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56 Orthodontics KCE Reports 77 The possible trauma-preventive effect of early overjet correction has to be verified by randomised controlled studies in children in the early mixed dentition 4 . There is a general acceptance of the need for early treatment of forced posterior cross bites 83 . The consequence of an untreated posterior cross bite is an asymmetric condular position, which may result in a craniofacial asymmetry and some studies indicate a possible association with an increased risk of temporomandibular disorders 83 . However, taken all malocclusions together, low evidence exists that there is no increase in TMD (see section 2.3.1.2). The correction of a posterior cross bite by maxillary expansion may be postponed to the early mixed dentition, because the transverse relations may have the capacity to normalize due to a favourable change in function 83 . Open bites due to sucking habits usually correct spontaneously after breaking the habit 83 109 , . There is no conclusive evidence on how to treat persistent open bites or open bites due to other causes (see section 2.3.1). The prolonged retention of deciduous teeth may be due to ankylosis or failure of the permanent successor to resorb the roots of the deciduous tooth. The preventive measure to take is the extraction of the deciduous tooth 109 . The limitations of early orthodontic treatment are unfavourable craniofacial growth, persistent habits, severe ectopic eruption and congenitally malformed or missing permanent teeth 109 . The goals of early orthodontic treatment should always be kept in mind in order to avoid unnecessary two – phase treatment 109 , since a second phase of treatment with fixed appliance is often required in adult dentition, due to recurrence of the malocclusion 109 . There is poor evidence to recommend for or against the use of space maintainers to prevent or reduce the severity of malocclusion in the permanent dentition 73 The early reduction of an increased overjet was not very productive 77 . The possible trauma –preventive effect of early overjet correction has to be verified by randomised controlled studies in children in the early mixed dentition 4 . Systematically applied early treatment may have contributed to a significant reduction of treatment need from 8 to 12 years, but this remains to be confirmed. If no treatment need existed at the age of 8, the prognosis for no treatment need at the age of 12 seemed good 111 . Evidence on the efficiency of early orthodontic treatment is rare 80 . One study was found that stated that the age of 12 is too early to make a decision about orthodontic treatment on aesthetic grounds both from psychological and physical viewpoint 77 PREVENTION VERSUS INTERCEPTION OF ORTHODONTIC PROBLEMS • Large overjets > 6 mm, which may predispose for traumatic injuries of upper front teeth and forced crossbites may benefit from an interceptive treatment. The possible trauma-preventive effect of early overjet correction has to be verified by randomised controlled studies in children in the early mixed dentition. • The extraction of lower deciduous canines for the ‘relief’ of lower arch crowding is questionable. • There is a no evidence to recommend for or against the use of space maintainers to prevent or reduce the severity of malocclusion in the permanent dentition.
KCE Reports 77 Orthodontics 57 2.3.8 Retention and stability Retention is the phase after an active orthodontic treatment with braces in which an attempt is made to keep the teeth in their well-aligned position. Without the retentionphase a relapse may occur or especially in the lower arch tertiary crowding is allowed to progress. The retention can be achieved by fixed or removable retainers or a combination of both. A Cochrane review was published in 2007 about retention procedures for stabilising tooth position after treatment with orthodontic braces 112 . However, insufficient evidence was available on which to base clinical guidance. Studies investigating the morphological stability 5 years or more after an orthodontic treatment have shown insufficient scientific evidence for conclusions on stability after treatment of other morphological discrepancies 2 Orthodontic treatment of crowding aligns the dental arch. However, the length and width of the mandibular dental arch gradually shorten in the long term, and crowding of the anterior teeth can reoccur. This condition cannot be predicted at the individual level (Low scientific evidence) 2 . On the other hand, crowding of the anterior teeth can develop newly during adulthood. Treatment of a large overjet with fixed appliances according to Herbst normalizes the occlusion. Relapses occur, but cannot be predicted at the individual level (Low scientific evidence) 2 Scientific evidence is insufficient for conclusions on patient satisfaction in the long term (at least 5 years) after the conclusion of orthodontic treatment. 2 . In conclusion it can be stated that there is an urgent need for more high quality randomised controlled trials. RETENTION AND STABILITY • Treatment of crowding aligns the dental arch. However, the length and width of the mandibular dental arch gradually shorten in the long term and crowding of the anterior teeth can reoccur (or develop newly during adulthood) if not retained. This condition cannot be predicted at the individual level (low quality of evidence). • Treatment of a large overjet with fixed appliances according to Herbst normalizes the occlusion. Relapses occur, but cannot be predicted at the individual level (low quality of evidence). • Scientific evidence is insufficient for conclusions on stability after treatment of other morphological discrepancies. • Scientific evidence is insufficient for conclusion on patient satisfaction in the long term (at least 5 years) after orthodontic treatment. 2.4 CONCLUSIONS OF THE REPORT OF THE CLINICAL LITERATURE SEARCH 2.4.1 Orthodontics and evidence-based medicine At the present time only for a few orthodontic topics there is adequately supported evidence. This is in agreement with the findings of other studies 2 ; 9 . Several of the assessed studies, yet included in this review, showed some limitations, which made it impossible to find evidence for them. The main limitations were: publication biases, no homogeneity of primary data, lack of information about sample and control group, the subjects included in the studies had different ages, the pre-treatment and outcome measures were assessed by a widely range of indexes, different types of interventions were compared.
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