The effectiveness of early intervention on malocclusion and its impact on craniofacial growth: A systematic review

Patrícia Valério1Orcid, Tina Poklepović Peričić2Orcid, Andrea Rossi3Orcid, Cristina Grippaud4Orcid, Júlia dos Santos Tavares Campos5Orcid, Israel Júnior Borges do Nascimento6Orcid


The early delivery of orthodontic treatment plays a critical role in craniofacial development and the establishment/re-establishment of appropriate stomatognathic function.
Early interventions effectively affect the masticatory system, increasing average bite force and general thickness of facial muscles.

This review emphasizes the need for well designed clinical trials that would consider patient-important outcomes.


This review aims to assess the available evidence related to the effectiveness of early interventions on malocclusion and its impact on the craniofacial structure among children under six years of age. Furthermore, we aimed to evaluate the correlation between nutritive sucking behavior mechanisms on the oral facial components. We searched Medline, Embase, Cochrane Library, Scopus, and the LILACS from inception to December 10, 2020, to identify published randomized and non-randomized controlled trials that investigated the broad spectrum of early interventions for the treatment of malocclusions among pediatric patients under six years old. We have also included studies that evaluated the impact or the relationship between feeding alternatives, malocclusion, and craniofacial growth. Reviewers working in pairs investigators independently performed title and abstract screening, full-text screening, data extraction, risk of bias assessment using ROBINS-I tool, and rated the certainty of evidence using GRADE. Seven studies were included (783 patients), with an overall risk of bias classified as critical. Early treatment was shown to improve facial asymmetry, particularly in the lower part of the face, along with an increase of palatal volume and palatal surface. Early treatment showed important reduction of mandibular protrusion and length, leading to favorable sagittal growth of the maxilla. Furthermore, the early intervention significantly enhanced the average bite force magnitude (from 318.20 N to 382.79 N) and increased the general thickness of facial muscles. Our findings suggest that the benefits generated by early orthodontic interventions are related to the improvement of craniofacial symmetry/bone structure, and refinement of masticatory ability and performance. Notwithstanding, there is still a need for further studies appraising patient-important outcomes, such as quality of life and nutritional features.

Keywords: Bone Growth; Early Intervention; Malocclusion; Maxillofacial Development; Systematic Review

