ORIGINAL ARTICLE

Effectiveness of interceptive orthodontic

treatment in reducing malocclusions
Gregory J. Kinga and Pongsri Brudvikb
Seattle, Wash, and Bergen, Norway

Introduction: In this retrospective cohort study of the effectiveness of interceptive orthodontic treatment, we
compared patients receiving interceptive orthodontic treatment with untreated control subjects. Methods:
Models were scored by using the index of complexity, outcome and need (ICON). Control models (n 5 113)
were archival and were selected based on malocclusion in the early mixed dentition and no orthodontic treat-
ment during the subsequent 2 years. The patients (n 5 133) were in the mixed dentition and consecutively
treated in the University of Bergen orthodontic clinic. Initial ages were 9.4 years (6 1.4) for the treated group
and 9.3 years (6 0.8) for the control group. The treatment took a mean of 27.2 months (6 16.3) for the patients;
the control group was observed for a mean of 24.4 months (6 3.6). Subject Groups were matched for age,
need, complexity, duration, and all ICON components except spacing (P \0.006) and crossbite (P \0.000).
Results: ICON scores decreased after treatment by 38.8% (P \0.0001) from 54.9 (6 16.6) to 33.6 (6 16.1).
The controls were unchanged, with ICON scores of 54.0 (6 14.8) and 54.2 (6 16.9). Improvement grades
were different (P \0.0001), with most controls categorized as ‘‘not improved or worse’’ (89.4%), whereas
only 36.1% of the treated group were in that category. However, there were increases in the ‘‘minimal,’’ ‘‘mod-
erate,’’ and ‘‘substantial’’ improvement categories for the treated subjects (22.6%, 21.1%, and 17.3%, re-
spectively). The controls did not change in any ICON component and worsened in crowding (P \0.007),
whereas the patients improved in esthetics, crowding, crossbite, and overbite (P \0.007). Conclusions:
These results indicate that interceptive orthodontic treatment is effective for improving malocclusion but
does not produce finished-quality results. (Am J Orthod Dentofacial Orthop 2010;137:18-25)

