Is early orthodontic treatment based on evidence? Looking for “needles in a haystack”.
One of the most controversial areas in orthodontics is about the timing of orthodontic treatment. There are many orthodontists who are starting to introduce “early or interceptive” treatment into their clinical practices. But is this evidence based? This systematic review provides us with good information on early orthodontic treatment.
Is orthodontics prior to 11 years of age evidence-based? A systematic review and meta-analysis
R. Sunnak, A. Johal, P.S. Fleming
Journal of Dentistry 43 (2015) 477–486
DOI: http://dx.doi.org/10.1016/j.jdent.2015.02.003
A team from Queen Mary’s University, London did this interesting and clinically relevant review.
What did they ask?
In the introduction the authors pointed out that the current trend to provide early or interceptive treatment is based around the concept of reducing the need for further treatment or attempting to reduce the severity of the developing malocclusion. The conditions that are commonly “intercepted” are
- Facial growth problems
- Impacting canines
- Development of dental crowding
- Correction of overjets
This philosophy is also reflected in the American Association of Orthodontists guidelines. These suggest all children should receive an orthodontic screening at age 7-8 years. However, we need to consider that while a screening may identify a developing problem, it is essential that any treatment for the problem is effective. Currently, evidence in this area is lacking and this team did this systematic review attempted to answer this question.
They aimed to “assess the effectiveness of a range of orthodontic interventions provided to children under 11 years both in the short and long term”.
What did they do?
They carried out a standard systematic review with the following criteria
Study design: RCT or CCT
Participants: Children under 11 years old
Interventions: Any interceptive treatment
Comparator: Untreated controls or participant having another active intervention
Outcomes:
- Improvement in arch relationship,
- Change in the position of teeth,
- Change in skeletal discrepancy.
- They also had secondary outcomes of:
- Need for a second phase of treatment
- Patient satisfaction
- Duration and process of treatment
- Any harms
- Need for extractions.
They did a high quality systematic review in which they identified the relevant literature from electronic sources, carried out a quality assessment and then only included the trials that were at low risk of bias. They extracted the outcomes and assessed the overall strength of evidence using the GRADE approach.
What did they find?
They identified 20 studies that were of low risk of bias. These looked at the following:
- Short term effects of skeletal growth modification for Class II and Class III malocclusion.
- Correction of anterior open bite
- Correction of posterior crossbite
- Interceptive extractions to reduce crowding
- Improving the position of ectopic maxillary canines
They provided a large amount of data. I have summarised this with respect to the conditions that they evaluated.
Class II growth modification
Early treatment resulted in small but not clinically significant effects on skeletal growth. These differences were not maintained at the end of a second and final phase of treatment. However, there was some reduction in incisal trauma (I have posted about this before).
Class III growth modification
There was some skeletal change with the use of protraction facemasks. This was a difference of 3.12 degrees of ANB. I think that this is clinically significant. (I have also posted about an excellent study that looked at the need for orthognathic surgery following protraction facemask treatment).
Correction of unilateral posterior crossbite
They found one study that suggested there was a high rate of crossbite correction from quad helix and expansion plates.
Interceptive extractions
They found one study that looked at the effect of extraction of the primary canines on relieving developing lower incisor crowding. This showed that incisal irregularity reduced in both the control and extraction groups by 1.27 mm (SD=2.4) and 6.03 mm (SD 4.44). However, irregularity reduced in the extraction group at the expense of reduction in arch length.
Improved position of ectopic primary canines.
It was interesting that they did not find many trials on this area. They did mention a study on facemask protraction by Baccetti in which expansion with RME resulted in and increase of almost 50% in canine eruption. However, they could not analyse this data because of reporting issues.
They classified the quality of evidence of the studies as low to moderate using the GRADE approach.
What did I think?
This was a good systematic review in which they only included RCTs. I would recommend that all orthodontists should read this interesting paper.
As with all research, there are some issues that need to be addressed. For example, the authors point out that as these studies were done in university or hospital settings. As a result, they may not reflect international practice and may only represent secondary care provision. They also suggested that further trials are necessary to help answer this important question. I completely agree with their suggestions.
I think that it was also important that they did not find much evidence to support the provision of early treatment. Nevertheless, this leads me to consider whether “Absence of evidence, is evidence of absence of a treatment effect”? In other words, there may be an effect of treatment but we have not found it due to methodological issues. I am going to expand on this in a blog post later this week.
A way forwards?