Author Affiliations

  1. Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte,
    Minas Gerais, Brazil
    Patricia Valerio Institute, Belo Horizonte, Minas Gerais, Brazil (✉ Correspondence:
  2. Department of Research in Biomedicine and Health, University of Split School of Medicine, Split, Croati
  3. School of Dentistry, Università Cattolica del Sacro Cuore, and Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
  4. School of Dentistry, Università Cattolica del Sacro Cuore, and Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
  5. Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  6. School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
    School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
  1. World Health Organization. Oral health [Internet]. Oral Health. [cited 2021 Apr 22]. Availablefrom:
  2. Perillo L, Esposito M, Caprioglio A, Attanasio S, Santini AC, Carotenuto M. Orthodontic treatment need for adolescents in the Campania region: the malocclusion impact on self-concept. Patient Prefer Adherence 2014;8:353–359
  3. Akbari M, Lankarani KB, Honarvar B, Tabrizi R, Mirhadi H, Moosazadeh M. Prevalence of malocclusion among Iranian children: A systematic review and meta-analysis. Dent Res J (Isfahan). 2016;13:387–395
  4. Alvarado K, López L, Hanke R, Picón F, Rivas-Tumanyan S. Prevalence of Malocclusion and Distribution of Occlusal Characteristics in 13- to 18-year-old Adolescents Attending Selected High Schools in the Municipality of San Juan, PR (2012-2013). Health Sci J 2017;36:61–66
  5. Lombardo G, Vena F, Negri P, Pagano S, Barilotti C, Paglia L, Colombo S, Orso M, Cianetti S. Worldwide prevalence of malocclusion in the different stages of dentition: A systematic review and meta-analysis. Eur J Paediatr Dent. 2020;21:115-122
  6. Grippaudo C, Paolantonio EG, Antonini G, Saulle R, La Torre G, Deli R. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol Ita 2016;36:386-394
  7. Kasparaviciene K, Sidlauskas A, Zasciurinskiene E, Vasiliauskas A, Juodzbalys G, Sidlauskas M, et al. The prevalence of malocclusion and oral habits among 5-7-year-old children. Med Sci Monit. 2014;20:2036–2042
  8. Majorana A, Bardellini E, Amadori F, Conti G, Polimeni A. Timetable for oral prevention in childhood—developing dentition and oral habits: a current opinion. Prog Orthod 2015;16:39-48
  9. Woon SC, Thiruvenkatachari B. Early orthodontic treatment for Class III malocclusion: A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2017;151:28-52
  10. Kallunki J, Bondemark L, Paulsson L. Outcomes of Early Class II Malocclusion Treatment – A Systematic Review. J Dent Oral Health Cosmesis 2018;3:009
  11. Grippaudo C, Valerio P, Romeo P, Fiasca F, Quinzi V. Bite and Sight: Is There a Correlation? ClinicalAssociation between Dental Malocclusion andVisual Disturbances in Pediatric Patients. Appl Sci 2020;10: 5913-5920
  12. Oka S, Kawanabe H, Yamanobe S, Fukui K, Baba Y, Deguchi T. Relationship between olfaction and maxillofacial morphology in children with malocclusion. Clin Exp Dent Res 2021;7(:33-39
  13. Souto-Souza D, Soares MEC, Primo-Miranda EF, Pereira LJ, Ramos-Jorge ML, Ramos-Jorge J. The influence of malocclusion, sucking habits and dental caries in the masticatory function of preschool children. Braz Oral Res 2020;34:e059
  14. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097
  15. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919
  16. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ 2020;368:l6890
  17. Kajiyama K, Murakami T, Suzuki A. Comparison of orthodontic and orthopedic effects of a modified maxillary protractor between deciduous and early mixed dentitions. Am J Orthod Dentofacial Orthop 2004;126:23–32
  18. Carrascoza KC, Possobon R de F, Tomita LM, Moraes ABA de. Conseqüências do uso da mamadeira para o desenvolvimento orofacial em crianças inicialmente amamentadas ao peito. Jornal de Pediatria 2006;82:395–407
  19. Tollaro I, Baccetti T, Franchi L. Craniofacial changes induced by early functional treatment of Class III malocclusion. Am J Orthod Dentofacial Orthop. 1996 Mar;109(3):310–8.
  20. Primozic J, Ovsenik M, Richmond S, Kau CH, Zhurov A. Early crossbite correction: a three-dimensional evaluation. Eur J Orthod. 2009;31:352–356
  21. Primožič J, Richmond S, Kau CH, Zhurov A, Ovsenik M. Three-dimensional evaluation of early crossbite correction: a longitudinal study. Eur J Orthod 2013;35:7–13
