Is there a better interceptive treatment for unerupted palatally displaced canines? A network meta-analysis

ARAUJO, Viviane Zis de; HECKMANN, Sani; ARAUJO, Fernando Borba de; CASAGRANDE, Luciano; ZIEGELMANN, Patricia Klarmann; ARAÚJO, Eustáquio Afonso; MARQUES, Leandro Silva; LENZI, Tathiane Larissa

doi:10.1590/1807-3107bor-2022.vol36.0119

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Meta-analysis, Orthodontics/Pediatric Dentistry • Braz. oral. res. 36 • 2022 • https://doi.org/10.1590/1807-3107bor-2022.vol36.0119 copy

Is there a better interceptive treatment for unerupted palatally displaced canines? A network meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This systematic review aimed to investigate if there is a better interceptive treatment for palatally displaced canines (PDC) in the mixed dentition stage. The PubMed/MEDLINE, CENTRAL, Scopus, and EMBASE databases were searched for randomized clinical trials related to the research topic. The gray literature and reference lists were also assessed. Network meta-analysis was conducted to analyze the effects of different approaches on PDC eruption. The surface under the cumulative ranking area was calculated to rank the treatments. The certainty of the evidence was evaluated using the GRADE approach. Of the 892 eligible studies, 18 were selected for full-text analysis and 9 for meta-analysis, involving 506 participants and 730 PDC, to compare 9 approaches. The proportion of erupted PDC was significantly higher for all interceptive treatments compared with control (no intervention). Furthermore, the proportion of erupted PDC was higher in patients subjected to rapid maxillary expansion (RME) than those who underwent double extraction of primary canine and primary molar (relative risk (RR) = 2.68 ICr95%: 1.12–9.35). A higher proportion of erupted PDC was found for RME (RR = 3.07 ICr95%: 1.31–10.67), RME plus use of transpalatal arch (TA) plus extraction of primary canine(s) (EC) (RR = 1.43 ICr95%: 1.09–1.95), EC plus use of cervical pull headgear (RR = 1.38 ICr95%: 1.11–1.79), and EC plus use of TA (RR = 1.36 ICr95%: 1.00–1.9) than for EC. RME was most likely to be considered as the best interceptive treatment. Overall, the certainty of the evidence was considered low due to imprecision and indirectness. In conclusion, no intervention in the mixed dentition stage is the worst choice for PDC.

Tooth, Impacted; Orthodontics, Interceptive; Network Meta-Analysis

Database	Search strategy
PubMed/MEDLINE	(((((((((((((((Cuspid[MeSH Terms]) OR Cuspid) OR Canine teeth) OR Canine tooth) OR Canine) AND Tooth, Impacted[MeSH Terms]) OR Impacted tooth) OR Impacted teeth) OR Displaced tooth) OR Displaced teeth) OR Unerupted tooth) OR Unerupted teeth) AND Dentition, Mixed[MeSH Terms]) OR Dentition, Mixed) OR Mixed Dentition) OR Transitional Dentition) AND ((((((((((((((((Palatal Expansion Technique[MeSH Terms]) OR Palatal Expansion Technique) OR Expansion Technique, Palatal) OR Technique, Palatal Expansion) OR Palatal Expansion Technic*) OR Maxillary Expansion) OR Tooth Extraction[MeSH Terms]) OR Tooth Extraction) OR cervical pull headgear) OR crossbar) OR nance button) OR transpalatal arch) OR non extraction)) OR Teeth extraction))
EMBASE	(((mixed AND dentition OR (transitional AND dentition)) AND cuspid OR canine) AND displaced AND tooth OR (impacted AND tooth) OR (unerupted AND tooth)) AND interceptive AND orthodontics
Scopus	(TITLE-ABS-KEY ( transitional AND dentition ) OR TITLE-ABS-KEY ( mixed AND dentition ) AND TITLE-ABS-KEY ( cuspid ) OR TITLE-ABS-KEY ( canine ) OR TITLE-ABS-KEY ( impacted AND t??th ) OR TITLE-ABS-KEY ( displaced AND t??th ) OR TITLE-ABS-KEY ( unerupted AND t??th ) AND TITLE-ABS-KEY ( palatal AND expansion AND technique ) OR TITLE-ABS-KEY ( maxillary AND expansion ) OR TITLE-ABS-KEY ( cervical AND pull AND headgear ) OR TITLE-ABS-KEY ( extraction ) OR TITLE-ABS-KEY ( crossbar ) OR TITLE-ABS-KEY ( nance AND button ) OR TITLE-ABS-KEY ( transpalatal AND arch ) OR TITLE-ABS-KEY ( non AND extraction ) )
CENTRAL	mixed dentition in All Text AND canine in All Text AND interceptive treatment in All Text
Clinical Trials	impacted canine AND interceptive treatment
Brazilian Clinical Trials Registry (REBEC)	mixed dentition AND canine AND interceptive treatment

