SLJO

Sri Lankan Journal of Orthodontics

THE PRACTICE OF EVIDENCE-BASED ORTHODONTICS: AN ANALYSIS PAPER OF ITS UNDERLYING PRINCIPLES AND CURRENT EVIDENCE FOR THE MANAGEMENT OF SKELETAL MALOCCLUSIONS

Priti Subhash Mulimani

Department of Orthodontics, Faculty of Dentistry, Melaka Manipal Medical College – Malaysia

Present day orthodontic practitioners are more aware and have a greater understanding regarding the importance of integrating evidence-based research findings with their clinical practice. However when it comes to implementing these findings in reality, most important barriers are stated to be either a poor understanding of evidence-based practice or ambiguous and conflicting research. The numerous systematic reviews and meta-analysis that are regularly conducted, often times conclude that there is insufficient data in orthodontic literature to get clear answers. These issues in orthodontic research often create a perception of lack of clarity and information for practical implementation of Evidence-based Orthodontics (EBO).

With an objective to facilitate better understanding and application of EBO in day-to-day clinical routine, this commentary presents an elaborate elucidation of the underlying principles of an evidence-based practice. It will provide insights into the different types of orthodontic study designs, with particular emphasis on systematic reviews (SRs) and meta-analysis. A section on Cochrane systematic reviews, considered to be the most rigorous types producing the most reliable evidence, is also included along with the current Cochrane evidence on the management of skeletal malocclusion in Orthodontics. The often encountered issues, which inhibit clinicians from adopting EBP are also addressed and suggestions to overcome the barriers are also provided.

Key words: Evidence based orthodontics, Evidence based practice, Cochrane, Systematic reviews, Meta-analysis

Introduction

Evidence-based practice (EBP) was defined by Sackett1 as the conscientious, explicit, and judicious use of current best evidence when making decisions about the care of a patient. Thus, evidence-based care is a triad of 3 domains – clinical expertise, best research evidence and patient preferences or values (Figure 1). Clinical expertise is not merely possessing an educational qualification but deepening and applying learnt knowledge further to acquire greater proficiency and acumen in diagnostic skills and treatment modalities through clinical practice and experience. Clinical expertise and research evidence are said to complement each other, one being incomplete without the other. To quote Sackett “without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.” Factors determining adoption of EBP by practitioners have been described in the “EPIC” framework as Environment (which includes the social, cultural and professional background of the practitioner), Personality of practitioner, Identity of practice, and Cognitive abilities2.

(Figure 1). 

How to find answers to the clinical questions? Research questions and study designs:

To obtain pertinent answers to clinical problems, clinicians and researchers should adopt the PICO format of questioning where P stands for participants or patients, I for Intervention, C for Comparisons and O for Outcome. For example, to investigate best treatment options for missing lateral incisors the PICO question would be – In patients undergoing orthodontic treatment for agenesis of  lateral incisors, will space closure and substitution with canines produce a better aesthetic and functional result as opposed to space opening and replacement with prosthesis? In this scenario, the Participants are patients with congenitally missing lateral incisors, Intervention is orthodontic treatment, Comparison is between the two methods viz space closure and substitution with canines Vs. space opening and replacement with prosthesis and Outcomes are aesthetic results and functional efficiency. Articulation of clinical problem in PICO format generates the closest, most relevant and best matches while searching the literature for evidence3.

                   The second aspect of EBP is to find the best research evidence, which is depicted by the pyramid of hierarchy of evidence (Figure 2). The evidence pyramid grades studies according to their design, indicating the extent to which they are susceptible to bias thus reflecting their internal validity or trustworthiness of the findings of the study as being close to reality. The higher the position of a research design in the pyramid, greater are its validity, reliability, objectivity and lesser are the biases. The broad base of the pyramid is reflective of the availability of larger number of studies or sources at lower levels of evidence as opposed to its tip indicating much lesser studies or sources available at higher levels of evidence.

