Cranial Base Characteristics in Growing Patients With Class III Skeletal Pattern: A Systematic Review and Meta-Analysis

INTRODUCTION AND AIMS: The treatment of skeletal Class III malocclusion presents challenges due to heterogeneous craniofacial growth patterns. The cranial base is a craniofacial growth centre, while its role in skeletal malocclusion remains unclear. This systematic review aimed to investigate the relationship between the cranial base characteristics and skeletal Class III malocclusion in growing patients. METHODS: Observational studies investigating cranial base characteristics among growing skeletal Class III patients were included. Six databases (PubMed, Web of Science, Cochrane Library, Embase, MEDLINE, and Scopus) were searched up to May 5, 2026. Risk of bias and evidence certainty were assessed using the AXIS tool, and the GRADE framework. Meta-analysis was performed using RevMan 5.4 software. Subgroup meta-analyses were conducted by growth stage and gender if applicable. RESULTS: Eleven studies were included, of which eight were eligible for meta-analysis. Compared to Class I patients, Class III patients exhibited a smaller NSBa angle (-1.84°, 95% CI: -2.80°, -0.89°, P < .001) and NSAr angle (-2.02°, 95% CI: -3.26°, -0.78°, P = .001). Subgroup analyses revealed shorter SN and SBa lengths among Class III patients before or during the growth spurt (SN: -1.59 mm, 95% CI: -2.69 mm, -0.50 mm, P = .004; SBa: -1.56 mm, 95% CI: -2.88, -0.24, P = .004). Additionally, SN length was significantly shorter in Class III males (-1.68 mm, 95% CI: -3.11mm, -0.25 mm, P = .020). CONCLUSIONS: Growing skeletal Class III patients presented significantly smaller cranial base angles. Moreover, those evaluated before or during the growth spurt showed shorter anterior and posterior cranial base lengths, with differences in anterior cranial base length demonstrating gender-specific variation. However, the preliminary findings necessitate cautious interpretation given the very low certainty of evidence. CLINICAL RELEVANCE: A better understanding of the etiology of skeletal malocclusion may inform individualized orthodontic diagnosis and treatment planning.