Cochrane Database of Systematic Reviews

Orthodontic treatment for crowded teeth in children

(Protocol)

Harrison JE, Scholey J, Worthington HV, Bickley S, O’Brien KD, Shaw BC

Harrison JE, Scholey J, Worthington HV, Bickley S, O’Brien KD, Shaw BC.
Orthodontic treatment for crowded teeth in children.
Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003453.
DOI: 10.1002/14651858.CD003453.

www.cochranelibrary.com

Orthodontic treatment for crowded teeth in children (Protocol)

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Orthodontic treatment for crowded teeth in children (Protocol) i

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Orthodontic treatment for crowded teeth in children

Jayne E Harrison1 , John Scholey2 , Helen V Worthington3 , Sylvia Bickley3 , Kevin D O’Brien4 , Bill C Shaw3

1 Department of Clinical Dental Sciences, Liverpool University Dental Hospital, Liverpool, UK. 2 Orthodontics, Liverpool University

Dental Hospital, Liverpool, UK. 3 Cochrane Oral Health Group, MANDEC, School of Dentistry, The University of Manchester,
Manchester, UK. 4 Orthodontics, School of Dentistry, The University of Manchester, Manchester, UK

Contact address: Jayne E Harrison, Department of Clinical Dental Sciences, Liverpool University Dental Hospital, Pembroke Place,
Liverpool, Merseyside, L3 5PS, UK. [email protected].

Editorial group: Cochrane Oral Health Group.

Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.

Citation: Harrison JE, Scholey J, Worthington HV, Bickley S, O’Brien KD, Shaw BC. Orthodontic treatment for crowded teeth in
children. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003453. DOI: 10.1002/14651858.CD003453.

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:

To test the null hypotheses that there are no differences in outcomes between

• the age at which orthodontic treatment for crowded teeth is carried out;

• different orthodontic interventions for correcting/preventing crowded teeth against the alternative hypothesis that there are.

BACKGROUND teeth that may be the source of teasing at school (Shaw 1980;
Shaw 1981) and/or later in life (Shaw 1985). Crowded teeth is
Orthodontics is the branch of dentistry concerned with the growth the commonest problem seen by orthodontists. Crowding affects
of the jaws and face, the development of the teeth and the way nearly a half of 12 year old children in the UK (Holmes 1992).
the teeth and jaws bite together. It also involves treatment of the Levels of crowding in other populations vary with whites and His-
teeth and jaws when they are irregular and/or bite in an abnormal panics having the greatest amount and black and Chinese the least
way. There are many reasons why the teeth may not bite together (Proffit 1998; Silva 2001). Crowding can affect the baby teeth
correctly. These include the position of the teeth, jaws, lips, tongue, (primary dentition) and/or the adult teeth (permanent dentition).
and/or cheeks or may be due to a habit or the way people breath. Crowding tends to increase with age, especially in the lower jaw,
The need for treatment can be decided by looking at the effect of so that only a third of adults have well aligned lower front teeth
any particular tooth position on the life expectancy of the teeth (incisors) (Proffit 1998). Crowding occurs when there is a differ-
and/or the effect that the appearance of the teeth has on how ence between the size of the jaws and teeth e.g. the jaws are too
people feel about themselves (Shaw 1991). small to hold the teeth. Crowding of the adult teeth can also occur
when space is lost following the early loss of baby teeth either as a
Crowded teeth develop when there is not enough space in the jaws
result of tooth decay or trauma.
for the teeth to erupt into. This gives the patient crooked or wonky
Orthodontic treatment for crowded teeth in children (Protocol) 1
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Several dental brace (orthodontic) treatments have been suggested Types of interventions
to correct or prevent crowding. Some treatments use braces to Active interventions: Orthodontic braces (removable, fixed, func-
expand the teeth and/or jaws. They can be carried out early, before tional), head-braces or extractions.
6 years of age, when the patients have only their baby teeth present. Control: may be no treatment, delayed treatment or another active
Other treatments can be carried out when the patients have a intervention.
mixture of their baby and adult teeth present (around 7 to11 years
of age). Treatments carried out at this stage use braces to maintain
the space that arises when the baby back teeth (molars) are lost and Types of outcome measures
replaced by smaller adult side teeth (premolars). Other treatments
Primary: Amount of crowding (measured in mm or by any index
can be used later when all the adult teeth have come into the
of malocclusion).
mouth (around 12 to 16 years of age) and either use braces to
Secondary: Relationship of the lower back teeth (molars) to the
expand the teeth and/or jaws or remove teeth to create space so that
lower jaw (mandible); relationship of the lower front teeth (in-
the remaining teeth can be straightened using a brace. The braces
cisors) to the lower jaw (mandible); self-esteem; patient satisfac-
can either be removed from the mouth or fixed to the teeth, with
tion; jaw joint problems.
special glue, during treatment. Other types of brace are attached,
Harms: Health of the gums; damage to the teeth e.g. tooth decay.
via the teeth, to devices (headgear) that allow a force to be applied
Outcomes will be recorded at all ages reported. The results will be
to the teeth and jaws from the back of the head.
reported according to the most common endpoints.
Harms will be recorded and the results reported in descriptive
terms.
OBJECTIVES
To test the null hypotheses that there are no differences in out-
comes between Search methods for identification of studies
For the identification of studies included or considered for this re-
• the age at which orthodontic treatment for crowded teeth is view detailed search strategies will be developed for each database
carried out; searched. These will be based on the search strategy developed for
MEDLINE but revised appropriately for each database. The sub-
ject search strategy will use a combination of controlled vocabulary
• different orthodontic interventions for correcting/ and free text terms based on the search strategy for MEDLINE, in
preventing crowded teeth against the alternative hypothesis that conjunction with phases 1 & 2 of the Cochrane sensitive search
there are. strategy for RCTs as published in the Cochrane Handbook for Sys-
tematic Reviews of Interventions 4.2, Appendix 5c. See Appendix 1.

