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32 Orthodontics KCE Reports 77 Figure 4: Class II division 2 malocclusion A Cochrane review about the orthodontic treatment for deep bite and retroclined upper front teeth in children, the so called Class II,2 malocclusion according to Angle’s classification, was published in 2006. In patients with a Class II, 2 malocclusion often due to the deep bite a palatal or lower labial gingival trauma is detected 18 ;furthermore there exists an aesthetic impairment. It seems to be likely that a greater percentage of upper permanent canines are impacted in patients with a Class II, 2 malocclusion. Different treatments may be used to correct this malocclusion. It is not possible to provide any evidence-based guidance to clinicians with respect to a Class II, 2 malocclusion due to the fact that no randomised controlled trial or controlled clinical trial was identified. 18 Although no clinical evidence was found on this topic, it is clear that from a dental health point of view gingival trauma should be avoided. No randomized or controlled clinical trials were found concerning the treatment of Class II,2 treatment and no recommendation can be made. CLASS III MALOCCLUSION In a Class III malocclusion, the lower molars and canines occlude too far mesially relative to the upper molars: this type of occlusion is also called a mesio-occlusion (Figure 5). Besides the deviation in the sagittal occlusion, all intra-arch deviations can also be superimposed on Cl III malocclusions. Figure 5: Class III malocclusion Only a protocol for a Cochrane systematic review exists. Therefore the treatment of Class III malocclusions is discussed by means of other original articles. In a meta-analysis Kim et al. 19 evaluated the effectiveness of maxillary protaction with orthopaedic appliances for the treatment of Class III patients. The conclusion drawn from this meta-analysis was that protraction face mask therapy is effective in growing patients, but to a lesser degree in patients older than 10 years, and that protraction combined with an initial period of expansion might provide more significant skeletal effects.
KCE Reports 77 Orthodontics 33 However the results of this meta-analysis should be regarded with caution, because there was a lack of standardization of the design of various studies and the necessity to use all studies that met the inclusion criteria 19 . Jager et al. 20 came to a similar conclusion in their meta-analysis on the treatment effects of maxillary protraction on the craniofacial growth of patients with Angle Class III malocclusions. Maxillary protraction could modify the skeletal and dental components of the face, thus it seems that protraction treatment is effective in growing patients but to a lesser degree in patients older than 10 yrs and that protraction combined with an initial period of expansion might provide more significant skeletal effects. The weakness of this study was the limited literature search in only one database (MEDLINE), the fact that a specially designed test for Meta Analysis was performed adds strength to this study. Although moderate quality of evidence exists for treatment of class III malocclusions before the age of 10 years, early treatment of Class III malocclusions in cases with an increased lower face height and minimal overbites is generally not successful 19 , 20 . The level of evidence for the effectiveness (especially before the age of 10 years) of protraction face mask therapy in Class III malocclusions is moderate. ANTERIOR OPEN BITE In patients with an anterior open bite no vertical overlap or contact between the maxillary and mandibular incisors is present (Figure 6). This vertical malocclusion can not only be superimposed with any type of sagittal malocclusion (Cl II,1 Cl II,2, Cl III), but also with all types of intra-arch deviations. Figure 6: Anterior open bite malocclusion A Cochrane review on the orthodontic and orthopaedic treatment for anterior open bite in children has been published in 2005 21 The causes of open bites are considered multifactorial. It can be due to a combination of skeletal, dental and soft tissue effects. The prevalence of an open bite ranges from 17 to 18% of the children in the mixed dentition. When associated with sucking habits the prevalence increases to 36.3% 21 Low evidence was found that a Frankel’s function regulator-4 (FR-4) with lip seal training, or a removable appliance with palatal crib associated with high-pull chincup, are able to correct open bite in children. Given that the two included trials have a potential bias, these results must be viewed with caution. Therefore it should be concluded that there is no clear evidence on which to make a clinical decision of the type of intervention to use in correcting an anterior open bite in children. 21 In a systematic review on early treatment of skeletal open-bite malocclusion Cozza et al 22 , the quality level of the studies was not sufficient enough to draw any evidence-based conclusions. Most of the studies had serious problems of lack of power because of small sample size, bias and confounding variables, lack of method error analysis, blinding in measurements, and deficient or lack of statistical methods. This was in agreement with the Cochrane Review of 2005. The evidence for treatment of anterior open bite is insufficient and no recommendation can yet be made.
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