Undertaking orthodontic procedures early may help to prevent problems arising or reduce the severity of the developing malocclusion; it may also be part of a ‘two-phase’ treatment plan. However the effectiveness of early treatment has been the subject of debate. The aim of this review was to determine whether interceptive orthodontics prior to the age of 11 years is more effective than later treatment in the short- and long-term.

Methods

Searches were conducted in Medline, Embase, Cochrane Oral Health Group’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, BBO, ClinicalTrials.gov, the National Research Register and Pro-Quest Dissertation Abstracts and Thesis database.

Randomised controlled trials (RCTs) and controlled trials (CCTs) in patients under 11 years at the start of treatment for a range of interventions eg. interceptive extractions, space maintenance, crossbite correction, habit dissuasion were considered. Two reviewers abstracted data independently and quality assessed using the Cochrane risk of bias tool. The overall quality of evidence was to be assessed using GRADE.

Results

• 22 studies (18 RCTs, 3 CCTs) were included.
• 20 were considered to be at low or unclear risk of bias.
• Meta-analysis was possible for 11 comparisons.
  • For Class II correction in the short-term, meta-analyses demonstrated
  • a statistically significant reduction in ANB (-1.4 degrees, 95 CI: -2.17, -0.64) and overjet (-5.81mm, 95 CI: -6.37, -5.25) with both functional appliances and headgear versus control.
  • For Class II correction in the long-term, however, statistical significance was not found for the same outcomes. Treatment duration was prolonged with both functional appliances (6.85 months, 95 CI: 3.24, 10.45) and headgear (12.47 months, 95 CI: 8.67, 16.26) compared to adolescent treatments.
• Meta-analyses were not possible for comparisons of other interceptive treatments due to heterogeneity and methodological limitations.
• The overall quality of the evidence based on the GRADE assessment suggested that the level of evidence was low to moderate

Conclusions

The authors concluded: –

The results suggest a lack of evidence to prove that early treatment carries additional benefit over and above that achieved with treatment commencing later; however, this does not necessarily imply that early treatment is ineffective. Further high quality trials are required to assess the effectiveness of early treatment compared to later intervention.

Comments

The question that this review considers is a broad one, a point that the authors note. The findings of this review support those of the 2013 Cochrane review (Dental Elf -7^th Jan 2014), which just focused on class II malocclusions finding that interceptive treatment for Class II correction is more effective in reducing the incidence of incisal trauma than later treatment. Although 22 trials were available for this review only small numbers were available for the separate meta-analysis. One of the reasons for this was the variation in outcome measures used. This is not just a problem for orthodontic studies and the COMET (Core Outcome Measures in Effectiveness Trials) Initiative is looking to support researches produce common outcome sets.  While having a core set of agreed outcome will be beneficial in the future there is also a need for more high quality studies.

Links

Original review protocol – CRD42014006287

Sunnak R, Johal A, Fleming PS. Is orthodontics prior to 11 years of age evidence-based? A systematic review and meta-analysis. J Dent. 2015 Feb 12. pii: S0300-5712(15)00032-9. doi:10.1016/j.jdent.2015.02.003. [Epub ahead of print] Review. PubMed PMID: 25684602.

COMET initiative

Dental Elf – 15^th Sept 2014 – Orthodontic treatment for crowding: review found similar results with early and late extractions

Dental Elf – 15^th Aug 2014 – Orthodontic treatment of posterior crossbite

Dental Elf – 5^th Jun 2014 – Second group of reviewers find some evidence for use of facemask for class III malocclusions

Dental Elf – 7^th Jan 2014 – Early orthodontic treatment may reduce incisal trauma in children with class II malocclusions