Study	Reason(s) for exclusion
Barros SE, Hoffelder L, Araújo F, Janson G, Chiqueto K, Ferreira E. Short-term impact of rapid maxillary expansion on ectopically and normally erupting canines. Am J Orthod Dentofacial Orthop. 2018 Oct;154(4):524-534.	Non-random allocation of subjects
	Did not consider the eruption of permanent canines without surgery and fixed braces as outcome
Naoumova J, Kiellberg H. The use of panoramic radiographs to decide when interceptive extraction is beneficial in children with palatally displaced canines based on a randomized clinical trial. Eur J Orthod. 2018 Nov 30;40(6):565-574.	Did not consider the eruption of permanent canines without surgery and fixed braces as outcome
	Overlapping data
Naoumova J, Kürol J, Kiellberg H. Extraction of the deciduous canine as an interceptive treatment in children with palatally displaced canines - part II: possible predictors of success and cut-off points for a spontaneous eruption. J Orthod. 2015 Apr;37(2):219-29.	Did not consider the eruption of permanent canines without surgery and fixed braces as outcome
	Overlapping data
Naoumova J. Interceptive treatment of palatally displaced canines. Swed Dent J Suppl. 2014;(234):7-118.	Overlapping data
Sigler LM, Baccetti T, McNamara Jr JA. Effect of rapid maxillary expansion and transpalatal arch treatment associated with deciduous canine extraction on the eruption of palatally displaced canines: A 2-center prospective study. Am J Orthod Dentofacial Orthop. 2011 Mar;139(3):e235-44.	Non-random allocation of subjects
Silvola A, Arvonen P, Julku J, Lähdesmäki, R, Kantomaa T, Pirttiniemi P. Early headgear effects on the eruption pattern of the maxillary canines. Angle Orthod. 2009 May;79(3):540-5.	Did not consider the eruption of permanent canines without surgery and fixed braces as outcome
Bonetti GA, Parenti SI, Zanarini M, Marini I. Double vs single primary teeth extraction approach as prevention of permanent maxillary canines ectopic eruption. Pediatr Dent. Sep-Oct 2010;32(5):407-12.	Overlapping data
Power SM, Short MB. An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to favourable eruption. Br J Orthod. 1993 Aug;20(3):215-23.	Non-random allocation of subjects
Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod. 1988. Nov;10(4):283-95.	Non-random allocation of subjects or less than 2 arms

Publication details	Diagnostic method of displaced canine	Treatments	Sample	Follow-up (months)	Dropout (%)	Number of erupted permanent canines/total of canines per group	Funding sources
Leonardi et al. (2004),⁸ Italy		Extraction of primary canine(s)
		Extraction of primary canine(s) plus cervical pull headgear	50 subjects with either unilateral or bilateral impacted canines			Extraction of primary canine(s): 7/14
	Panoramic and periapical radiographs	No intervention	8-13 years	48	8	Extraction of primary canine(s) plus cervical pull headgear: 26/32
						No intervention: 8/16	Not reported
Baccetti et al. (2008),²² Italy		Extraction of primary canine(s)
	Panoramic radiographs and lateral cephalograms	Extraction of primary canine(s) plus cervical pull headgear	75 subjects and 92 maxillary canines			Extraction of primary canine(s): 16/25
		No intervention	8-13 years	18	6.7	Extraction of primary canine(s) plus cervical pull headgear: 31/35	Not reported
						No intervention: 9/26
Bacetti et al. (2009),²³ Italy
	Posteroanterior cephalograms and panoramic radiographs	Rapid maxillary expansion	60 subjects with either unilateral or bilateral impacted canines	52	10	Rapid maxillary expansion: 27/42
		No intervention				No intervention: 4/31	Not reported
			7.6-9.6 years
Baccetti et al. (2011),²⁴ Italy		Rapid maxillary expansion plus transpalatal arch plus extraction of primary canine(s)
		Transpalatal arch plus extraction of primary canine(s)				Rapid maxillary expansion plus transpalatal arch plus extraction of primary canine(s): 53/66
		Extraction of primary canine(s)				Transpalatal arch plus extraction of primary canine(s): 26/36
	Panoramic radiographs and lateral cephalograms	No intervention	120 subjects with either unilateral or bilateral impacted canines	36-52	2.5	Extraction of primary canine(s): 21/34
			9.5-13 years			No intervention: 11/42	Not reported
Armi et al. (2011),²⁵ Italy
	Panoramic and periapical radiographs	Cervical pull headgear	64 subjects and 81 maxillary canines			Cervical pull headgear: 20/25
		Rapid maxillary expansion plus cervical pull headgear	8-13 years	18	6.2	Rapid maxillary expansion plus cervical pull headgear: 26/30	Not reported
		No intervention				No intervention: 9/26
Bonetti et al. (2011),⁹ Italy		Extraction of primary canine(s)					Not reported
		Extraction of primary canine plus first molar (Double extraction)				Extraction of primary canine: 22/28
	Panoramic radiographs		71 subjects and 123 maxillary canines	18	4.3	Extraction of primary canine plus first molar (Double extraction): 36/37
			8-13 years
		Extraction of primary canine	24 subjects and 48 maxillary canines			Extraction of primary canine: 16/24
Bazargani et al. (2014),⁶ Sweden	Panoramic and intraoral occlusal radiographs	No intervention	10-14 years	18	0	No intervention: 10/24	Supported by the Uppsala-örebro Regional Research Council; however, the authors’ work was independent of the funders

