Abstract

Aim: Orthodontic appliance selection in adolescence has an impact on skeletal correction, dental control, periodontal health, and patient-reported outcomes. Clear aligners (CAs), fixed appliances (FAs), and functional appliances, including removable (RFAs) and fixed functional appliances (FFAs), are used. However, comparative evidence evaluating these appliances across multiple clinical domains in adolescents remains limited.
Materials and Methods: A systematic search of PubMed, Embase, Web of Science, and the Cochrane Library was conducted for studies published between January 2000 and March 2025. Randomized controlled trials and prospective observational studies involving adolescents aged 8–18 years and comparing at least two orthodontic appliance types were included. Primary outcomes were skeletal changes, ANB angle reduction, periodontal health indices, and patient-reported outcomes satisfaction and pain. Secondary outcomes included treatment duration, treatment precision, and adverse effects. Pairwise meta-analyses were performed when only direct comparisons were available, while network meta-analyses were conducted for outcomes forming connected evidence networks. Risk of bias was assessed using RoB 2 and ROBINS-I. The review protocol was registered in PROSPERO and followed PRISMA-NMA guidelines.
Results: Nineteen studies involving 2.569 adolescents were included. Network meta-analysis demonstrated that FFAs produced the greatest skeletal effects, showing the largest reduction in ANB angle. CAs were associated with higher patient satisfaction and less initial pain compared with FAs. Periodontal outcomes favored CAs over FAs; however, these findings were derived exclusively from direct pairwise comparisons and were not supported by a connected evidence network, limiting comparisons with functional appliances. No significant difference in treatment duration was observed between CAs and FAs. FAs demonstrated superior control of complex tooth movements but were associated with a higher risk of white spot lesions, while RFA effectiveness depended on patient compliance.
Conclusion: Orthodontic appliance selection in adolescents should be individualized, balancing skeletal objectives, biomechanical demands, periodontal risk and patient-reported outcomes.

Key words: Clear aligners, fixed appliances, functional appliances, adolescent orthodontics, network meta-analysis