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. Jayne.Harrison@rlbuht.nhs.uk.

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
Orthodontics is the branch of dentistry concerned with the growth
of the jaws and face, the development of the teeth and the way
the teeth and jaws bite together. It also involves treatment of the
teeth and jaws when they are irregular and/or bite in an abnormal
way. There are many reasons why the teeth may not bite together
correctly. These include the position of the teeth, jaws, lips, tongue,
and/or cheeks or may be due to a habit or the way people breath.
The need for treatment can be decided by looking at the effect of
any particular tooth position on the life expectancy of the teeth
and/or the effect that the appearance of the teeth has on how
people feel about themselves (Shaw 1991).
Crowded teeth develop when there is not enough space in the jaws
for the teeth to erupt into. This gives the patient crooked or wonky
Orthodontic treatment for crowded teeth in children (Protocol)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
teeth that may be the source of teasing at school (Shaw 1980;
Shaw 1981) and/or later in life (Shaw 1985). Crowded teeth is
the commonest problem seen by orthodontists. Crowding affects
nearly a half of 12 year old children in the UK (Holmes 1992).
Levels of crowding in other populations vary with whites and His-
panics having the greatest amount and black and Chinese the least
(Proffit 1998; Silva 2001). Crowding can affect the baby teeth
(primary dentition) and/or the adult teeth (permanent dentition).
Crowding tends to increase with age, especially in the lower jaw,
so that only a third of adults have well aligned lower front teeth
(incisors) (Proffit 1998). Crowding occurs when there is a differ-
ence between the size of the jaws and teeth e.g. the jaws are too
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
result of tooth decay or trauma.
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Several dental brace (orthodontic) treatments have been suggested
to correct or prevent crowding. Some treatments use braces to
expand the teeth and/or jaws. They can be carried out early, before
6 years of age, when the patients have only their baby teeth present.
Other treatments can be carried out when the patients have a
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
replaced by smaller adult side teeth (premolars). Other treatments
can be used later when all the adult teeth have come into the
mouth (around 12 to 16 years of age) and either use braces to
expand the teeth and/or jaws or remove teeth to create space so that
the remaining teeth can be straightened using a brace. The braces
can either be removed from the mouth or fixed to the teeth, with
special glue, during treatment. Other types of brace are attached,
via the teeth, to devices (headgear) that allow a force to be applied
to the teeth and jaws from the back of the head.
OBJECTIVES
To test the null hypotheses that there are no differences in out-
comes 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.
METHODS
Criteria for considering studies for this review
Types of studies
All randomised and controlled clinical trials of orthodontic treat-
ments to correct or prevent crowding.
Types of participants
Trials will be eligible for inclusion in the review if they have re-
cruited children and/or adolescents (age 16 years or less) receiving
orthodontic treatment to correct or prevent crowding.
Trials including patients with a cleft lip and/or palate or other
cranio-facial deformity/syndrome will be excluded as will trials
that have recruited less than 80% children or adolescents.
Orthodontic treatment for crowded teeth in children (Protocol)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Types of interventions
Active interventions: Orthodontic braces (removable, fixed, func-
tional), head-braces or extractions.
Control: may be no treatment, delayed treatment or another active
intervention.
Types of outcome measures
Primary: Amount of crowding (measured in mm or by any index
of malocclusion).
Secondary: Relationship of the lower back teeth (molars) to the
lower jaw (mandible); relationship of the lower front teeth (in-
cisors) to the lower jaw (mandible); self-esteem; patient satisfac-
tion; jaw joint problems.
Harms: Health of the gums; damage to the teeth e.g. tooth decay.
Outcomes will be recorded at all ages reported. The results will be
reported according to the most common endpoints.
Harms will be recorded and the results reported in descriptive
terms.
Search methods for identification of studies
For the identification of studies included or considered for this re-
view detailed search strategies will be developed for each database
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
and free text terms based on the search strategy for MEDLINE, in
conjunction with phases 1 & 2 of the Cochrane sensitive search
strategy for RCTs as published in the Cochrane Handbook for Sys-
tematic Reviews of Interventions 4.2, Appendix 5c. See Appendix 1.
Databases to be searched
The following databases will be searched:
Cochrane Central Register of Controlled Trials (CENTRAL) (The
Cochrane Library current issue)
Cochrane Oral Health Group Specialised Register (to current
date)
MEDLINE (1966 to present)
EMBASE (1980 to present).
Handsearching
