Comparative Effectiveness of Skeletal Versus Fixed Anterior Traction in Growing Patients With Skeletal Class III Malocclusion: A Systematic Review and Meta-Analysis

To compare the skeletal, dentoalveolar, soft-tissue, and treatment-burden effects of skeletal anterior traction (SAT) versus fixed anterior traction (FAT) in growing patients with skeletal Class III malocclusion. PubMed/MEDLINE, Embase, Scopus, Web of Science, and CENTRAL were searched from inception through 15 May 2021, with citation tracking through 30 June 2021. Randomised and non-randomised comparative studies directly evaluating SAT versus FAT in growing Class III patients were eligible. Two reviewers independently screened records, extracted data, and assessed risk of bias with RoB 2 or ROBINS-I as appropriate; certainty was interpreted with GRADE. Random-effects meta-analysis was used for compatible continuous outcomes. The quantitative dataset comprised six comparative studies. In that dataset, SAT was associated with greater maxillary advancement (MD +1.23, 95% CI 0.88 to 1.57), greater intermaxillary sagittal correction (MD +1.38, 95% CI 1.04 to 1.73), less forward mandibular positional change (MD −0.94, 95% CI −1.38 to −0.49), less clockwise mandibular rotation (MD −1.12, 95% CI −1.79 to −0.45), less maxillary-incisor proclination (MD −3.12, 95% CI −4.05 to −2.18), and improved facial convexity (MD +1.42, 95% CI 0.96 to 1.89). Publication-level reconciliation identified two additional pre-2021 direct comparisons already cited in the manuscript and six direct comparative reports published after the original database-search boundary; these were not retrospectively mixed into the retained pooled estimates without a reproducible re-extraction of the original dataset. The retained pooled dataset suggests that SAT shifts early Class III correction toward a more skeletal and less dentoalveolar pattern, but the exact magnitude of the skeletal advantage is uncertain. RCT-only syntheses published subsequently report only small incremental maxillary effects of skeletal anchorage, while the reduction in maxillary-incisor proclination is more consistent. The pooled estimates in this manuscript should therefore be treated as provisional until a complete multi-database update and re-extraction incorporate all eligible direct comparisons.