Orthodontic treatment for prominent lower front teeth (Class III malocclusion) in children.

BACKGROUND: Prominent lower front teeth (Class III malocclusion) may be due to jaw or tooth position or both. The upper jaw (maxilla) can be too far back or the lower jaw (mandible) too far forward; the upper front teeth (incisors) may be tipped back or the lower front teeth tipped forwards. Orthodontic treatment uses different types of braces (appliances) fitted inside or outside the mouth (or both) and fixed to the teeth. A facemask is the most commonly reported non-surgical intervention used to correct Class III malocclusion. The facemask rests on the forehead and chin, and is connected to the upper teeth via an expansion appliance (known as 'rapid maxillary expansion' (RME)). Using elastic bands placed by the wearer, a force is applied to the top teeth and jaw to pull them forwards and downward. Some orthodontic interventions involve a surgical component; these go through the gum into the bone (e.g. miniplates). In severe cases, or if orthodontic treatment is unsuccessful, people may need jaw (orthognathic) surgery as adults. This review updates one published in 2013. OBJECTIVES: To assess the effects of orthodontic treatment for prominent lower front teeth in children and adolescents. SEARCH METHODS: An information specialist searched four bibliographic databases and two trial registries up to 16 January 2023. Review authors screened reference lists. SELECTION CRITERIA: We looked for randomised controlled trials (RCTs) involving children and adolescents (16 years of age or under) randomised to receive orthodontic treatment to correct prominent lower front teeth (Class III malocclusion), or no (or delayed) treatment. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcome was overjet (i.e. prominence of the lower front teeth); our secondary outcomes included ANB (A point, nasion, B point) angle (which measures the relative position of the maxilla to the mandible). MAIN RESULTS: We identified 29 RCTs that randomised 1169 children (1102 analysed). The children were five to 13 years old at the start of treatment. Most studies measured outcomes directly after treatment; only one study provided long-term follow-up. All studies were at high risk of bias as participant and personnel blinding was not possible. Non-surgical orthodontic treatment versus untreated control We found moderate-certainty evidence that non-surgical orthodontic treatments provided a substantial improvement in overjet (mean difference (MD) 5.03 mm, 95% confidence interval (CI) 3.81 to 6.25; 4 studies, 184 participants) and ANB (MD 3.05°, 95% CI 2.40 to 3.71; 8 studies, 345 participants), compared to an untreated control group, when measured immediately after treatment. There was high heterogeneity in the analyses, but the effects were consistently in favour of the orthodontic treatment groups rather than the untreated control groups (studies tested facemask (with or without RME), chin cup, orthodontic removable traction appliance, tandem traction bow appliance, reverse Twin Block with lip pads and RME, Reverse Forsus and mandibular headgear). Longer-term outcomes were measured in only one study, which evaluated facemask. It presented low-certainty evidence that improvements in overjet and ANB were smaller at 3-year follow-up than just after treatment (overjet MD 2.5 mm, 95% CI 1.21 to 3.79; ANB MD 1.4°, 95% CI 0.43 to 2.37; 63 participants), and were not found at 6-year follow-up (overjet MD 1.30 mm, 95% CI -0.16 to 2.76; ANB MD 0.7°, 95% CI -0.74 to 2.14; 65 participants). In the same study, at the 6-year follow-up, clinicians made an assessment of whether surgical correction of participants' jaw position was likely to be needed in the future. A perceived need for surgical correction was observed more often in participants who had not received facemask treatment (odds ratio (OR) 3.34, 95% CI 1.21 to 9.24; 65 participants; low-certainty evidence). Surgical orthodontic treatment versus untreated control One study of 30 participants evaluated surgical miniplates, with facemask or Class III elastics, against no treatment, and found a substantial improvement in overjet (MD 7.96 mm, 95% CI 6.99 to 8.40) and ANB (MD 5.20°, 95% CI 4.48 to 5.92; 30 participants). However, the evidence was of low certainty, and there was no follow-up beyond the end of treatment. Facemask versus another non-surgical orthodontic treatment Eight studies compared facemask or modified facemask (with or without RME) to another non-surgical orthodontic treatment. Meta-analysis did not suggest that other treatments were superior; however, there was high heterogeneity, with mixed, uncertain findings (very low-certainty evidence). Facemask versus surgically-anchored appliance There may be no advantage of adding surgical anchorage to facemasks for ANB (MD -0.35, 95% CI -0.78 to 0.07; 4 studies, 143 participants; low-certainty evidence). The evidence for overjet was of very low certainty (MD -0.40 mm, 95% CI -1.30 to 0.50; 1 study, 43 participants). Facemask variations Adding RME to facemask treatment may have no additional benefit for ANB (MD -0.15°, 95% CI -0.94 to 0.64; 2 studies, 60 participants; low-certainty evidence). The evidence for overjet was of low certainty (MD 1.86 mm, 95% CI 0.39 to 3.33; 1 study, 31 participants). There may be no benefit in terms of effect on ANB of alternating rapid maxillary expansion and constriction compared to using expansion alone (MD -0.46°, 95% CI -1.03 to 0.10; 4 studies, 131 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: Moderate-certainty evidence showed that non-surgical orthodontic treatments (which included facemask, reverse Twin Block, orthodontic removable traction appliance, chin cup, tandem traction bow appliance and mandibular headgear) improved the bite and jaw relationship immediately post-treatment. Low-certainty evidence showed surgical orthodontic treatments were also effective. One study measured longer-term outcomes and found that the benefit from facemask was reduced three years after treatment, and appeared to be lost by six years. However, participants receiving facemask treatment were judged by clinicians to be less likely to need jaw surgery in adulthood. We have low confidence in these findings and more studies are required to reach reliable conclusions. Orthodontic treatment for Class III malocclusion can be invasive, expensive and time-consuming, so future trials should include measurement of adverse effects and patient satisfaction, and should last long enough to evaluate whether orthodontic treatment in childhood avoids the need for jaw surgery in adulthood.

