## 4 Discussion  
This SR and MA compared the orthodontic surgery and orthodontic camouflage treatment in C-III-M. This study included a total of six studies for the qualitative analysis after conducting the literature search through different databases. This insignificant number of selected studies indicates that further research needs to be conducted concerning C-III-M to overcome the constraint of qualitative and quantitative secondary systematic studies. This current SR included only the non-randomized retrospective observational studies. A randomized clinical trial would not be ethical to compare the surgery and camouflage treatment as the patients have the right to know and give consent about the surgical procedure. Therefore, randomly selecting a patient for surgery or non-surgery is not an option in these types of studies. This non-randomization process is one of the reasons that most of the studies scored low in the quality assessment. Only two studies scored 19 which is considered moderate quality. Power analysis is another explanation due to the lower scores as power analysis consists of a '5' score in the modified Downs and Black assessment [25]. Retrospective studies are mostly available of data-dependent, yet a sample size calculation would strengthen the study design than the studies which followed convenience sample techniques. Due to the lack of compliance with any methodological guideline, studies may introduce bias caused by methodological inaccuracies [32]. Figure 4: Forest plot of dental measurements. Figure 3: Forest plots for sagittal measurements. Studies that compared the different cephalometric measurements between the camouflage and surgical treatment of C-III-M were included in this SR. However, two studies among the six selected studies were compared only to the pre-treatment cephalometric radiographs [27; 28]. Therefore, these two studies were excluded from the MA. Another study compared the pre-treatment and post-treatment radiographs to compare the long-term stability and satisfaction; therefore, to eliminate the heterogeneity this study was also excluded from the MA as it slightly deviated from the aim of this SR [29]. Only the studies which assessed the pre-treatment and post-treatment cephalometric measurements for assessing the treatment effect were included for MA [15; 30; 31]. Although the aim of all included studies was similar, the variation was observed in the measurement of cephalometric variables. The most common skeletal variables (SNA, SNB, ANB and Wits appraisal) were measured by all the included studies. [PERSON] et al. (2017) examined additional skeletal variable facial angle (FA) [31], and [PERSON] et al. (2008) added maxillary mandibular plane [15]. [PERSON] et al. (2008) found no significant difference among all the skeletal variables included in the MA between the post-treatment orthodontic group and post-treatment surgical group except the ANB [15]. In addition, [PERSON] and [PERSON] (2015) discovered a significant difference concerning all variables except SNB between the two groups [30]. On the other hand, [PERSON] et al. (2017) did not find a significant difference in Wits appraisal between these two groups [31]. All the mean skeletal variables decreased in both treatment procedures except the SNA observed increased by both [PERSON] et al. (2017) and [PERSON] and [PERSON] (2015) in surgical treatment [30; 31]. The most inconsistency was noted in dental variables. Only L1-MDP and IIA were common dental measurements among these three studies. [PERSON] and [PERSON] (2015) examined overjet (OJ), upper incisor to Sella Nasion plane (U1-SN), upper incisor to palatal plane (U1-Pal), upper incisor to Nasion-Point A (U1-SA) and lower incisor to Nasion B point (L1-NB) along with L1-MDP and IIA [30]. On the other hand, [PERSON] et al. (2008) measured additional U1-SN for upper incisor which is coherent with [PERSON] and [PERSON] (2015); however, [PERSON] et al. (2017) measured U1-Pal for upper incisor dental measurement [15; 30; 31].