(Figure 2).

Evidence-based sources can be primary or secondary. Primary sources, mostly forming the base of the pyramid, consist of original research articles or individual studies which can be quantitative or qualitative. Quantitative research studies are the ones which test a hypothesis and can be of two types –1. Experimental – where the researcher controls or manipulates variables to study the corresponding effects like in a Randomized Controlled Trial (RCT) and Controlled Clinical Trial (CCT) to establish a cause-and-effect relationship or 2. Non-experimental or Observational – wherein  the researcher does not give a treatment, intervention, or provide an exposure, instead they just study or observe the events that exist or have taken place (Case control studies or Case reports)  or are about to take place in certain populations (Cohort studies).On the other hand, qualitative research explores questions in depth with respect to their hows and whys and may result in generation of new theories. To investigate what are the patients’ perceptions regarding risks or benefits of orthodontic treatment is an example of qualitative research whereas to measure how many had an improvement in malocclusion or how many experienced an adverse event is a quantitative study.

Systematic reviews and Meta-analysis: what are they and why do we need them?

This body of research and scientific literature is ever expanding and cumulative. As more and more studies are conducted and research data piles up, the research questions often get entangled in the complex web of varied and contradictory findings from several different studies, which defy simple summarization or deductions and are more prone to being misinterpreted. As evidence based practice started to gain prominence in 1990s and clinicians turned to scientific literature for evidence it would often be the case that the basic question was still unanswered or had ambiguous or confusing answers to be put into use for simple clinical application. This created an important role for secondary research sources which essentially filter, integrate and synthesize data already generated by primary research and these occupy the tip of the evidence pyramid. Examples of secondary research sources are reviews, meta-analyses or evidence-based practice guidelines4. To ‘review’   has   been   defined   as: ‘To   view, inspect, or examine a second time or again’5. In the healthcare domain 14 types of reviews have been identified5. The classical literature review or narrative review also called as traditional reviews are of the nature of descriptive reporting of the findings of individual studies supporting or refuting the research question under investigation. Although they may provide a good overview of the studies existing in literature on a certain topic, these reviews have been criticized for lacking rigorous methodology, pre-stated objectives or data analysis which makes them prone to bias by not objectively investigating, questioning or critically evaluating the validity of the statements or observations made in included studies. The validity of these reviews may also have been affected by selective reporting as authors would have cherry-picked only those studies that support their hypothesis thus drawing up a biased or misleading picture5.

These limitations of traditional reviews have led to the rise and increased popularity of more systematic, objective, pre-specified and standardized methods for reviewing the literature namely the Systematic reviews (SR), which are considered to be the “gold standard” in evidence pyramid. Chalmers defines SR as a review that has been prepared using a systematic approach to minimizing biases and random errors which is documented in the Materials and methods section6.  SRs have gained wide acceptance as reliable instruments of evidence detection due to their objective, meticulous, unbiased and transparent approach in conducting and reporting the methodology so that the same process can be replicated by anyone. SRs synthesize research evidence by following pre-specified guidelines laid down by international organizations like Cochrane Collaboration or the NHS Centre for Reviews and Dissemination. Thus there are said to be two types of SRs – Cochrane reviews and non-Cochrane reviews. The key steps in conducting any SR are – formulating the review question, defining the criteria for inclusion of studies, identifying all relevant studies by a meticulous search process, including studies which meet pre-defined criteria and finally analysis and interpretation of collective findings from included individual studies.