The effect of treatment timing on clinical and psychological outcomes with Twin Block therapy: A multicentre two-arm parallel randomised controlled trial.

OBJECTIVE: To evaluate whether delaying treatment with a twin block appliance affects treatment outcomes, in terms of skeletal and dental change and psychological disadvantage. DESIGN: Multicentre, two-arm parallel randomised controlled trial. SETTING: Three UK hospital orthodontic units. METHODS: A total of 75 participants were randomly allocated into an Immediate Treatment Group (ITG) (n= 41) and an 18-month delayed Later Treatment Group (LTG) (n=34). OUTCOMES: Dentofacial changes were recorded from lateral cephalograms and study models, psychological impact was measured using a child perception questionnaire (CPQ11-14) and an Oral Aesthetic Subjective Impact Score (OASIS) at registration (DC1), 18 months (DC2) and 3 years (DC3). RESULTS: The ITG initial effect was a mean ANB reduction was 1.6° (P<0.001) (95% confidence interval [CI] = 0.89-2.29), and an overjet reduction of 5.06 mm (P<0.001) (95% CI = 3.96-6.16) (boys: aged 12 years 8 months; girls: aged 11 years 8 months). There were no statistically significant differences between the ITG and LTG for twin block treatment outcomes, but the ITG active treatment time was longer (P=0.004) (ITG: 13.1 months; LTG: 9.8 months). There was insufficient evidence to state that patients were psychologically disadvantaged by waiting 18 months for active twin block treatment (P>0.05). CONCLUSION: Participants achieved similar clinical and psychological outcomes irrespective of whether they started their twin block at the age of referral (ITG) or 18 months later (LTG). This suggests that boys aged 12 years 8 months and girls aged 11 years 8 months, on average, are not disadvantaged by waiting 18 months for active twin block treatment.

Patient and clinician satisfaction with video consultations during the COVID-19 pandemic: an opportunity for a new way of working.

OBJECTIVE: To assess satisfaction of patients and clinicians with virtual appointments using Attend Anywhere for their orthodontic consultation and to identify any areas where the technology could be further utilised. DESIGN: Service evaluation involving descriptive cross-sectional questionnaire. SETTING: Orthodontic Departments at Royal Blackburn Teaching Hospital and Burnley General Teaching Hospital. PARTICIPANTS: Patients and clinicians involved in video consultations. METHODS: Patient- and clinician-specific questionnaires were designed and those involved in virtual clinics were invited to complete these at the end of their consultation. The questionnaires focused on setting up and connecting to the virtual clinic, assessing if the correct types of patients were involved in the clinics and satisfaction with these types of remote consultations. RESULTS: A total of 121 questionnaires (59 patient and 62 clinician) were completed. Of the patients, 93% found the instructions provided to access the consultation easy to follow and 70% of clinicians did not report any connection issues. In 90% of cases, a virtual appointment was seen to be appropriate by the clinician. Respondents showed a high level of satisfaction with 76% of patients saying a remote consultation was more convenient than face-to-face, and 66% reporting they would, if appropriate, like more appointments like this in the future. CONCLUSION: The overall satisfaction among patients with virtual clinics introduced during the COVID-19 pandemic was generally high. The majority of patients would, where appropriate, prefer more virtual appointments in the future in comparison to face-to-face appointments and it was found to be more convenient for the patient.

Comparison of statural height growth velocity at different cervical vertebral maturation stages.

INTRODUCTION: Knowledge of a patient's stage of growth and development plays a vital role in diagnosis, treatment planning, results, and stability of the outcome. Cervical vertebral maturation (CVM) predicts the stage of growth and development, but its validity has only been investigated restrospectively, using historic samples. Our objective was to assess prospectively whether a correlation exists between CVM stage and statural height growth velocity. METHODS: Participants were aged between 8 and 18 years and of both sexes. Standing height was measured every 6 weeks with participants barefoot and in natural head position. CVM stage was assessed from lateral cephalograms taken at the start of treatment. Intraobserver and interobserver reliability of CVM staging and statural height measurements were assessed using the Cohen weighted kappa, percentage of agreement, intraclass correlation coefficient, and Bland-Altman plots, respectively. Analysis of variance was used to test for statistically significant differences between growth velocities at the CVM stages. RESULTS: We analyzed 108 participants. The peak in statural height growth velocity occurred at CVM stage 3 (P = 0.001). There was a statistically significant difference in the mean annualized growth velocity between all CVM stages except stages 2 and 4. Girls had their peak pubertal growth spurt an average of 1.2 years earlier than did boys. CONCLUSIONS: This study suggests that there is a significant relationship between CVM stage and statural height velocity.