This whole area of early provision of treatment is interesting and clinically important because it would be great if we could intercept the development of severe malocclusion. Nevertheless, we should also remember that all treatment comes at a price in terms of the associated risks and the additional cost to the patients. Furthermore, we have to consider whether it is more effective to wait until our patients are older and then solve their problems with one course of treatment.
In this respect, I found this case report on Facebook very interesting. It is clear that the orthodontist wants to illustrate his treatment and the comments made by other people are complimentary. We also need to remember that orthodontic philosophy is very different in the USA from other parts of the World. You can see that this patient had a developing crossbite and, what some would feel, normal incisor eruption with a midline diastema. In some countries operators would simply observe further development, in others the orthodontist may correct the posterior cross bite or ask a general dental practitioner to correct this problem, or as in this case a more extensive treatment was provided with Haas expansion, upper fixed appliance and two cephalograms. I have used this as an illustration to open a discussion on who is right and does this matter?
Finally, we can conclude that further research in this area is necessary. We can do this by running trials in specialist practice using outcomes that are relevant to our patients. These would be great orthodontic studies. I wonder if someone will do them or will we simply base our treatment on clinical experience, hearsay and Facebook?
Emeritus Professor of Orthodontics, University of Manchester, UK.
Although I am not a proponent of early treatment for most malocclusions, one variable not considered in this review is the pyscho-social aspect of a malocclusion, i.e., severe Class II with large overjet, on the young child. So while the facial- dental outcomes might be equivical in these cases, maybe not the child’s developing psyche.
It is interesting that someone thought about the psycho-social aspect which for me is of great value with all the bullying existing in every society, sometime a partial correction or a short term improvement is worthwhile even at a higher cost and treatment time. Thank you Andrew for bringing that up.
Kevin
if you want to undertake up such a study in UK primary care… i’m in: we have 5 practices that i can offer to participate
Ross
Sometimes is not only the psycho-social aspect of the child at school or bullying but I also see a lot of pressure from the parents. The thing here is not to abuse on early treatment, always fully inform the patient and parents about the outcomes of one and two phase treatment plans and if you altogether take the two phase route do the first phase as short as possible.
I think some of the most obvious stuff gets lost in the rhetoric of the argument. Specifically bilateral crossbites. In general the floor of your nose is the top of your mouth, right? Even if you do nothing more than fixed expansion with a hyrax or Haas, etc…You allow the development of the future erupting teeth to occur easier. I am not a nut about Phase I, but we have 5 triggers to suggest treatment which I am happy to share. 1. Bilateral crossbites 2. Unilateral crossbites (posterior unilateral or anterior scissor bite) 3. Delayed eruption of anterior tooth (conebeam often shows a mesiodens or severe crowding etc..) 4. Severe speech issues (usually kids are in speech therapy and failing) 5. Severely protrusive teeth that either generate psychosocial issues from kids teasing them, or are at risk due to their positioning for trauma.
I think these all can have their merits as to why a kid needs to have interceptive work. There is no single reason why Phase I is required. In our practice about 1 in 3 kids do not require further work. Parents appreciate our honesty and see the cost benefit. I can usually guess if it will require a second phase. But if the second phase is non extraction or avoided surgical exposures I think you are doing good. I think it is quite efficient to perform orthopedic changes when kids are young. As they age, and they all age at various rates, you may need to do additional work. That is just the facts. Bad growth vectors are still bad after Phase I so retain appropriately. I have a private practice as well as a significant position at a university based cleft palate team and I can honestly say that there is no correct answer other than they both are correct given an individual’s concerns. Last time I checked kids don’t come out with an owner’s manual. Parents make mistakes my self included. But educated people are aware of the potential of what can occur so I let the parents decide for me always. I will say it is imperative to have a cone beam to make some of these decisions. So that is how my team practices and I think we do a nice service to anyone who comes in for an evaluation.