The data from individual studies included in a systematic review may or may not be combined together. If they are pooled together and subjected to statistical analysis, then it becomes a Meta-analysis. For example, consider that an SR assessing the effects of face mask on maxillary protraction and correction of Skeletal Class III malocclusion has 2 included studies and study no. 1 has 60 participants and study no. 2 has 40. If all these participants are combined together to obtain a sample size of 100 and then statistical analysis is carried out to detect the overall amount of maxillary protraction in all these 100 participants, then this becomes a meta-analysis. However it is not possible to carry out a meta-analysis all the time because in order to do so there has to be some uniformity in the methodology, interventions used (appliances), comparisons made and outcomes measured (Change in SNA or ANB or Witts appraisal – outcomes indicating change in skeletal Class III) in the same way at the same time intervals. In other words, a meta-analysis can be done if studies are comparing one type of apple with another type of apple but not an apple with a pineapple. For example, in the above illustration if one study is using pre and post-treatment SNA values to detect maxillary protraction and another is measuring change in ANB to detect skeletal Class III correction then these studies cannot be combined. Similarly, even if both studies are measuring ANB but one has presented values at the end of 6 months and another at the end of 1 year then these cannot be combined. Thus, Meta-analysis which is referred to as the statistical pooling of the results of included studies in a systematic review, if carried out leads to an increase in the overall sample size thus increasing the statistical power of the analysis and the precision to assess the treatment effects, and are therefore said to produce “the highest quality of evidence available in medical science”7.

Patient preferences: The part of EBP set to become increasingly important in current era

The final aspect of EBP is patients’ preferences or values which involves informing them about all available treatment options, helping them understand these options, the outcomes, risks, benefits, cost and time associated with each and allowing them to express their preference based on the consequences which matter the most to them. Even if the patient leaves it up to the orthodontist to make the choice or is unable to fully comprehend to make a decision, informed consent, explanation of treatment procedures with their probable pros, cons and consequent outcomes and executing the plan which is in the best interest of the patient are crucial in building trust and providing ethical treatment to the patient. Needless to say when patients are children, parental consent and involvement in the treatment decision-making process is paramount not only in terms of ethics but also for medicolegal reasons.   With the abundance of information available at fingertips courtesy the internet, treatment options research by patients themselves has become greater than ever, thanks in large part to Google. However, an overabundance of information might not always be the most credible. A great disparity exists between freely available, unauthenticated information on the internet and scientifically validated, research-based facts.

Cochrane systematic reviews attempt to bridge this gap for both clinicians and patients. For clinicians the Cochrane network provides a platform to seek evidence at its highest level and for patients, lay-people or care-givers it provides plain language summaries, encourages participation in review groups or forums and makes information about healthcare evidence easier to access, use   and   understand for all. Cochrane was founded as an international, independent, not-for-profit collaboration of researchers, professionals, patients, care-givers, and people interested in health by Iain Chalmers in 1993 in honour of Archie Cochrane, a British medical researcher who had first envisioned and highlighted the necessity of collecting and publishing critical reviews of knowledge from randomised controlled trials. Its objective itself is to gather and summarize the best evidence from research to help make informed choices about treatment. To fulfill this objective Cochrane maintains an online library of which the Cochrane Database of Systematic Reviews (CDSR) is the most important part and it consists of high quality Cochrane reviews on various important health topics8,9.

Cochrane systematic reviews & current evidence on skeletal malocclusion management:

Cochrane reviews not only summarize evidence but they also critically appraise the findings of included study, the quality of evidence and consequent recommendations based on this evidence. Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool used in Cochrane reviews, rates quality of evidence as high, moderate, low or very low quality and strength of recommendations as strong and weak. This assessment takes into account the risk of bias of the included studies, the directness of the evidence, the inconsistency of the results, the precision of the estimates and the risk of publication bias10. After peer-review and correction cycle of the prepared review and passing the quality control check it is published on the Cochrane library. Published reviews are a life-long commitment and a top-up search and updating of the review has to be done every two years.