	Cone beam computed tomography	Extraction of primary canine(s)	Sixty-seven subjects with either unilateral or bilateral impacted canines	24	0	Extraction of primary canine(s): 31/45	The Local Research and Development Board for Gothenburg and Södra Bohuslän and from the Health & Medical Care Committee of the Regional Executive Board, Västra Götaland Region
Naoumova et al. (2015)²⁶ Sweden		No intervention	10-13 years			No intervention: 17/44	The Local Research and Development Board for Gothenburg and Södra Bohuslän and from the Health & Medical Care Committee of the Regional Executive Board, Västra Götaland Region
		Extraction of primary canine(s)	Thirty-two subjects and 48 maxillary canines			Extraction of primary canine(s): 18/23
	Periapical radiographs	Extraction of primary canine plus first molar (Double extraction)	9.5-13.5 years	24	0	Extraction of primary canine plus first molar (Double extraction): 16/25
							No funding

Study	Randomization process	Deviations from intended interventions	Missing outcome data	Measurement of the outcome	Selection of the reported results	Overall
Leonardi et al. (2004)⁸	-	+	?	?	?	-
Baccetti et al. (2008)²²	-	+	?	?	?	-
Bacetti et al. (2009)²³	-	+	?	?	?	-
Baccetti et al. (2011)²⁴	-	+	+	?	?	-
Armi et al. (2011)²⁵	-	+	?	?	?	-
Bonetti et al. (2011)⁹	+	+	?	?	?	?
Bazargani et al. (2014)⁶	?	+	+	?	?	?
Naoumova et al. (2015)²⁶	+	+	+	?	+	?
Hadler-Olsen et al., (2020)²⁷	?	+	+	?	?	?

RME								4.98 (1.94, 12.78)
2.15 (0.87, 7.37)	RME_TPA			1.03 (0.84, 1.28)			1.30 (0.97, 1.74)	3.07 (1.82, 5.17)
2.08 (0.72, 7.49)	0.97 (0.47, 1.77)	CPH_RME			1.08 (0.85, 1.38)			2.50 (1.45, 4.32)
2.22 (0.93, 7.69)	1.03 (0.72, 1.49)	1.07 (0.59, 2.16)	EC_CPH				1.44 (1.09,1.90)	1.62 (0.97, 2.73)
2.27 (0.91, 7.91)	1.04 (0.86, 1.33)	1.09 (0.58, 2.29)	1.01 (0.69, 1.5)	EC_TPA			1.26 (0.92, 1.73)	2.97 (1.74, 5.08)
2.27 (0.78, 8.48)	1.06 (0.51, 2.00)	1.09 (0.86, 1.46)	1.02 (0.5, 1.89)	1.01 (0.48, 1.93)	CPH			2.31 (1.32, 4.06)
2.68 (1.12, 9.35)	1.25 (0.9, 1.76)	1.30 (0.72, 2.63)	1.21 (0.91, 1.63)	1.19 (0.83, 1.73)	1.18 (0.64, 2.41)	DE	1.04 (0.69, 1.55)
3.07 (1.31, 10.67)	1.43 (1.09, 1.95)	1.49 (0.84, 2.97)	1.38 (1.11, 1.79)	1.36 (1.00, 1.90)	1.35 (0.75, 2.7)	1.14 (0.98, 1.37)	EC	1.73 (1.35, 2.21)
5.36 (2.37, 18.12)	2.51 (1.85, 3.55)	2.58 (1.59, 4.98)	2.42 (1.82, 3.3)	2.39 (1.7, 3.44)	2.35 (1.41, 4.6)	2 (1.50, 2.71)	1.75 (1.38, 2.24)	NO

