Two-phase orthodontic treatment can significantly reduce damage to incisor teeth

Malocclusion Class IIProminent (or sticking out) upper front teeth are a common problem affecting about a quarter of 12 year-old children in the UK.  This condition can develop when a child’s permanent (adult) teeth erupt, and children are often referred for treatment with dental braces to reduce the prominence of the teeth. Prominent upper front teeth are more likely to be injured and their appearance can cause distress.  In two phase treatment, treatment is given first at an early age (7-11) and then again in adolescence (11-16). In one phase treatment, there is only one course of treatment, in adolescence. This review looks at whether one or two stage treatment is more effective, and also looks at the different types of braces used.

What was the research?

A systematic review of the evidence to find out when treatment is best provided to children with prominent upper front teeth, and which type of brace is more effective.

Who conducted the research?

The research was conducted by a team led by Badri Thiruvenkatachari from the University of Manchester, on behalf of the Cochrane Oral Health Group. Jayne E. Harrison, Helen V. Worthington and Kevin D. O’Brien were also on the team.

What evidence was included in the review?

Data was extracted from 17 randomised controlled trials. A total of 712 under 16 year olds with prominent upper front teeth participated in the trials, and were randomly assigned to early treatment or late treatment. Trials comparing any type of orthodontic brace (removable, fixed, functional) or head brace compared with another type of brace or no treatment, were also included.

What did the evidence say?

The evidence suggests that providing orthodontic treatment for children with prominent upper front teeth in two phases appears to significantly reduce the incidence of damage to incisor teeth (middle four teeth at the top), as compared to treatment that is provided in one phase when the child is in early adolescence. There are no other advantages for providing a two-phase treatment i.e. early from age seven to 11 years and again in adolescence compared to one phase in adolescence.

When functional appliance treatment is provided in early adolescence it appears that there are minor beneficial changes in skeletal pattern, however, these are probably not clinically significant. Similarly, the choice of functional appliance when compared to the Twin Block does not result in any advantageous effects.

How good was the evidence?

The quality of the evidence was low, with only 2 trials being assessed at low risk of bias.

What are the implications for dentists and the general public?

Orthodontic treatment for young children, followed by a later phase of treatment when the child is in early adolescence appears to significantly reduce the incidence of incisal trauma.

What should researchers look at in the future?

Researchers need to form a consensus on the type of measures that are used in orthodontic trials. Studies should be carried out at the same time points and reported according to the CONSORT guidelines.


Thiruvenkatachari B, Harrison JE, Worthington HV, O’Brien KD. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD003452. DOI: 10.1002/14651858.CD003452.pub3.

One of the review’s authors Professor Kevin D. O’Brien, discusses the review and its importance on his Orthodontic Blog.