Our specialty of Orthodontics, is not only the first specialty created in the field of dentistry but also a pioneer in research and evidence-based practice. The name of the specialty was changed to “Orthodontics and dentofacial orthopaedics” to reflect the role of our field, in being able to influence or change not only the position of teeth but also of the underlying bone structure and jaw morphology. The extent of this influence has always been a topic of hot debate in orthodontics. Randomized controlled trials in the 90s and systematic reviews in recent years have found little influence of growth modification techniques on jaw growth11-15. Cochrane reviews by the Cochrane Oral Health Group have stepped in to investigate the role of orthodontics in treatment of skeletal malocclusions in both children and adults. As of October 2016, two hundred and six reviews (in different stages of title registered, protocol and review) were found in Cochrane Oral Health Group (COHG) on all topics related to dentistry, out of which 25 were on Orthodontic treatment. Of these 25, twenty-two were full reviews, two were protocols and one was a registered title. Treatment modalities for skeletal deformities in various malocclusions in adults and children were analysed in six of these 22 full reviews, the summary of which is provided in Tables 1 -4.

Table 1: Treatment of Class II Division 1 Malocclusion in Children

Summary of Evidence from a Cochrane Systematic Review

ParticipantsInterventions No. of RCTs included in ReviewComparisonsOutcomesResultsConclusion
Orthodontic Treatment for Prominent Upper Front Teeth (Class II malocclusion) in Children 16
Children or adolescents (age 16 years or less) or both receiving orthodontic
treatment to correct Class

II malocclusion.		Early treatment (either one or two-phase) with any type of removable, fixed or functional appliances or head-gear compared with late treatment with any type of removable, fixed or functional appliances or head-gear. Early treatments were defined as those commencing in children aged between seven and 11 years of age.17a. Early (two-phase) intervention with adolescent (one-phase) treatment
b. Functional appliance (Bionator, FR II) Vs Headgear for early treatment
c. Functional appliances Vs. no treatment in adolescents
d. Different types of functional appliances in adolescents like - Twin Block with other types of appliances (R-appliance, Bass, Bionator, Dynamax) or modifications to twin blocks (incremental Vs. single-step advancement and with or without labial bow), R-appliance with Anterior Inclined Bite Plate and a fixed functional appliance with a functional appliance (Activator Vs. Forsus)
Primary –
Overjet

Secondary - Relationship between upper and lower jaws - ANB, PAR index etc self-esteem, patient satisfaction,
a. When headgear (two-phase treatment) was compared with adolescent treatment (one phase) or headgear and functional appliances in phase one treatment were compared with each other - at the end of the first phase of treatment statistically significant differences, in favour of functional appliances, were shown with respect to final overjet only. At the end of phase two, there was no evidence of a difference between appliances with regard to overjet
b. Late orthodontic treatment for adolescents with functional appliances showed a statistically significant reduction in overjet compared to no treatment (very low quality evidence).
c. There was no evidence of a difference in overjet when Twin Block was compared to other appliances but, a statistically significant reduction in ANB was shown in favour of Twin Block. There was no evidence of a difference between Twin Block and its modifications
d. There was insufficient evidence to determine the effects of Activator, FORSUS FRD EZ appliances, R-appliance or AIBP.		The evidence suggests that providing early orthodontic treatment for children with prominent upper front teeth is more effective in reducing the incidence of incisal trauma than providing one course of orthodontic treatment when the child is in early adolescence. There appears to be no other advantages for providing treatment early when compared to treatment in adolescence.

Table 2: Treatment of Class II Division 2 Malocclusion and Anterior Open Bite in Children

