. Early timely treatment of class III malocclusion. Semin Orthod 2005;11(3):140–145. DOI: 10.1053/j.sodo.2005.04.007
Ngan P. Early treatment of class III malocclusion: is it worth the burden? Am J Orthod Dentofacial Orthop 2006;129(4):S82–S85. DOI: 10.1016/j.ajodo.2005.09.017
Campbell PM. The dilemma of class III treatment. Early or late? Angle Orthod 1983;53(3):175–191. DOI: 10.1043/0003-3219(1983)053<0175:TDOCIT>2.0.CO;2
Yepes E, Quintero P, Rueda ZV, et al. Optimal force for maxillary protraction facemask therapy in the early treatment of class III malocclusion. Eur J Orthod 2014;36(5):586–594. DOI: 10.1093/ejo/cjt091
Smyth RSD, Ryan FS. Early treatment of class III malocclusion with facemask. Evid Based Dent 2017;18(4):107–108. DOI: 10.1038/sj.ebd.6401269
Menéndez-Díaz I, Muriel J, Cobo JL, et al. Early treatment of class III malocclusion with facemask therapy. Clin Exp Dent Res 2018;4(6):279–283. DOI: 10.1002/cre2.144
Alarcón JA, Bastir M, Rosas A, et al. Chincup treatment modifies the mandibular shape in children with prognathism. Am J Orthod Dentofacial Orthop 2011;140(1):38–43. DOI: 10.1016/j.ajodo.2009.10.046
Singh V, Kumar N, Gauba K. Removable mandibular retractor- an effective treatment for early class III malocclusion: a case report and review. J Sci Dent 2018;8(2):8–12. DOI: 10.5005/jsd-8-2-8
Du Y, Huang S, Rao N, et al. Skeletal class III patients treated with Fränkel function regulator type III in the early and late mixed dentition. Zhonghua Kou Qiang Yi Xue Za Zhi 2016;51(5):257–262. DOI: 10.3760/cma.j.issn.1002-0098.2016.05.001
Sargod SS, Shetty N, Shabbir A. Early class III management in deciduous dentition using reverse twin block. J Indian Soc Pedod Prev Dent 2013;31(1):56. DOI: 10.4103/0970-4388.112418
Nguyen T. Dentofacial orthopedics for class III corrections with bone-anchored maxillary protraction. Temporary Anchorage Devices in Clinical Orthodontics; 2020. pp. 185–190. DOI: 10.1002/9781119513636.ch20
Cordasco G, Matarese G, Rustico L, et al. S16: efficacy of orthopedic treatment with protraction facemask on skeletal class III malocclusion: a systematic review and meta-analysis. Evid Based Orthod 2018;17:133–143. DOI: 10.1002/9781119289999.oth16
Chatzoudi MI, Ioannidou-Marathiotou I, Papadopoulos MA. Clinical effectiveness of chin cup treatment for the management of class III malocclusion in pre-pubertal patients: a systematic review and meta-analysis. Prog Orthod 2014;15(1):62. DOI: 10.1186/s40510-014-0062-9
Woon SC, Thiruvenkatachari B. Early orthodontic treatment for class III malocclusion: a systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2017;151(1):28–52. DOI: 10.1016/j.ajodo.2016.07.017
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159–174. DOI: 10.2307/2529310
Tollaro I, Baccetti T, Franchi L. Mandibular skeletal changes induced by early functional treatment of class III malocclusion: a superimposition study. Am J Orthod Dentofacial Orthop 1995;108(5):525–532. DOI: 10.1016/s0889-5406(95)70053-6
Almeida MR, Almeida RR, Oltramari-Navarro PVP, et al. Early treatment of class III malocclusion: 10-year clinical follow-up. J Appl Oral Sci 2011;19(4):431–439. DOI: 10.1590/s1678-77572011000400022
Baccetti T, Tollaro I. A retrospective comparison of functional appliance treatment of class III malocclusions in the deciduous and mixed dentitions. Eur J Orthod 1998;20(3):309–317. DOI: 10.1093/ejo/20.3.309
Majanni AM, Hajeer MY. The removable mandibular retractor vs the bone-anchored intermaxillary traction in the correction of skeletal class III malocclusion in children: a randomized controlled trial. J Contemp Dent Pract 2016;17(5):361–371. DOI: 10.5005/jp-journals-10024-1856
Saleh M, Hajeer MY, Al-Jundi A. Short-term soft- and hard-tissue changes following class III treatment using a removable mandibular retractor: a randomized controlled trial. Orthod Craniofac Res 2013;16(2):75–86. DOI: 10.1111/ocr.12007
Majanni AMR, Hajeer MY, Khattab TZ, et al. Evaluation of pain, discomfort, and acceptance during the orthodontic treatment of class III malocclusion using bone-anchored intermaxillary traction versus the removable mandibular retractor: a randomised controlled trial. J Clin Diag Res 2020;14(3):ZC18–ZC23. DOI: 10.7860/jcdr/2020/43577.13580
Saleh M, Hajeer MY, Al-Jundi A. Assessment of pain and discomfort during early orthodontic treatment of skeletal class III malocclusion using the removable mandibular retractor appliance. Eur J Paediatr Dent 2013;14(2):119–124. https://pubmed.ncbi.nlm.nih.gov/23758461