## 4 Discussion
Hence, only IIA and L1-MDP were included in the forest plot. All three studies included in the MA showed significant differences in L1-MDP and IIA in both treatment groups [15; 30; 31]. Therefore, it is obvious that dental changes are consistent in all the included studies where L1-MDP increases in surgical treatment and decreases in camouflage treatment. Moreover, IIA decreases in surgical treatment and increases in camouflage treatment. [PERSON] and [PERSON] (2015) found a decrease in IIA in camouflage treatment, though significant differences were observed between both groups [30]. Although surgical treatment is more stable and provides a better outcome in C-III-M [2; 3], the current MA showed conflicting outcomes. Therefore, statistical heterogeneity test 12 was observed which indicated significant heterogeneity in the selected study and ultimately suggest bias in the analyzed study [33]. Though clinical heterogeneity is constantly persisting in the MA which may be due to the sample size, study design, intervention and outcome of the selected studies. This quantitative analysis also denoted clinical heterogeneity based on the ethnic background as selected three studies in this MA were performed in three different continents Asia, Europe and Oceania. Sample size would be another issue as there is a variety of sample sizes in the included studies. In general, studies included in this SR did not commence with similar treatment groups due to the non-randomized nature of the studies. Moreover, there was limited information on whether the sample represented the entire population or not. In addition, only one study performed the sample size calculation [31]. Therefore, further studies are compulsory where these issues need to be addressed. Other than the forest plots, visual observation of funnel plots is also showing publication bias. All the studies recruited patients who were showing skeletal C-III-M before starting the orthodontic treatment with ANB value <0. However, C-III-M can be classified as mild, moderate and severe. [PERSON] et al. (2008) and [PERSON] and [PERSON] (2015) mentioned recruit ing borderline C-III-M patients in their study [15; 30], whereas other studies only mentioned the ANB value [27; 28; 29; 31]. ANB value <0\({}^{\circ}\) could include mild, moderate and severe types of C-III-M. Therefore, the treatment plan would vary based on the nature of the malocclusion. The patients in both groups should present similar characteristics before starting any comparison studies [34]; however, this MA only involved non-randomized observational studies where pre-treatment characteristics should not impact the overall effect. Treatment of C-III-M in adult patients has always been a challenge for orthodontists [35]. Therefore, assessing and comparing the cephalometric variables in camouflage and orthodontic surgery to estimate the treatment effect is important for appropriate treatment planning depending on the patients' profile. It is imperative to emphasize all the cephalometric variables with large sample size. Cephalometric dental values are as important as skeletal values as in camouflage both upper and lower dentition change in the greater value to compensate the skeletal deformities [36]. As per our best knowledge, this is the first SR and MA which compared the treatment effects of orthognathic surgery and camouflage treatment of C-III-M. Different databases were searched extensively to include a maximum number of studies for this systematic review. Only six previous studies assessed the treatment effects of orthognathic surgery and camouflage treatment of C-III-M. However, only three studies were included for the MA. Though the most important skeletal variables could evaluate from this MA, the dental and soft tissue variables were not fully explained. This SR fails to assess any changes in the upper dentition and soft tissue changes due to the lack of similar measurements observed in the selected studies. Therefore, it is understandable that more studies related to this topic are necessary.