METHODS
Databases to be searched
The following databases will be searched:
Criteria for considering studies for this review Cochrane Central Register of Controlled Trials (CENTRAL) (The
Cochrane Library current issue)
Cochrane Oral Health Group Specialised Register (to current
date)
Types of studies MEDLINE (1966 to present)
All randomised and controlled clinical trials of orthodontic treat- EMBASE (1980 to present).
ments to correct or prevent crowding.

Handsearching
Types of participants Handsearching of the following journals, that has been carried
Trials will be eligible for inclusion in the review if they have re- out as part of the Cochrane Oral Health Group’s handsearching
cruited children and/or adolescents (age 16 years or less) receiving programme, will be updated to the most current issue:
orthodontic treatment to correct or prevent crowding. • American Journal of Orthodontics & Dentofacial Orthopedics
Trials including patients with a cleft lip and/or palate or other • Angle Orthodontist
cranio-facial deformity/syndrome will be excluded as will trials • European Journal of Orthodontics
that have recruited less than 80% children or adolescents. • Journal of Orthodontics.

Orthodontic treatment for crowded teeth in children (Protocol) 2

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
In addition, the following journals will be handsearched from their crowding and the secondary outcomes will be the size of the up-
inception to date: per jaw, size of the lower jaw, self-esteem patient satisfaction and
• Seminars in Orthodontics (from 1995 to the most current jaw joint problems. Other outcomes studied will be recorded for
issue) descriptive purposes e.g. relationship of the lower back teeth (mo-
• Clinical Orthodontics and Research (from 1998 to the most lars) and lower front teeth (incisors) to the lower jaw (mandible).
current issue) Harms e.g. health of the gums, damage to the teeth e.g. tooth de-
• Australian Journal of Orthodontics (from 1956 to the most cay will be recorded and the results reported in descriptive terms.
current issue). Outcome data will be grouped into those measured post phase I
(growth modification phase) and post phase II (fixed brace phase)
The bibliographies of the clinical trials identified will be checked
and, where available, post-retention outcomes will be recorded
for references to trials published outside the handsearched jour-
and reported. If outcome data are recorded at other time points
nals.
then consideration will be given to examining these as well.
Personal references will be checked.

Quality assessment
Language
The quality assessment of the included trials will be undertaken
Databases will be searched to include all languages and attempts
independently and in duplicate by two review aurhos (JH and
will be made to translate non-English language papers.
JMS) as part of the data extraction process.
Four main quality criteria will be examined:
Unpublished studies 1) Allocation concealment, recorded as:
(A) Adequate
The first named authors of all trial reports will be contacted in an
(B) Unclear
attempt to identify unpublished studies and to obtain any further
(C) Inadequate
information about the trials.
as described in the Cochrane Handbook for Systematic Reviews of
Interventions 4.2.
2) Blind outcome assessment.
Data collection and analysis 3) Completeness of follow up
4) Intention-to-treat analysis.

Study selection
Data analysis
Two review authors (J Harrison and J Scholey (JH and JMS)) will
independently assess the eligibility of all reports that are identified The Cochrane Collaboration statistical guidelines will be followed
by the search strategy as being potentially relevant to the review. and the data will be analysed using RevMan and reported accord-
The review authors will not be blind to author(s), institution or ing to Cochrane Collaboration criteria. Heterogeneity will be as-
site of publication. Agreement will be assessed using the kappa sessed using Cochran’s test and, if significant heterogeneity is de-
statistic (Landis 1977). tected, the significance of treatment effects will be assessed using
the random-effects model. Risk ratio, the number needed to treat
and corresponding 95% confidence intervals, will be calculated
Data extraction for dichotomous data. The weighted mean difference and 95%
Two review authors (JH and JMS) will independently record the confidence intervals will be calculated for continuous data. A sub-
year of publication, interventions assessed, outcomes, sample size group analysis will be carried out on the age (stage of dental de-
and age of subjects. The primary outcome will be the amount of velopment) that treatment was carried out.