Summary of Evidence from a Cochrane Systematic Review

ParticipantsInterventions No. of RCTs included in ReviewComparisonsOutcomesResultsConclusion
Orthodontic Treatment for Deep bite and Retroclined Upper Front Teeth (Class II division 2) in Children17
Children or adolescents or both (age 16 years or less) receiving
treatment for Class II division 2 malocclusion
Orthodontic braces (removable, fixed, functional) or headgear with or without extraction of permanent teeth.0NoneNone measured
(Primary-
PAR Index
Secondary-
Number of visits required to complete treatment and
the duration of treatment, ANB, teeth inclination changes, Patient discomfort etc)
No RCTs or CCTs were identified that assessed the treatment of Class II division 2 malocclusion in children.It is not possible to provide any evidence-based guidance to recommend or discourage any type of orthodontic treatment to correct Class II division 2 malocclusion in children.
Orthodontic and Orthopaedic Treatment for Anterior Open Bite in Children18
Children and adolescents 16 years old or younger at the start of treatment, with anterior open bite.Non-surgical modalities of correcting anterior open bite like functional orthopaedic appliances, fixed and removable orthodontic appliances 3a. Frankel's function regulator-4 (FR-4) with lip-seal training versus no treatment;
b. Repelling-magnet splints versus bite-blocks;
c. Palatal crib associated with high-pull chincup versus no treatment.
Primary - Correction of the anterior open bite

Secondary- Incisors position and inclination,
alteration of hyper divergent growth pattern,
mandibular ramus growth,
expansion of the upper and lower jaw – inter-canine and molar width
a. FR-4 associated with lip-seal and removable palatal crib associated with high-pull chincup were able to correct anterior open bite.
b. The study comparing repelling-magnet splints versus bite-blocks could not be analysed because the authors interrupted the treatment earlier than planned due to side effects in patients.
There is weak evidence that the interventions FR-4 with lip-seal training and palatal crib associated with high-pull chincup are able to correct anterior open bite. Given that the trials included have potential bias, these results must be viewed with caution.

Table 3: Treatment of Class III Malocclusion in Children & Adults

Summary of Evidence from a Cochrane Systematic Review

ParticipantsInterventions No. of RCTs included in ReviewComparisonsOutcomesResultsConclusion
Orthodontic Treatment for Prominent Lower Front Teeth (Class III malocclusion) in Children19
Children or adolescents or both (age 16 years or less) receiving
treatment for Class III malocclusion
Orthodontic braces (removable, fixed, functional), chin cups, facemasks, reverse headgear, bone-anchored appliances, or any other intra or extra-oral appliance aimed at correcting Class III malocclusion7a. Facemask versus untreated control
b. Facemask with expansion versus facemask only
c. Nanda facemask versus conventional facemask
d. A 600 g chin cup versus 300 g chin cup versus untreated
e. Tandem traction bow appliance versus untreated control
f. Mandibular headgear versus chin cup versus untreated control
Primary –
Overjet

Secondary –
ANB,
Wits appraisal,
self-concept,
Oral Aesthetic Subjective Impact Score (OASIS)
a. Change in overjet and ANB favouring the face mask as opposed to untreated controls was found
b. Improvements in overjet and ANB were still present three years post-treatment with face mask when compared with untreated controls (low quality evidence)
c. Chin cup compared with an untreated control showed a statistically significant improvement in ANB (low quality evidence)
d. Tandem traction bow appliance compared to untreated control (very low quality evidence) showed a statistically significant difference in both overjet and ANB favouring the intervention group.
There is some evidence that the use of a facemask to correct Class III malocclusion in children is effective when compared to no treatment on a short-term basis. However, in view of the general poor quality of the included studies, these results should be viewed with caution. Further randomised controlled trials with long follow-up are required.
Treatments for Adults with Prominent Lower Front Teeth20
Adults with Class III malocclusion Orthodontic or surgical treatment or both, to correct Angle Class III malocclusion2a Bilateral Vertical Ramus Osteotomy (VRO) by extraoral approach with or without osteosynthesis

b. Intraoral Vertical Ramus Osteotomy (IVRO) versus Sagittal Split Ramus Osteotomy (SSRO).
Secondary –
Changes in condyle position, Stability of correction
(Primary outcome of overjet, canine and molar relationship were not reported by included studies)
Neither trial found any difference between the two treatments. The trials did not provide adequate data for assessing effectiveness of the techniques described.There is insufficient evidence from the two included trials, to conclude that one procedure is better or worse than another. Further high quality randomized controlled trials with long term follow-up are required.

