Skeletally anchored forsus fatigue resistant device for correction of Class II malocclusions-A systematic review and meta-analysis

The use of skeletal anchorage with fixed functional appliances (FFA) has been proposed by various authors to produce skeletal changes and reduce lower incisor proclination. To compare the skeletal and dentoalveolar effects of Forsus Fatigue Resistant Device (FFRD) with or without skeletal anchorage (miniplates and mini-implants). The electronic database PubMed, Cochrane Library, Medline, Embase and Google Scholar along with a manual search of orthodontic journals till the year 2019. Only randomized control trials (RCTs) were included in the systematic review. One controlled clinical trial (CCT) which involved FFRD was included in the review since it was a continuation of an RCT which was expanded to a CCT. Skeletal and dentoalveolar outcome data were extracted to collect study characteristics. After evaluating risk of bias, the standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated. Three RCTs and one prospective CCT were evaluated. The analysis included data from 116 Class II subjects [(58) treated with FFA along with skeletal anchorage and (58) treated with FFA]. There were no significant difference between the two groups with respect to mandibular length changes (P value = .10) and SNB angle changes (P value = .22). With respect to lower incisor inclination however, there was a significant difference between the two groups (P value = .005) signifying better results with respect to skeletal anchorage. The studies reviewed provide insufficient evidence to form a conclusion regarding the effects of the use of skeletal anchorage with FFRD. The available weak evidence suggests that the use of skeletal anchorage with FFRD has no superior skeletal effects but is able to reduce proclination of the lower incisors. Control of lower incisor proclination remains the most significant advantage of skeletal reinforcement, and miniplate-anchored FFRD showed more promising results in preventing lower incisor proclination than miniscrew-anchored FFRD.