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

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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

    • Evidence Based OrthodonticsEvidence Based Orthodontics www.indiandentalacademy.comwww.indiandentalacademy.com INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • • Advantages and disadvantagesAdvantages and disadvantages • LimitationsLimitations • Clinical implicationsClinical implications • ConclusionConclusion • ReferencesReferences www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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” www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • `` 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: www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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? www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • Step 5Step 5 • Assessing the outcome of applyingAssessing the outcome of applying the evidence in your patients.the evidence in your patients. www.indiandentalacademy.comwww.indiandentalacademy.com
    • Step 6Step 6 • Summarizing and storing recordsSummarizing and storing records for future reference.for future reference. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 www.indiandentalacademy.comwww.indiandentalacademy.com
    • Clinical ImplicationsClinical Implications www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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.. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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 Dentofacial Orthop 1996;109:163-72.Dentofacial Orthop 1996;109:163-72. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • • 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. www.indiandentalacademy.comwww.indiandentalacademy.com
    • REFERENCESREFERENCES • Harrison JE. Clinical trials in orthodontics II: assessmentHarrison JE. Clinical trials in orthodontics II: assessment of the quality of reporting of clinical trials published inof the quality of reporting of clinical trials published in three orthodontic journals between 1989 and 1998. Jthree orthodontic journals between 1989 and 1998. J Orthod 2003;30:309-15.Orthod 2003;30:309-15. • Proffit WR, Fields HW Jr. Contemporary orthodontics.Proffit WR, Fields HW Jr. Contemporary orthodontics. 3rd ed. St Louis: Mosby; 2000.3rd ed. St Louis: Mosby; 2000. • Harrison JE. Evidence-based orthodontics—how do IHarrison JE. Evidence-based orthodontics—how do I assess the evidence? J Orthod 2000;27:189-97.assess the evidence? J Orthod 2000;27:189-97. • Ackerman M. Evidence-based orthodontics for the 21stAckerman M. Evidence-based orthodontics for the 21st century. J Am Dent Assoc 2004;135:162-7.century. J Am Dent Assoc 2004;135:162-7. • Kalha AS. Is anchorage reinforcements with implantsKalha AS. Is anchorage reinforcements with implants effective in orthodontics?effective in orthodontics? Evid Based Dent.Evid Based Dent. 2008;9(1):13-42008;9(1):13-4 www.indiandentalacademy.comwww.indiandentalacademy.com
    • • A critical evaluation of meta-analyses in orthodontics (Am J Orthod Dentofacial Orthop 2007;131:589-99) • Tulloch JFC, Antzack AA, Tuncay OC. Review ofTulloch JFC, Antzack AA, Tuncay OC. Review of clinical research in orthodontics. Am J Orthodclinical research in orthodontics. Am J Orthod Dentofacial Orthop 1989;95:499-504.Dentofacial Orthop 1989;95:499-504. • Kim MR, Graber TM, Viana MA. OrthodonticsKim MR, Graber TM, Viana MA. Orthodontics and temporomandibular disorder: a meta-and temporomandibular disorder: a meta- analysis. Am J Orthod Dentofacial Orthopanalysis. Am J Orthod Dentofacial Orthop 2002;121:438-46.2002;121:438-46. • Kim JH, Viana MA, Graber TM, Omerza FF,Kim JH, Viana MA, Graber TM, Omerza FF, BeGole EA. The effectiveness of protraction faceBeGole EA. The effectiveness of protraction face mask therapy: a meta-analysis.Am J Orthodmask therapy: a meta-analysis.Am J Orthodwww.indiandentalacademy.comwww.indiandentalacademy.com
    • • Jager A, Braumann B, Kim C, Wahner S. Skeletal and dental effectsJager A, Braumann B, Kim C, Wahner S. Skeletal and dental effects of maxillary protraction in patients with Angle Class III malocclusion.of maxillary protraction in patients with Angle Class III malocclusion. A meta-analysis. J Orofac Orthop 2001;62: 275-84.A meta-analysis. J Orofac Orthop 2001;62: 275-84. • 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. • Schiffman PH, Tuncay OC. Maxillary expansion: a meta-analysis.Schiffman PH, Tuncay OC. Maxillary expansion: a meta-analysis. Clin Orthod Res 2001;4:86-96.Clin Orthod Res 2001;4:86-96. • 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. • Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. ANguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of the relationship between overjet size andsystematic review of the relationship between overjet size and traumatic dental injuries. Eur J Orthod 1999;21:503-15.traumatic dental injuries. Eur J Orthod 1999;21:503-15. • Miles PG, Vig PS, Weyant RJ, Forrest TD, Rockette HE Jr.Miles PG, Vig PS, Weyant RJ, Forrest TD, Rockette HE Jr. www.indiandentalacademy.comwww.indiandentalacademy.com
    • • Segal GR, Schiffman PH, Tuncay OC. Meta-analysis of theSegal GR, Schiffman PH, Tuncay OC. Meta-analysis of the treatment-related factors of external apical root resorption. Orthodtreatment-related factors of external apical root resorption. Orthod Craniofac Res 2004;7:71-8.Craniofac Res 2004;7:71-8. • Buwembo W, Luboga S. Moyer’s method of mixed dentitionBuwembo W, Luboga S. Moyer’s method of mixed dentition analysis: a meta-analysis. Afr Health Sci 2004;4:63-6.analysis: a meta-analysis. Afr Health Sci 2004;4:63-6. • 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. • Polder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers-Jagtman AM.Polder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers-Jagtman AM. A meta-analysis of the prevalence of dental agenesis of permanentA meta-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. AmericanAmerican Journal of Orthodontics and Dentofacial Orthopedics VolumeJournal of Orthodontics and Dentofacial Orthopedics Volume 131,131, NumberNumber 55 Papadopoulos and GkiaourisPapadopoulos and Gkiaouris 599599 www.indiandentalacademy.comwww.indiandentalacademy.com
    • Thank youThank you For more details please visitFor more details please visit www.indiandentalacademy.comwww.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com