Lettre à l’éditeur de Oral Surgery Oral Medecine Oral Pathology Oral Radiology

Une méta-analyse au sujet de L’EPRAC a été récemment publiée dans le journal OOOO (suivre ce lien).(Long-term dental and skeletal changes in patients submitted to surgically assisted rapid maxillary expansion- A meta-analysis).

Connaissant plutôt bien le sujet de l’EPRAC et les articles répertoriés dans l’article de Vilani et al, je trouvais que la méta-analyse avait d’importante faiblesse.

Fort de mon expérience de réviseur pour l’AJODO, je me suis donc permis d’écrire à l’éditeur pour faire part de mes observations. J’avais au préalable discuté avec Dr Proffit, le co-auteur de mes 2 articles sur l’EPRAC et il avait approuvé le contenu de ma lettre.

Les auteurs ont donc répondu et j’avoue que leur réponse ne m’a guère satisfait. Ils ne m’ont pas convaincu qu’il est normal d’inclure des résultats de stabilité avec des mesures prises lorsque les patients sont encore en traitement orthodontique et d’autres dont les mesures sont prises après la dépose des appareils fixes du traitement orthodontique. Il est intéressant de constater qu’un de leurs arguments utilisés était le critère d’inclusion — no history of another craniofacial surgery— ne signifie pas que, dans les études retenues dont la période d’observation est de 12 mois suivants l’EPRAC, il n’y a pas de patient qui ont ou auront une seconde procédure chirurgicale. En effet, Byloff & Mossaz et Antilla et al précisent, chacun dans leur article que 2 patients ont subi une seconde procédure chirurgicale.

Dr Proffit partage mon opinion et en ajoute.

Je cite:

They essentially admit that their inclusion criteria led them to accept papers with small samples, poor monitoring of the stages of treatment and exaggerated conclusions, while excluding papers with better data because of their imperfect search criteria.
There are so many « systematic reviews » now that are worthless to clinicians, and the one you criticized is a nice example. I have helped AJODO reject several by now because they totally missed their presumed target and didn’t know enough clinically to understand.

Prenez connaissance desdits articles.

Long-term dental and skeletal changes following surgically assisted rapid palatal expansion. (Long-term dental and skeletal changes following surgically assisted rapid palatal expansion-letter to editor)

To the Editor:

I think article by Vilani et al¹ in the December issue of your journal does not meet the level of research quality or methodological soundness that a meta-analysis should have. There are several significant problems:

1) The inclusion criterion of follow-up of at least 1 year after expansion should be interpreted with caution because it does not differentiate studies with patients who are still in orthodontic treatment from studies with patients whose orthodontic treatment is completed. So final dental changes (expansion and relapse) cannot be estimated with precision. Specifically, the studies of Koudstaal et al.², Byloff and Mossaz³, and Berger et al.⁴ are 12-month studies, while the other studies have follow-up after the end of ortho treatment.^5-8
2) The short-term data were pooled with longer-term data that ranged from 2 to 6 years at follow-up. Moreover, the observation time points differ among the studies.
Three studies report the maximum expansion point at the end of the distraction period being their T2^2-4 while other studies report an expansion point taken
at the end of ortho treatment.^5-7 The study of Kurt et al.⁵ recruited in the Surgically Assisted Rapid Palatal Expansion (SARPE) group 4 patients who underwent orthopedic expansion that had failed.

The meta-analysis would have benefited from an objective of differentiating short-term and long-term dental and skeletal changes. Our prospective study9 who include 38 consecutively treated patients with SARPE was an attempt to clarify these points.

Best regards,

Sylvain Chamberland, DMD, MSc
Université Laval, Quebec, Canada

REFERENCES

1. Vilani GN, Mattos CT, de Oliveira Ruellas AC, Maia LC. Longterm dental and skeletal changes in patients submitted to surgically assisted rapid maxillary expansion: A meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114:689-697.
2. Koudstaal MJ, Smeets JB, Kleinrensink GJ, Schulten AJ, van der Wal KG. Relapse and stability of surgically assisted rapid maxillary expansion: an anatomic biomechanical study. J Oral Maxillofac Surg. 2009;67:10-14.
3. Byloff FK, Mossaz CF. Skeletal and dental changes following surgically assisted rapid palatal expansion. Eur J Orthod. 2004;26:403-409.
4. Berger JL, Pangrazio-Kulbersh V, Borgula T, Kaczynski R. Stability of orthopedic and surgically assisted rapid palatal expansion over time. Am J Orthod Dentofacial Orthop. 1998;114:638-645.
5. Kurt G, Altug-Ataç AT, Ataç MS, Karasu HA. Stability of surgically assisted rapid maxillary expansion and orthopedic maxillary expansion after 3 years’ follow-up. Angle Orthod. 2010;80:425-431.
6. Magnusson A, Bjerklin K, Nilsson P, Marcusson A. Surgically assisted rapid maxillary expansion: long-term stability. Eur J Orthod. 2009;31:142-149.
7. Sokucu O, Kosger HH, Bicakci AA, Babacan H. Stability in dental changes in RME and SARME: a 2-year follow-up. Angle Orthod. 2009;79:207-213.
8. Anttila A, Finne K, Keski-Nisula K, Somppi M, Panula K, Peltomaki T. Feasibility and long-term stability of surgically assisted rapid maxillary expansion with lateral osteotomy. Eur J Orthod. 2004;26:391-395.
9. Chamberland S, Proffit WR. Short-term and long-term stability of surgically assisted rapid palatal expansion revisited. Am J Orthod Dentofacial Orthop. 2011;139:815-822.e1.