Table 4: Treatment for Posterior Crossbites

Summary of Evidence from a Cochrane Systematic Review

ParticipantsInterventions No. of RCTs included in ReviewComparisonsOutcomesResultsConclusion
Orthodontic Treatment for Posterior Crossbites21
Although this study intended to include non-surgical interventions for correction of posterior crossbite, without a Class III skeletal relationship, in both children and adults, all 14 included studies were on children and no studies on adults with crossbites were found.Any orthodontic or dentofacial orthopaedic (not surgical) treatment used to correct posterior crossbites15
a. Rapid expansion like banded versus bonded Hyrax or Minne,
b. Different rates of expansion – slow and sem-rapid against rapid
c. Fixed versus removable like Quad-helix versus expansion plate
d. Grinding - occlusal grinding in the primary dentition (aged five years old) with/without an upper removable expansion appliance in the mixed dentition versus no treatment
e. Quad-helix plus multi-bracket versus expansion arch plus multi-bracket
f. Conventional mid-line expansion screw versus springloaded expansion screw
Primary- Correction of the posterior crossbite.
Secondary-Stability of crossbite correction and changes in inter-canine or molar width

a. Fixed quad-helix appliances may be 20% more likely to correct crossbites than removable expansion plates (low-quality evidence).
b. Quad-helix appliances may achieve 1.15 mm more molar expansion than expansion plates (moderate-quality evidence).
c. Fixed quad-helix appliances and removable expansion plates are superior to composite onlays for crossbite correction, molar expansion and canine expansion (Very low quality evidence).
d. Both tooth grinding, with or without an expansion plate and fixed bonded Hyrax followed by U-bow activator are superior to no treatment for the outcomes crossbite correction and molar/canine correction (Very low quality evidence).
e. No evidence was found for other comparisons
There is a very small body of low- to moderate-quality evidence to suggest that the quad-helix appliance may be more successful than removable expansion plates at correcting posterior crossbites and expanding the inter-molar width for children in the early mixed dentition (aged eight to 10 years). The remaining evidence found was of very low quality and was insufficient to allow the conclusion that any one intervention is better than another.
The often encountered barriers in EBP and measures to overcome them:

Despite EBP gaining more ground, there are certain issues in applying it clinically and also in generating evidence in the field of orthodontics for the following reasons –

  1. Etiology of malocclusion is complex, multi-factorial and ambiguous, which means there can be different treatment plans for the same malocclusion in different patients based on age, severity, compliance, patient response and several other factors. This makes hypothesis testing in the field of Orthodontics non-linear unlike the disease-drug testing in medical field.
  2. There are rapid advances in Orthodontic products and new products are released in the market with laboratory values, company claims and figures being used for advertisement which are often untested or authenticated by independent research. In this void of evidence there exists a lag between availability of reliable evidence & clinical usage of products.
  3. Clinicians have cited the following barriers for their failure to practice evidence-based orthodontics in practice22 –
  4. “No evidence is available and there is conflicting data from different studies. Even systematic reviews fail to provide answers and conclude that there is lack of evidence to make recommendations”
  5. “Practice pressure, patient workload, time constraints”
  6. “EBO devalues clinicians’ experience & skill”

To each of the issues mentioned above, following are the respective solutions –

  1. Refinement of Orthodontic research methodology to generate new evidence or improve existing evidence:

It is a common grouse that systematic reviews don’t reach any conclusion and cite that there is insufficient evidence or there are no good studies. Grant and Booth5 have mentioned that a meta-analysis cannot be better than its included studies allow. Similarly, a systematic review can only provide the answers that its included studies allow. It cannot generate any new data on its own unless the primary research has detected it. Hence the onus is on improving the quality of primary research and not just increase the quantity, build on existing literature and add new information.