Handsearching of the following journals, that has been carried
out as part of the Cochrane Oral Health Group’s handsearching
programme, will be updated to the most current issue:
• American Journal of Orthodontics & Dentofacial Orthopedics
• Angle Orthodontist
• European Journal of Orthodontics
• Journal of Orthodontics.
2
In addition, the following journals will be handsearched from their
inception to date:
• Seminars in Orthodontics (from 1995 to the most current
issue)
• Clinical Orthodontics and Research (from 1998 to the most
current issue)
• Australian Journal of Orthodontics (from 1956 to the most
current issue).
The bibliographies of the clinical trials identified will be checked
for references to trials published outside the handsearched jour-
nals.
Personal references will be checked.
Language
Databases will be searched to include all languages and attempts
will be made to translate non-English language papers.
Unpublished studies
The first named authors of all trial reports will be contacted in an
attempt to identify unpublished studies and to obtain any further
information about the trials.
Data collection and analysis
Study selection
Two review authors (J Harrison and J Scholey (JH and JMS)) will
independently assess the eligibility of all reports that are identified
by the search strategy as being potentially relevant to the review.
The review authors will not be blind to author(s), institution or
site of publication. Agreement will be assessed using the kappa
statistic (Landis 1977).
Data extraction
Two review authors (JH and JMS) will independently record the
year of publication, interventions assessed, outcomes, sample size
and age of subjects. The primary outcome will be the amount of
Orthodontic treatment for crowded teeth in children (Protocol)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
crowding and the secondary outcomes will be the size of the up-
per jaw, size of the lower jaw, self-esteem patient satisfaction and
jaw joint problems. Other outcomes studied will be recorded for
descriptive purposes e.g. relationship of the lower back teeth (mo-
lars) and lower front teeth (incisors) to the lower jaw (mandible).
Harms e.g. health of the gums, damage to the teeth e.g. tooth de-
cay will be recorded and the results reported in descriptive terms.
Outcome data will be grouped into those measured post phase I
(growth modification phase) and post phase II (fixed brace phase)
and, where available, post-retention outcomes will be recorded
and reported. If outcome data are recorded at other time points
then consideration will be given to examining these as well.
Quality assessment
The quality assessment of the included trials will be undertaken
independently and in duplicate by two review aurhos (JH and
JMS) as part of the data extraction process.
Four main quality criteria will be examined:
1) Allocation concealment, recorded as:
(A) Adequate
(B) Unclear
(C) Inadequate
as described in the Cochrane Handbook for Systematic Reviews of
Interventions 4.2.
2) Blind outcome assessment.
3) Completeness of follow up
4) Intention-to-treat analysis.
Data analysis
The Cochrane Collaboration statistical guidelines will be followed
and the data will be analysed using RevMan and reported accord-
ing to Cochrane Collaboration criteria. Heterogeneity will be as-
sessed using Cochran’s test and, if significant heterogeneity is de-
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
for dichotomous data. The weighted mean difference and 95%
confidence intervals will be calculated for continuous data. A sub-
group analysis will be carried out on the age (stage of dental de-
velopment) that treatment was carried out.
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 REFERENCES
Additional references
Holmes 1992
Holmes A. The prevalence of orthodontic treatment need.
British Journal of Orthodontics 1992;19(3):177–82.
Landis 1977
Landis JR, Koch GG. The measurement of observer
agreement for categorical data. Biometrics 1977;33(1):
159–74.
Proffit 1998
Proffit WR, Fields HW Jr, Moray LJ. Prevalence of
malocclusion and orthodontic treatment need in the
United States: estimates from the NHANES III survey.
International Journal of Adult Orthodontics and Orthognathic
Surgery 1998;13(2):97–106.
Shaw 1980
Shaw WC, Addy M, Ray C. Dental and social effects of
malocclusion and effectiveness of orthodontic treatment: a
review. Community Dentistry and Oral Epidemiology 1980;8
(1):36–45.
Shaw 1981
Shaw WC. The influence of children’s dentofacial
appearance on their social attractiveness as judged by peers
and lay adults. American Journal of Orthodontics 1981;79
(4):399–415.
Shaw 1985
Shaw WC, Rees G, Dawe M, Charles CR. The influence of
dentofacial appearance on the social attractiveness of young
adults. American Journal of Orthodontics 1985;87(1):21–6.
Shaw 1991
Shaw WC, Richmond S, O’Brien KD, Brook P, Stephens
CD. Quality control in orthodontics: Indices of treatment
need and treatment standards. British Dental Journal 1991;
170(3):107–12.
Silva 2001
Silva RG, Kang DS. Prevalence of malocclusion among
Latino adolescents. American Journal of Orthodontics and
Dentofacial Orthopedics 2001;119(3):313–5.
∗
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.

Orthodontic treatment for crowded teeth in children (Protocol) 5

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.