Orthodontic treatment for prominent lower front teeth (Class III malocclusion) in children

Prominent lower front teeth (Class III malocclusion) may be due to jaw or tooth position or both. The upper jaw (maxilla) can be too far back or the lower jaw (mandible) too far forward; the upper front teeth (incisors) may be tipped back or the lower front teeth tipped forwards. Orthodontic treatment uses different types of braces (appliances) fitted inside or outside the mouth (or both) and fixed to the teeth. A facemask is the most commonly reported non-surgical intervention used to correct Class III malocclusion. The facemask rests on the forehead and chin, and is connected to the upper teeth via an expansion appliance (known as 'rapid maxillary expansion' (RME)). Using elastic bands placed by the wearer, a force is applied to the top teeth and jaw to pull them forwards and downward. Some orthodontic interventions involve a surgical component; these go through the gum into the bone (e.g. miniplates). In severe cases, or if orthodontic treatment is unsuccessful, people may need jaw (orthognathic) surgery as adults. This review updates one published in 2013.

To assess the effects of orthodontic treatment for prominent lower front teeth in children and adolescents.

An information specialist searched four bibliographic databases and two trial registries up to 16 January 2023. Review authors screened reference lists.

We looked for randomised controlled trials (RCTs) involving children and adolescents (16 years of age or under) randomised to receive orthodontic treatment to correct prominent lower front teeth (Class III malocclusion), or no (or delayed) treatment.

We used standard methodological procedures expected by Cochrane. Our primary outcome was overjet (i.e. prominence of the lower front teeth); our secondary outcomes included ANB (A point, nasion, B point) angle (which measures the relative position of the maxilla to the mandible).

We identified 29 RCTs that randomised 1169 children (1102 analysed). The children were five to 13 years old at the start of treatment. Most studies measured outcomes directly after treatment; only one study provided long-term follow-up. All studies were at high risk of bias as participant and personnel blinding was not possible. Non-surgical orthodontic treatment versus untreated control We found moderate-certainty evidence that non-surgical orthodontic treatments provided a substantial improvement in overjet (mean difference (MD) 5.03 mm, 95% confidence interval (CI) 3.81 to 6.25; 4 studies, 184 participants) and ANB (MD 3.05°, 95% CI 2.40 to 3.71; 8 studies, 345 participants), compared to an untreated control group, when measured immediately after treatment. There was high heterogeneity in the analyses, but the effects were consistently in favour of the orthodontic treatment groups rather than the untreated control groups (studies tested facemask (with or without RME), chin cup, orthodontic removable traction appliance, tandem traction bow appliance, reverse Twin Block with lip pads and RME, Reverse Forsus and mandibular headgear). Longer-term outcomes were measured in only one study, which evaluated facemask. It presented low-certainty evidence that improvements in overjet and ANB were smaller at 3-year follow-up than just after treatment (overjet MD 2.5 mm, 95% CI 1.21 to 3.79; ANB MD 1.4°, 95% CI 0.43 to 2.37; 63 participants), and were not found at 6-year follow-up (overjet MD 1.30 mm, 95% CI -0.16 to 2.76; ANB MD 0.7°, 95% CI -0.74 to 2.14; 65 participants). In the same study, at the 6-year follow-up, clinicians made an assessment of whether surgical correction of participants' jaw position was likely to be needed in the future. A perceived need for surgical correction was observed more often in participants who had not received facemask treatment (odds ratio (OR) 3.34, 95% CI 1.21 to 9.24; 65 participants; low-certainty evidence). Surgical orthodontic treatment versus untreated control One study of 30 participants evaluated surgical miniplates, with facemask or Class III elastics, against no treatment, and found a substantial improvement in overjet (MD 7.96 mm, 95% CI 6.99 to 8.40) and ANB (MD 5.20°, 95% CI 4.48 to 5.92; 30 participants). However, the evidence was of low certainty, and there was no follow-up beyond the end of treatment. Facemask versus another non-surgical orthodontic treatment Eight studies compared facemask or modified facemask (with or without RME) to another non-surgical orthodontic treatment. Meta-analysis did not suggest that other treatments were superior; however, there was high heterogeneity, with mixed, uncertain findings (very low-certainty evidence). Facemask versus surgically-anchored appliance There may be no advantage of adding surgical anchorage to facemasks for ANB (MD -0.35, 95% CI -0.78 to 0.07; 4 studies, 143 participants; low-certainty evidence). The evidence for overjet was of very low certainty (MD -0.40 mm, 95% CI -1.30 to 0.50; 1 study, 43 participants). Facemask variations Adding RME to facemask treatment may have no additional benefit for ANB (MD -0.15°, 95% CI -0.94 to 0.64; 2 studies, 60 participants; low-certainty evidence). The evidence for overjet was of low certainty (MD 1.86 mm, 95% CI 0.39 to 3.33; 1 study, 31 participants). There may be no benefit in terms of effect on ANB of alternating rapid maxillary expansion and constriction compared to using expansion alone (MD -0.46°, 95% CI -1.03 to 0.10; 4 studies, 131 participants; low-certainty evidence).

Moderate-certainty evidence showed that non-surgical orthodontic treatments (which included facemask, reverse Twin Block, orthodontic removable traction appliance, chin cup, tandem traction bow appliance and mandibular headgear) improved the bite and jaw relationship immediately post-treatment. Low-certainty evidence showed surgical orthodontic treatments were also effective. One study measured longer-term outcomes and found that the benefit from facemask was reduced three years after treatment, and appeared to be lost by six years. However, participants receiving facemask treatment were judged by clinicians to be less likely to need jaw surgery in adulthood. We have low confidence in these findings and more studies are required to reach reliable conclusions. Orthodontic treatment for Class III malocclusion can be invasive, expensive and time-consuming, so future trials should include measurement of adverse effects and patient satisfaction, and should last long enough to evaluate whether orthodontic treatment in childhood avoids the need for jaw surgery in adulthood.