Implementing the following guidelines can greatly improve quality of research –

  1. a) Using standardized measures for diagnostic criteria and outcome assessment – COMET (Core Outcome Measures in Effectiveness Trials) is an Initiative which is working on developing core outcomes in orthodontics which can subsequently be the minimum set of outcomes that are measured in all clinical trials and systematic reviews.
  2. b) Designing RCTs with adequate sample size based on power calculations, adequate sequence of randomisation with allocation concealment, blind outcome assessment, and completeness of follow up.
  3. c) Conforming to the Consolidated Standards of Reporting Trials (CONSORT) statement while reporting the methodology of RCTs, which will enable appraisal and interpretation of results, and accurate judgements to be made about the risk of bias and the overall quality of the evidence.

The intention of standardization of outcomes, study designs, reporting or methodology is so that, no matter which corner of the world a study is conducted in, the results of the study can be compared or added to findings of other similar studies, thus making them more comparable, useful, relevant and additive to existing knowledge. It also helps in reducing resource and research wastage and adding valuable new outputs to the work in progress of building a sound and sensible Orthodontic evidence base.

  1. Learn to practice Evidence Based Orthodontics with the currently available evidence and even in the absence of it: To do this one has to read and be up to date with the latest scientific and research findings, acquaint oneself with research methodology to be able to evaluate evidence, develop critical appraisal skills and objectively assess treatment claims or findings. Look at what works and also at what “does not” work. Do not ignore negative findings or findings of no differences. Apply evidence where it exists and where it does not exist, use clinical expertise to select the best option and explain to the patient regarding the same, since EBO is not only about research it is also about clinical expertise and patient’s opinion23. In the June 2016 issue of AJODO, Rolf Behrents the Editor-in-Chief mentions the writing of a 14th Century French Philosopher, Buridan in the editorial piece of “Buridan’s Paradox”. Applying the principle of this paradox to Orthodontics implies suspending judgment as to the best course of action until more is known. In our specialty, for new products or techniques or even old techniques with lack of evidence, when more and better research is conducted, then we will know more. Until that time our treatment choice should not be determined by our biases but instead should be guided by what is the best treatment for the patient at that time and be based on sound scientific principles24. Newer evidence as, when and if it becomes available can then be incorporated into practice if one remains in constant touch with the latest developments in the scientific literature.
  2. Finally, the response to the resistance to EBP put up by certain practitioners saying it is too theoretical, idealistic, imperfect for practical situations and a denial of their clinical experience, is embodied in the words of Robert Kiem, editor of JCO that EBP is not a division or debate between “evidence-based” and “experience based” practice, but rather a mutually beneficial continuum between the two philosophies25. Continuing professional development, life-long learning and keeping oneself updated with latest findings are an integral part of being able to deliver the best orthodontic treatment to our patients, instead of stagnating and relying only on what was taught in dental colleges, since Orthodontics is continuously evolving. Various options like systematic reviews, clinical summaries, guidelines or Cochrane reviews exist to considerably reduce the volume of clinical reading thus saving time and facilitating easy availability of evidence summary for clinical application.

The tradition of looking up to respected, well-established and prominent authorities in other words known as “key opinion leaders” for showing the path still continues in the field of Orthodontics. While expert opinions form the foundation and provide the strong base for the pyramid of evidence and is much valuable in many instances, independent thinking and critical appraisal faculties should be maintained by clinicians to make an informed choice instead of becoming dogmatic followers of a certain philosophy without objective evaluation like during the Angle era. Orthodontics is not only an art but also a science, and the key to practicing it likewise lies with implementing evidence-based orthodontics.