The William Houston gold medal of the Royal College of Surgeons of Edinburgh and British Orthodontic Society cases prize 2013.

This paper describes the orthodontic treatment of two cases presented by the winner of the William Houston gold medal at the Membership in Orthodontics examination at the Royal College of Surgeons of Edinburgh and which also won the British Orthodontic Society (BOS) cases prize in 2013. The first case describes the management of a 20-year-old female patient with a Class II division 2 malocclusion complicated by moderate upper and severe lower arch crowding, increased overjet and overbite, a crossbite and centreline discrepancies. Treatment involved a combination of a transpalatal arch, temporary anchorage devices and fixed appliances. The second case describes the management of a 15-year-old male patient with a Class I malocclusion complicated by crossbites affecting the right buccal segment and UR2, an associated mandibular displacement forward and to the right, mild upper arch crowding and a centreline discrepancy. Treatment involved a combination of a quad-helix, headgear and fixed appliances.

Orthodontic treatment for prominent lower front teeth (Class III malocclusion) in children.

BACKGROUND: Prominent lower front teeth (termed reverse bite; under bite; Class III malocclusion) may be due to a combination of the jaw or tooth positions or both. The upper jaw (maxilla) can be too far back or the lower jaw (mandible) too far forward, or both. Prominent lower front teeth can also occur if the upper front teeth (incisors) are tipped back or the lower front teeth are tipped forwards, or both. Various treatment approaches have been described to correct prominent lower front teeth in children and adolescents. OBJECTIVES: To assess the effects of orthodontic treatment for prominent lower front teeth in children and adolescents. SEARCH METHODS: We searched the following databases: Cochrane Oral Health Group's Trials Register (to 7 January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE via OVID (1946 to 7 January 2013), and EMBASE via OVID (1980 to 7 January 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) recruiting children or adolescents or both (aged 16 years or less) receiving any type of orthodontic treatment to correct prominent lower front teeth (Class III malocclusion). Orthodontic treatments were compared with control groups who received either no treatment, delayed treatment or a different active intervention. DATA COLLECTION AND ANALYSIS: Screening of references, identification of included and excluded studies, data extraction and assessment of the risk of bias of the included studies was performed independently and in duplicate by two review authors. The mean differences with 95% confidence intervals were calculated for continuous data. Meta-analysis was only undertaken when studies of similar comparisons reported comparable outcome measures. A fixed-effect model was used. The I2 statistic was used as a measure of statistical heterogeneity. MAIN RESULTS: Seven RCTs with a total of 339 participants were included in this review. One study was assessed as at low risk of bias, three studies were at high risk of bias, and in the remaining three studies risk of bias was unclear. Four studies reported on the use of a facemask, two on the chin cup, one on the tandem traction bow appliance, and one on mandibular headgear. One study reported on both the chin cup and mandibular headgear appliances.One study (n = 73, low quality evidence), comparing a facemask to no treatment, reported a mean difference (MD) in overjet of 4.10 mm (95% confidence interval (CI) 3.04 to 5.16; P value < 0.0001) favouring the facemask treatment. Two studies comparing facemasks to untreated control did not report the outcome of overjet. Three studies (n = 155, low quality evidence) reported ANB (an angular measurement relating the positions of the top and bottom jaws) differences immediately after treatment with a facemask when compared to an untreated control. The pooled data showed a statistically significant MD in ANB in favour of the facemask of 3.93 ° (95% CI 3.46 to 4.39; P value < 0.0001). There was significant heterogeneity between these studies (I2 = 82%). This is likely to have been caused by the different populations studied and the different ages at the time of treatment.One study (n = 73, low quality evidence) reported outcomes of the use of the facemask compared to an untreated control at three years follow-up. This study showed that improvements in overjet and ANB were still present three years post-treatment. In this study, adverse effects were reported but due to the low prevalence of temporomandibular (TMJ) signs and symptoms no analysis was undertaken.Two studies (n = 90, low quality evidence) compared the chin cup with an untreated control. Both studies found a statistically significant improvement in ANB, and one study also found an improvement in the Wits appraisal. Data from these two studies were not suitable for pooling.A single study of the tandem traction bow appliance compared to untreated control (n = 30, very low quality evidence) showed a statistically significant difference in both overjet and ANB favouring the intervention group.The remaining two studies did not report the primary outcome of this review. AUTHORS' CONCLUSIONS: There is some evidence that the use of a facemask to correct prominent lower front teeth in children is effective when compared to no treatment on a short-term basis. However, in view of the general poor quality of the included studies, these results should be viewed with caution. Further randomised controlled trials with long follow-up are required.