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| Title |
Single-Phase Treatment of Class II Malocclusion Patients During Adolescence Results in More Efficient Treatment and Better Clinical Outcomes |
| Clinical Question |
In children with class II malocclusions, does early two-phase orthodontic treatment produce a better clinical outcome compared to single-phase treatment in late adolescence? |
| Clinical Bottom Line |
For patients with class II malocclusions, single phase treatment during adolescence results in more efficient treatment times and better clinical outcomes compared with patients treated with two phase orthodontic treatment. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 29534303 | Batista/2018 | 27 studies/1251 participants presenting with prominent upper front teeth (Class II Division 1 malocclusion) ranging from 7-15 years old | Cochrane Review of RCTs | | Key results | Moderate evidence indicates that early phase treatment in patients with class II malocclusions reduces incidence of incisal trauma significantly (OR 0.56, 95% CI 0.33 to 0.95), but there are no other advantages to a two-phase treatment. After both the single-phase and two-phase groups concluded comprehensive treatment, no difference was observed in final overjet or ANB angles (MD 0.21, 95% CI -0.10 to 0.51, P = 0.18) in the studies comparing early and late treatment. Overall quality of evidence in this review was determined to be low due to only two of the included trials being at low risk of bias. The review also included single-phase and two-phase studies, the latter of which being much more prone to bias. | | #2) 15179390 | Tulloch/2004 | 137 participants | 2-Phased parallel Randomized Controlled Trial | | Key results | Key Results – Two phase treatment of most young patients with class II malocclusion and normal face height is less efficient and not more effective than single stage treatment in adolescence. Time in fixed appliance for the group that completed phase 1 treatment and the control group only receiving comprehensive treatment: the average is almost identical - 26.7 months vs 26.2 respectively (P = 0.20) | | #3) 2111647 | King/1990 | N/A | Literature Review | | Key results | Early treatment of class II malocclusions should include patient considerations such as increased treatment time, financial burden, patient burnout, and loss of compliance. Skeletal corrections achieved during phase 1 treatment with an aim to reduce the need for dentoalveolar compensation during phase 2 treatment has not been clarified. The author of the literature review is skeptical of the increased popularity of early treatment. The study recommends solving this clinical question with “carefully controlled prospective studies”, as the available literature had deficient methods due to being retrospective, lacking control groups and only analyzing successful cases. | |
| Evidence Search |
Treatment timing of class II malocclusions, Class II malocclusion two-phase treatment |
Comments on
The Evidence |
While Batista’s Cochrane review directly addresses early treatment vs. treatment during adolescence, 15 of the 27 studies included were at high risk of bias with selection, detection, and reporting bias. The 3 studies directly comparing the two treatment modalities may be of limited validity due to high degree of heterogeneity (I2=62%). The PICO question was clearly stated in the study, with mesh terms of “Child 6-12 years, adolescent 13-18 years, Angle Class II malocclusion, early treatment, and delayed treatment” clearly stated as a reference for the search. Inclusion criteria of RCT clearly stated in study as “trials of orthodontic treatments to correct prominent upper front teeth (Class II malocclusion) in children and adolescents…that compared early treatment in children (two‐phase) with any type of orthodontic braces (removable, fixed, functional) or head‐braces versus late treatment in adolescents”. Trials with cleft lip patients, syndromes, craniofacial deformities, and patients with prior orthodontic treatment were excluded. Heterogeneity in the studies were directly addressed by analyzing the trials according to the functional appliances used.
Tulloch’s RCT clearly delineated the criteria for patients enrolled in the study (7 mm overjet, mixed dentition, growth potential remaining, no prior orthodontic therapy) but were assigned to treatment groups by block randomization rather than centralized computer assisted randomization. The study reported an 82% retention rate going into phase two of treatment, a significant loss in participants. Although no mention of blinding was seen in the study, evaluation of equivalence for the 4 groups treated by a different clinician was conducted. Chi square test was used for proportion of patients in early treatment group and sex, and ANOVA for skeletal, dental and inter-jaw characteristics. Although both groups were treated equally, it is impossible to account for differences in treatment due to different assigned clinicians.
King’s literature review failed to answer any clinical questions concerning treatment timing of class II malocclusions but did bring to light gaps in the literature on whether early treatment offer significant improvement, are any growth modification therapies in early treatment maintained into adolescence, and if the benefit of early treatment is worth the cost/risks.
|
| Applicability |
In orthodontic practice, class II malocclusions account for 15% of all treated cases. Although clinicians must use their best judgement on who would benefit from early treatment, taking into account risk of trauma and psychosocial factors, evidence shows single phase treatment in adolescence leads to a clinically equivalent results in a shorter treatment time. |
| Specialty/Discipline |
(Orthodontics) (Pediatric Dentistry) |
| Keywords |
Class II malocclusion treatment timing, two-phase vs. single phase treatment
|
| ID# |
3541 |
| Date of submission: |
10/19/2023 |
| E-mail |
ojedaj1@livemail.uthscsa.edu |
| Author |
Jesus Ojeda, DDS |
| Co-author(s) |
James Otani, DDS |
| Co-author(s) e-mail |
otani@livemail.uthscsa.edu |
| Faculty mentor/Co-author |
Maria Karakousoglou, DDS |
| Faculty mentor/Co-author e-mail |
karakousoglo@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
|
Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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