Kevin. Understandable that treatment/non-treatment of malocclusions like this are dependent on mindset(training)…but..should limits of mindset dictate exploration of treatment modalities? Everything is results based IMO. We’ve had this circular conversation before on the inadequacy of the research in the last 25yrs. The void is Huge and I see very little in attempts at improvement in study of ‘gray areas’ as I suspect you see this treatment. Let’s talk
Thanks for the comments. You are correct in that treatment philosophies are dependent on training. But they are also influenced by an understanding of research, interpretation of research and clinical experience. The main issue with early treatment is that we just do not know if it is effective. If we use your case as an example. We know that the patient has a crossbite and this can be corrected very simply. Some would also say that the spacing in the incisors is normal development and that all that was needed was crossbite correction without the sectional fixed appliance. The end result would be same but with less burden and cost to the patient/parent. We can all correct malocclusion but do it in different ways, as long as the patient understands that the treatment is not based on evidence but on clinical experience, then there are no problems. Unfortunately, issues arise when the “early treatment” is not needed because it “corrects” normal development.
if the treatment is not supported by evidence, because nobody has asked the right questions or performed the correct studies…does the tree not make a sound when it falls in the Forest? let’s talk about he psycho-social implications (which are also regional i suppose). Who’s the gatekeeper on that decision?
Thanks Kevin. This is a really nice package about early treatment. Another modality not mentioned here is E space saving with a lower lingual arch to relieve lower anterior crowding. Part of my evaluation to suitability includes the position of the second permanent molars. With regard to Class III protraction facemask therapy, which I do use, it should be remembered that A point is a dentoalveolar landmark and thus a change in ANB can be related to dental changes and also any elimination of mandibular displacement if this was not accounted for in the initial assessment.
Nice to see the problem of early treatment viewed by different angles! Skeletal(only), growth, socio-psychological, cost and evidence(most-stressed), dento-alvoelar, in the discussions. I may like to add ‘function’ and soft tissues to the list. Especially with unilateral posterior crossbites,(laterally deviated path of closure of mandible), anterior crossbites (associated with forward shift of various degrees and also without) and to some extent functionally retruded mandible in some class IIs(with posiitve VTO) are some of the(definite) indications for early interventions in my experience and practice. I do agree the ‘evidence people’ will dismiss my view as a claim/anecdote! What we do not ‘see’ or hear, still exists, just like the light wavelengths beyond “VIBGYOR”, if one can take a cue. Experimental methods needs to be refined to ‘show’ the obvious truth. Over the years the evidence school is improving, but sole dependence on RCTs, may narrow our clinical perspective and practice.
Thank you for this very useful and interesting article. I am not a dentist but a parent of a child who has a palet expander, I am also a University professor. When I was told by a pediatric dentist that my child had over crowding issues and would need to have their palet expanded at the age of 7 (we are currently based in the UAE) it was a shock coming from the non-interventionist British dental system. I did a lot of reading into the topic but couldn’t find any research that conclusively said early intervention was the best approach. Nevertheless after seeking 4 separate dentist opinions I was persuaded. Being an economist initially my thoughts were that the early interventionist approach was a good way in which US dentists had found to tap into a new market, the under elevens. As you can imagine several dentists we visited were not happy to hear this concern. Having read your article I now wonder if this is one of the reasons why there hasn’t been more research into this very important topic. The second point I want to raise is with regard to the non-financial costs to the patient, parents and child. Having been through 1 year of my child wearing an expanded at the age of 8 I can say that the costs are not insignificant in terms of speech loss (everyone says this is temporary I don’t agree), discomfort, inconvenience and problems for parents (constantly reminding and nagging the child to wear the device). It is asking a lot of a small child to remember to wear such a device and not forget it. All in all I think the cost-benefit analysis has to be carefully weighed by the parents. Furthermore, I have heard multiple dentists here and also in replies to your blog stating that early intervention is justified on the basis of the psychological cost to young children of having imperfect teeth and being bullied at schoo, I find this an assanine argument. Perhaps children should also therefore be encouraged to have plastic surgery if there facial features are imperfect? Most children I went to school with had imperfect teething throighout most of their childhood years, including myself, and most of them weren’t bullied.
HI Anna, thanks for the comments and it is great to get comments from someone who is not a dentist. I agree completely with you and your comments reflect what I was trying to say in my blog post. There are some indications for early orthodontic treatment but our current research knowledge suggests that these are not common. In general terms, it is best to wait until most children are 11-12 years old.
Hello,
I’ve followed your posts on Class II treatments with great interest. I would like to know your thoughts on the use of headgear (cervical, high and asymmetric pull). I’m beginning to wonder if they have gone the way of the dinosaurs.
Thank you for your time,
Hwee
Hi, these treatment methods were evaluated as part of the early treatment for Class II that were done by UNC and Florida. The results were very similar to the use of functional appliances early. That is early treatment was rarely indicated.
Late to the conversation, but I wanted to thank you for digesting the research article by Sunnak, Johal & Fleming. As a layperson (and a parent), it was very helpful.