  22. Castelo PM, Gavião MBD, Pereira LJ, Bonjardim LR. Evaluation of changes in muscle thickness, bite force and facial asymmetry during early treatment of functional posterior crossbite. J Clin Pediatr Dent 2010;34:369–374
  23. Ferrer AL de, Villalba TBV de. Influencia de la succión deglución sobre el crecimiento y desarrollo orofacial. Rev Fac Cien Med Univ Nac Cordoba 2006;63:33–37
  24. Huh A, Horton MJ, Cuenco KT, Raoul G, Rowlerson AM, Ferri J et al. Epigenetic influence of KAT6B and HDAC4 in the development of skeletal malocclusion. Am J Orthod Dentofacial Orthop. 2013;144:568-576
  25. Valerio P, Perfeito F, Moura LP. Mandible protraction alters Type I collagen, osteocalcin and osteonectin gene expression in adult mice condyle. Ann Stomatol (Roma) 2018;8:95-103
  26. Seelan, Ratnam S, Warner DR, Webb CL, Pisano M, Greene MR. Epigenetic regulation of Sox4 during palate development. Epigenomics 2013;5:131-146
  27. Raterman, ST, Metz JR, Wagener FADTG, Hoff JW. Zebrafish Models of Craniofacial Malformations: Interactions of Environmental Factors. Front Cell Dev Biol 2021;9:650948
  28. Liberton DK, Verma P, Almpani K, Fung PW, Mishra R, Oberoi S, et al. Craniofacial Analysis May Indicate Co-Occurrence of Skeletal Malocclusions and Associated Risks in Development of Cleft Lip and Palate. J Dev Biol 2020;8:2-11
  29. Doraczynska-Kowalik A, Nelke KH, Pawlak W, Sasiadek MM, Gerber H. Genetic Factors Involved in Mandibular Prognathism. J Craniofac Surg 2017;28:422-431
  30. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ 2020;368:l6890
  31. Musich, DR, Busch, MJ. Early Orthodontic Treatment: Current Clinical Perspectives. Alpha Omegan 2007;100:17–24
  32. Fleming C. Ejection problems and injuries: their causes, effects and treatments, and suggestions for preventive measures. Aviat Space Environ Med 1979;50:829–833
  33. Kluemper GT, Beeman CS, Hicks EP. Early orthodontic treatment: what are the imperatives? J Am Dent Assoc 2000;131:613–620
  34. Scheffel DLS, Jeremias F, Fragelli CMB, Dos Santos-Pinto LAM, Hebling J, de Oliveira OB Jr. Esthetic dental anomalies as motive for bullying in schoolchildren. Eur J Dent 2014;8:124–128
  35. Bagley H, Gorst S, Morley R, Young B. Using patient-important outcomes for systematic reviews [Internet] [cited 2021 Apr 22]. Available from:
  36. Gaudry S, Messika J, Ricard J-D, Guillo S, Pasquet B, Dubief E, et al. Patient-important outcomes in randomized controlled trials in critically ill patients: a systematic review. Ann Intensive Care 2017;7:28-35
  37. Fleming PS. Timing orthodontic treatment: early or late? Aust Dent J 2017;62:11-19
  38. Kiyak HA, Haluk I, Miotti FA. Orthodontists’ perspectives regarding treatment timing: a cross-national study. World J Orthod 2004;5:40-47
  39. Keim RG, Gottlieb EL, Nelson AH, Vogels DS 3rd. 2013 JCO Orthodontic Practice Study. Part 1: trends. J Clin Orthod. 2013 Nov;47(11):661-80. PMID: 24605392.
  40. Batista KB, Thiruvenkatachari B, Harrison JE, O’Brien KD. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children and adolescents – PubMed. Cochrane Database of Systematic Reviews 2018;3:CD003452.
  41. Murad MH, Chu H, Lin L, Wang Z. The effect of publication bias magnitude and direction on the certainty in evidence. BMJ Evid Based Med. 2018;23:84-86
  42. Koletsi D, Fleming PS, Eliades T, Pandis N. The evidence from systematic reviews and meta-analyses published in orthodontic literature. Eur J Orthod 2015;37:360-369
  43. American Dental Association. Tooth eruption-The primary teeth. [Internet] [cited 2021 June 11] Availablefrom:
  44. Cochrane Effective Practice and Organisation Care. Synthesising results when it does not make sense to do a meta-analysis [Internet] [cited 2021 June 11]Cochrane Group; Available from:

Article Info

Contemp Pediatr Dent 2021:2(2):72-89

Received: 31 May 2021

Accepted: 14 July 2021

Online First: 29 July 2021


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					Patrícia Valério, Tina Poklepović Peričić, Andrea Rossi, Cristina Grippaudo, Júlia dos Santos Tavares Campos, Israel Júnior Borges do Nascimento. The effectiveness of early intervention on malocclusion and its impact on craniofacial growth: a systematic review. Contemp Pediatr Dent 2021:2(2):72-89.

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