Orthodontic treatment for crowded teeth in children (Protocol) 3

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 REFERENCES
Additional references Shaw 1981
Shaw WC. The influence of children’s dentofacial
Holmes 1992 appearance on their social attractiveness as judged by peers
Holmes A. The prevalence of orthodontic treatment need. and lay adults. American Journal of Orthodontics 1981;79
British Journal of Orthodontics 1992;19(3):177–82. (4):399–415.
Landis 1977
Shaw 1985
Landis JR, Koch GG. The measurement of observer
Shaw WC, Rees G, Dawe M, Charles CR. The influence of
agreement for categorical data. Biometrics 1977;33(1):
dentofacial appearance on the social attractiveness of young
159–74.
adults. American Journal of Orthodontics 1985;87(1):21–6.
Proffit 1998
Proffit WR, Fields HW Jr, Moray LJ. Prevalence of Shaw 1991
malocclusion and orthodontic treatment need in the Shaw WC, Richmond S, O’Brien KD, Brook P, Stephens
United States: estimates from the NHANES III survey. CD. Quality control in orthodontics: Indices of treatment
International Journal of Adult Orthodontics and Orthognathic need and treatment standards. British Dental Journal 1991;
Surgery 1998;13(2):97–106. 170(3):107–12.
Shaw 1980 Silva 2001
Shaw WC, Addy M, Ray C. Dental and social effects of Silva RG, Kang DS. Prevalence of malocclusion among
malocclusion and effectiveness of orthodontic treatment: a Latino adolescents. American Journal of Orthodontics and
review. Community Dentistry and Oral Epidemiology 1980;8 Dentofacial Orthopedics 2001;119(3):313–5.
(1):36–45. ∗
Indicates the major publication for the study

APPENDICES

Appendix 1. MEDLINE search strategy

#1 MALOCCLUSION-ANGLE-CLASS-I (ME)
#2 MALOCCLUSION-ANGLE-CLASS-II (ME)
#3 MALOCCLUSION-ANGLE-CLASS-III (ME)
#4 (“Class I” AND ((Angle OR Angle’s) OR malocclusion OR bite)
#5 (“Class II” AND ((Angle OR Angle’s) OR malocclusion OR bite)
#6 (“Class III” AND ((Angle OR Angle’s) OR malocclusion OR bite)
#7 crowd* NEAR teeth
#8 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7
#9 (Explode) ORTHODONTIC-APPLIANCES-FUNCTIONAL (ME)
#10 (Explode) ORTHODONTIC-APPLIANCES-REMOVABLE (ME)
#11 (Explode) ORTHODONTICS-PREVENTIVE (ME)
#12 (Explode) ORTHODONTICS-INTERCEPTIVE (ME)
#13 (Explode) TOOTH EXTRACTION (ME)
#14 “leeway space*”
#15 ((Extraoral OR “extra oral” OR extra-oral) AND appliance*)
#16 “Lip bumper*”
#17 ((“two-phase” (treatment OR therapy)) AND (orthodontic* OR malocclusion))
#18 (“arch development” AND (jaw or mandible OR maxilla*))
#19 ((extraction AND (dental OR teeth OR tooth)) AND orthodontic*)
#20 expansion AND (jaw or maxilla*)
#21 (“serial extract*” AND (teeth OR orthodontic*))
#22 (“space maintenance” AND orthodontic*)
#23 #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17
Orthodontic treatment for crowded teeth in children (Protocol) 4
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
OR #18 OR #19 OR #20 OR #21 OR #22
#24#8 AND #23

WHAT’S NEW

Date Event Description

23 June 2008 Amended Converted to new review format.

HISTORY
Protocol first published: Issue 1, 2002

CONTRIBUTIONS OF AUTHORS
The review was conceived by Jayne Harrison (JEH), Kevin O’Brien (KDO’B) and Bill Shaw (WCS). Previous work, that was the
foundation of current study, was undertaken by Sylvia Bickley (SRB), JEH and KDO’B. The protocol was written by JEH, SRB, Helen
Worthington (HVW), KDO’B and WCS.
The review will be co-ordinated by JEH and J Scholey (JMS). SRB will develop the search strategy and undertake the electronic
searches. JMS will undertake the handsearching. JEH and JMS will screen the search results and retrieved papers, appraise the quality
of the papers and extract data from them. HVW will check the data extraction, analyse and interpret the data. JEH, JMS and HVW
will write the review.

DECLARATIONS OF INTEREST
None known.

SOURCES OF SUPPORT

Internal sources
• The Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK.
• The University of Manchester, UK.

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
External sources
• NHS National Primary Dental Care R&D programme, UK.
• NHS R&D programme supports the Cochrane Oral Health Group Editorial Base, UK.

Orthodontic treatment for crowded teeth in children (Protocol) 6

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.