Comparison	Inform	Direct evidence		Indirect evidence		Network meta-analysis
Comparison	Inform	RR (95%CI)	Certainty of evidence	RR (95%CI)	Certainty of evidence	RR (95%CI)	Certainty of evidence
RME	NO	4.98 (1.94–12.78)	Very low^1,3	-	-	5.36 (2.37–18.12)	Very low
RME+TPA	NO	3.07 (1.82–5.17)	Low^1,2	-	-	2.51 (1.85–3.55)	Low
CPH+RME	NO	2.50 (1.45–4.32)	Low^1,2	-	-	2.58 (1.59–4.98)	Low
EC+CPH	NO	1.62(0.97–2.73)	Moderate¹	-	-	2.42 (1.82–3.3)	Moderate
EC+TPA	NO	2.97 (1.74–5.08)	Low^1,2	-	-	2.39 (1.70–3.44)	Low
CPH	NO	2.31(1.32–4.06)	Low^1,2	-	-	2.35 (1.41–4.60)	Low
DE	NO	-	-	2.00 (1.5–2.71)	Low^2,4	2.00 (1.5–2.71)	Low
EC	NO	1.73 (1.35–2.21)	Moderate¹	-	-	1.75 (1.38–2.24)	Moderate
RME	EC	-	-	3.07 (1.31–10.67)	Very low^3,4	3.07 (1.31–10.67)	Very low
RME+TPA	EC	1.30 (0.97–1.74)	Moderate¹	-	-	1.43 (1.09–1.95)	Moderate
CPH+RME	EC	-	-	1.49 (0.84–2.97)	Low^2,4	1.49 (0.84–2.97)	Low
EC+CPH	EC	1.44 (1.09–1.90)	Moderate¹	-	-	1.38 (1.11–1.79)	Moderate
EC+TPA	EC	1.26 (0.92–1.73)	Moderate¹	-	-	1.36 (1.00–1.9)	Moderate
CPH	EC	-	-	1.35 (0.75–2.70)	Low^2,4	1.35 (0.75–2.70)	Low
DE	EC	1.04 (0.69–1.55)	Moderate¹	-	-	1.14 (0.98–1–37)	Moderate
RME	DE	-	-	2.68 (1.12–9.35)	Very low^3,4	2.68 (1.12–9.35)	Very low
RME+TPA	DE	-	-	1.25 (0.90–1.76)	Low^2,4	1.25 (0.90–1.76)	Low
CPH+RME	DE	-	-	1.30 (0.72–2.65)	Low^2,4	1.30 (0.72–2.65)	Low
EC+CPH	DE	-	-	1.21 (0.91–1.63)	Low^2,4	1.21 (0.91–1.63)	Low
EC+TPA	DE	-	-	1.19 (0.83–1.73)	Low^2,4	1.19 (0.83–1.73)	Low
CPH	DE	-	-	1.18 (0.64–2.41)	Low^2,4	1.18 (0.64–2.41)	Low
RME	CPH	-	-	2.27 (0.78–8.48)	Very low^3,4	2.27 (0.78–8.48)	Very low
RME+TPA	CPH	-	-	1.06 (0.51–2.00)	Low^2,4	1.06 (0.51–2.00)	Low
CPH+RME	CPH	1.08 (0.85–1.38)	Moderate¹	-	-	1.09 (0.86, 1.46)	Moderate
EC+CPH	CPH	-	-	1.02 (0.5–1.89)	Low^2,4	1.02 (0.5–1.89)	Low
EC+TPA	CPH	-	-	1.01 (0.48–1.93)	Low^2,4	1.01 (0.48–1.93)	Low
RME	EC+TPA	-	-	2.27 (0.91–7.91)	Very low^3,4	2.27 (0.91–7.91)	Very low
RME+TPA	EC+TPA	1.03 (0.84–1.28)	Moderate¹	-	-	1.04 (0.86–1,33)	Moderate
CPH+RME	EC+TPA	-	-	1.09 (0.58–2.29)	Low^2,4	1.09 (0.58–2.29)	Low
EC+CPH	EC+TPA	-	-	1.01 (0.69–1.5)	Low^2,4	1.01 (0.69–1.5)	Low
RME	EC+CPH	-	-	2.22 (0.93–7.69)	Very low^3,4	2.22 (0.93–7.69)	Very low
RME+TPA	EC+CPH	-	-	1.03 (0.72–1.49)	Low^2,4	1.03 (0.72–1.49)	Low
CPH+RME	EC+CPH	-	-	1.07 (0.59–2.16)	Low^2,4	1.07 (0.59–2.16)	Low
RME	CPH+RME	-	-	2.08 (0.72–7.49)	Very low^3,4	2.08 (0.72–7.49)	Very low
RME+TPA	CPH+RME	-	-	0.97 (0.47–1.77)	Low^2,4	0.97 (0.47–1.77)	Low
RME	RME+TPA	-	-	2.15 (0.87–7.37)	Very low^3,4	2.15 (0.87–7.37)	Very low

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[1] Corresponding Author: Tathiane Larissa Lenzi E-mail: tathilenzi@hotmail.com