  1. Sackett DL, Rosenberg WM, Gray JM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312 :71
  2. Greenhalgh T, Cassam Q, Heath I, Virtues and vices in evidence based clinical practice. Available at http://www.cebm.net/5395-2/ Last accessed 30th September, 2016
  3. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123(3):A12-3.
  4. Forrest JL, Miller SA, Overman PR, Newman MG. Research Design and Sources of Evidence in Evidence-Based Decision Making: A Translational Guide for Dental Professionals. Philadelphia: Lippincott Williams & Wilkins; 2008
  5. Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91-108.
  6. Chalmers I, Altman D. Systematic reviews. London: BMJ Publishing Group; 1995
  7. Papadopoulos MA. Meta-Analyses and Orthodontic Evidence-Based Clinical Practice in the 21st Century. Open Dent J. 2010;4:92
  8. Available at: http://www.cochrane.org/. Last accessed 2nd October 2016
  9. Cochrane Library. Available at: http://www.cochranelibrary.com/ Last accessed 2nd October 2016
  10. Oxman AD, GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328(19):1490-4.
  11. Tulloch JFC, Proffit WR, Phillips C. Permanent dentition outcomes in a two-phase randomized clinical trial of early Class II treatment. Am J Orthod Dentofac Orthop 2004, 125:657-667.
  12. Wheeler TT, McGorray SP, Dolce C, et al. Effectiveness of early treatment of Class II malocclusion. Am J Orthod Dentofac Orthop 2002;127:9-17.
  13. King GJ, McGorray SP, Wheeler TT, Dolce C, Taylor M. Comparison of peer assessment ratings (PAR) from 1-phase and 2-phase treatment protocols for Class II malocclusions. Am J Orthod Dentofac Orthop 2003;123:489- 496.
  14. Nucera R, Giudice AL, Rustico L, Matarese G, Papadopoulos MA, Cordasco G. Effectiveness of orthodontic treatment with functional appliances on maxillary growth in the short term: A systematic review and meta-analysis. Am J Orthod Dentofac Orthop 2016;149(5):600-11.
  15. Ishaq RA, AlHammadi MS, Fayed MM, El-Ezz AA, Mostafa Y. Fixed functional appliances with multibracket appliances have no skeletal effect on the mandible: A systematic review and meta-analysis. Am J Orthod Dentofac Orthop 2016;149(5):612-24.
  16. 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
  17. Millett DT, Cunningham S, O’Brien KD, Benson PE, Williams A, de Oliveira CM. Orthodontic treatment for deep bite and retroclined upper front teeth in children. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005972. DOI: 10.1002/14651858.CD005972.pub2.
  18. Lentini-Oliveira DA, Carvalho FR, Rodrigues CG, Ye Q, Hu R, Minami-Sugaya H, Carvalho LBC, Prado LBF, Prado GF. Orthodontic and orthopaedic treatment for anterior open bite in children. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD005515. DOI: 10.1002/14651858.CD005515.pub3
  19. Watkinson S, Harrison JE, Furness S, Worthington HV. Orthodontic treatment for prominent lower front teeth (Class III malocclusion) in children. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD003451. DOI: 10.1002/14651858.CD003451.pub2.
  20. Minami-Sugaya H, Lentini-Oliveira DA, Carvalho FR, Machado MAC, Marzola C, Saconato H, Prado GF. Treatments for adults with prominent lower front teeth. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD006963. DOI: 10.1002/14651858.CD006963.pub2
  21. Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P. Orthodontic treatment for posterior crossbites. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD000979. DOI: 10.1002/14651858.CD000979.pub2
  22. Madhavji A, Araujo EA, Kim KB, Buschang PH. Attitudes, awareness, and barriers toward evidence-based practice in orthodontics. Am J Orthod Dentofac Orthop 2011;140(3):309-16.
  23. O’Brien K. Evidence based orthodontics is not as straightforward as it seems. Available at http://kevinobrienorthoblog.com/evidence-based-orthodontics-not-straightforward/. Last accessed on 1st October, 2016
  24. Behrents RG. One phase or two, and Buridan’s paradox. Am J Orthod Dentofacial Orthop. 2016;149(6):A1-4.
  25. Keim RG. The power of the pyramid. J Clin Orthod. 2007 Oct;41(10):587-8.
Figure legends:

Figure 1: Triad of Evidence Based Practice

Figure 2: Hierarchy of Evidence