http://dx.doi.org/10.1016/j.oooo.2013.01.054

In Reply:

Long-term dental and skeletal changes following SARPE.(Long-term dental and skeletal changes following SARPE-In reply)

We are grateful for the opportunity to start a debate on our systematic review and meta-analysis.¹ We appreciate the interest of Dr. Chamberland in our article¹ published in the December issue of this journal and we wish to discuss some aspects raised in his evaluation. His letter raised some interesting points worthy to be discussed by the scientific community.

As to the point raised that the follow-up of at least 1 year after expansion does not differentiate studies where orthodontic treatment was completed from those where it was not, leading to final dental changes imprecisely estimated, we believe that this inclusion criteria did not impair our results. Specifically, the study of Byloff and Mossaz² described a follow-up of at least 12 month post-surgery (after fixed appliance therapy) and Berger et al.³ described a follow-up of 1 year after removal of the retention appliance before any additional orthodontic treatment. Only Koudstaal et al.⁴ reported a follow-up of 1 year after treatment and did not specify if it was 1 year after expansion or 1 year after orthodontic treatment. The other studies^5-7 presented a follow-up after the end of orthodontic treatment. Most importantly, from all comparisons performed in the meta-analysis, only one presented any level of heterogeneity (I² > 0%) among the studies, which means that this variable, which could be a confounder, in fact was statistically proved as not having influenced the results among the included studies.
As to observation time points differing among the studies, this variable was not considered a problem either as the heterogeneity among studies was very low, as mentioned before. And the heterogeneity measurement shows to what extent the results of studies are consistent.⁸ The lower the heterogeneity, the more
consistent the results are.

Our inclusion criteria also prevented us from including the interesting and contributive study from Dr. Chamberland9 in our systematic review and metaanalysis, as we did not include studies where patients presented any history of another craniofacial surgery. In the referenced article, 28 patients were submitted to a second surgical phase. Additionally, the results from this study are very similar to the results from our metaanalysis, which further validate our data.

We would like to thank Dr. Chamberland for the opportunity of this discussion, but we cannot agree with him that our published article does not meet the level of research quality or methodological soundness that a meta-analysis should have. According to the Cochrane Handbook,⁸ the process of undertaking a systematic review involves a sequence of decisions and while many of these decisions are clearly objective and non-contentious, some will be somewhat arbitrary or unclear because there is no consensus about them on the literature. In a systematic review or meta-analysis, the inclusion criteria for selection of studies are a prerogative of the authors and abiding by them in a transparent way is a sign of methodological soundness.

Giselle Naback Lemes Vilani, MD
Claudia Trindade Mattos, DDS, MSc, PhD
Antônio Carlos de Oliveira Ruellas, DDS, MSc, PhD
Lucianne Cople Maia, DDS, MSc, PhD
Departments of Pediatric Dentistry and Orthodontics
Universidade Federal do Rio de Janeiro
Rio de Janeiro, Brazil

REFERENCES

1. Vilani GNL, Mattos CT, Ruellas ACO, Maia LC. Long-term dental and skeletal changes in patients submitted to surgically assisted rapid maxillary expansion: a meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114:689-697.
2. Byloff FK, Mossaz CF. Skeletal and dental changes following surgically assisted rapid palatal expansion. Eur J Orthod. 2004;26: 403-409.
3. Berger JL, Pangrazio-Kulbersh V, Borgula T, Kaczynski R. Stability of orthopedic and surgically assisted rapid palatal expansion over time. Am J Orthod Dentofacial Orthop. 1998;114: 638-645.
4. Koudstaal MJ, Wolvius EB, Schulten AJ, Hop WC, van der Wal KG. Stability, tipping and relapse of bone-borne versus toothborne surgically assisted rapid maxillary expansion: a prospective randomized patient trial. Int J Oral Maxillofac Surg. 2009;37: 74-78.
5. Kurt G, Altug-Ataç AT, Ataç MS, Karasu HA. Stability of surgically assisted rapid maxillary expansion and orthopedic maxillary expansion after 3 years’ follow-up. Angle Orthod. 2010;80: 425-431.
6. Magnusson A, Bjerklin K, Nilsson P, Marcusson A. Surgically assisted rapid maxillary expansion: long-term stability. Eur J Orthod. 2009;31:142-149.
7. Sokucu O, Kosger HH, Bicakci AA, Babacan H. Stability in dental changes in RME and SARME: a 2-year follow-up. Angle Orthod. 2009;79:207-213.
8. Deeks JJ, Higgins JPT, Altman DG, eds. Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions
Version 5.1.0 (updated March 2011). The Cochrane Collaboration; 2011. Available from: www.cochrane-handbook.org.
9. Chamberland S, Proffit WR. Short-term and long-term stability of surgically assisted rapid palatal expansion revisited. Am J Orthod Dentofacial Orthop. 2011;139:815-822.e1.

http://dx.doi.org/10.1016/j.oooo.2013.02.018