I
nterceptive and preventive orthodontic procedures
are relatively simple and inexpensive treatment ap-
proaches that target developing malocclusions dur-
ing the mixed dentition. Orthodontists perceive these as
useful ways to reduce the severity of malocclusions,1
improve a patient’s self-image, eliminate destructive
habits, facilitate normal tooth eruption, and improve
some growth patterns.2 Because of this, some have ad-
vocated their wider use as public health measures aimed
at reducing the burden of malocclusion in underserved
populations3 and as a strategy for increasing access to
orthodontic treatment when resources are limited.1
Available evidence suggests that patients at risk for
severe malocclusion can readily be identified in the
a
Moore Reidel Professor, Department of Orthodontics, University of
Washington, Seattle.
b
Associate professor, Department of Orthodontics, University of Bergen,
Bergen, Norway.
Supported by NIDCR grant U54 DE14254.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Gregory J. King, University of Washington, Department of
Orthodontics, Box 357446, Seattle, WA 98195; e-mail, gking@u.washington.
edu.
Submitted, December 2007; revised and accepted, February 2008.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.02.023
18
mixed dentition, and that the burden of these malocclu-
sions in this age group is substantial (about 25%-30%).
In 1 study, patients at risk for future orthodontic prob-
lems were identified in 28% of those examined, and
most of the developing malocclusions were judged to
be suitable for interceptive orthodontic treatment.4 A
similar study found that about 27% of the children ex-
amined in a large Nigerian sample needed some form
of interceptive orthodontic treatment.3 A third study
of children screened in a community dental clinic at
ages 9 and 11 years also found that one-third would
benefit from interceptive orthodontic treatment.5
Although interceptive orthodontic procedures often
do not produce finished orthodontic results without
a second phase of treatment in the permanent dentition,
several studies have suggested that systematically
planned interceptive treatment in the mixed dentition
might contribute to a significant reduction in treatment
need between the ages of 8 and 12 years, often produc-
ing results so that further need can be categorized as
elective. In a Finnish study, the need was reduced signif-
icantly from ages 8 to 12 in a small group receiving in-
terceptive treatment.6 In a similar study, 94% of the
children receiving interceptive treatment in a commu-
nity health clinic were judged to have completely suc-
cessful results, with only 2% showing deterioration.5
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 1
Using the peer assessment rating (PAR)7 and the index
of complexity, outcome and need (ICON),8 the authors
of another study reported significant reductions in mal-
occlusion severity after early treatment in both Medic-
aid and privately financed patients, with comparable
results in both groups.9 In addition, about two thirds
of those patients changed from a ‘‘medically necessary’’
category, as judged by the handicapping labiolingual
deviation index10 to ‘‘elective’’ after mixed dentition
orthodontic intervention.11
Although the available data suggest that interceptive
orthodontic treatment can be effective, no randomized
clinical trials or large cohort studies have compared in-
terceptive outcomes with no treatment in either the near
or long term. This has been primarily due to the lack of
suitable cohorts of untreated patients with malocclu-
sions to serve as control subjects. During the 1970s,
the orthodontic faculty at the University of Bergen in
Norway collected orthodontic study casts biannually
from many local school children. A substantial number
of these children had orthodontic needs and were not
treated during the mixed dentition. Thus, it was possible
to collect an archival cohort of study casts of untreated
subjects with excellent matching for malocclusion
severity to compare with a contemporary sample of pa-
tients treated in an interceptive clinic. We hypothesized
that interceptive orthodontic treatment would improve
malocclusions with reductions in their complexity and
need.
MATERIAL AND METHODS
This was a retrospective cohort design. Power calcu-
lations were based on a similar study with a 40% im-
provement in ICON scores after interceptive
treatment.9 A sample size of 100 provided a power of
90% and an alpha of 0.05 for this level of difference
in ICON scores. For the treated group, 133 patients
with pre- and postinterceptive sets of dental casts were
selected from consecutively treated patients who met
our inclusion criteria and were treated in the orthodontic
clinic at the University of Bergen by dental students su-
pervised by orthodontic faculty members. Most of these
patients were treated for dental misalignment, crowding
or spacing, inversions, anterior open bite, and crossbite
with various removable appliances. The control group,
consisting of 113 patients with 2 sets of dental casts
that also met the inclusion criteria, was randomly se-
lected from departmental archives of biannual records
of school children taken during the 1970s. Inclusion
and exclusion criteria were initial casts in the early
mixed dentition, final casts after interceptive orthodon-
tic treatment but no later than the late mixed dentition
King and Brudvik 19
(ie, final casts with a fully erupted permanent dentition
mesial to the first molars were excluded), final casts for
the control group who received no orthodontic treat-
ment were taken 2 years after the first, initial casts show-
ing a malocclusion suitable for funding under the
Norwegian Social Security System as judged subjec-
tively by an orthodontist (P.B.) experienced with these
criteria, Scandinavian ethnicity, and no exclusion based
on sex.
All casts were scored with the ICON by a calibrated
examiner (G.J.K.) who was not blinded to group or time
point. True blinding was not possible because the casts
of the control group were easily recognizable because of
their rough trimming, and the time points were obvious
based on the stage of tooth development evident on the
casts. The ICON scores overall occlusion and an es-
thetic component of malocclusion on an interval scale,
from 0 to 120 for the former and 0 to 10 for the latter.
The higher the ICON score, the worse the malocclusion.
The ICON has been validated based on the subjective
judgments of 97 orthodontists from 9 countries on 240
initial and 98 treated dental casts. Created as a single
measure of need, complexity, and outcome simulta-
neously, the ICON has 2 advantages over the more com-
monly used PAR as a dental outcome measure.7,12 It has
an esthetic component that is weighted highly by clini-
cians and valued by patients, and it has clear and inter-
nationally validated cut points for treatment need and
outcome with categories for complexity and improve-
ment. Five weighted parameters are scored and com-
prise the components of the ICON: dental esthetics,
crossbite, anterior vertical relationship, maxillary
crowding or spacing, and buccal segment anteroposte-
rior relationship. The components were individually
scored from dental casts and multiplied by their respec-
tive weights to yield a single summary ICON score. This
final score was then used to determine initial need
(ICON .43) and final outcome acceptability (ICON
\31), and difference scores were used to determine im-
provement. According to the convention recommended
by the developers of the ICON, improvement scores
were calculated by subtracting 4 3 final scores from
the initial scores.8 This permitted us to compare the im-
provement in our samples with the categories validated
for the ICON. Intrarater reliability of the examiner was
determined by using Dahlberg’s formula13 on 10 sets of
models remeasured 2 weeks apart and was considered to
be acceptable (4.1 ICON points).
Initial equivalence of the groups was assessed by us-
ing age, sex, and malocclusion characteristics. The lat-
ter consisted of weighted initial ICON scores and
unweighted ICON component scores. Equivalence in
ICON components was assessed by using multiple
20 King and Brudvik American Journal of Orthodontics and Dentofacial Orthopedics
January 2010

Table I. Initial comparison of groups Table II. Changes in ICON scores by group
lnterceptive Control P value lnterceptive Control ICON cut points
(n 5 133) (n 5 113) (need or acceptability)
Age (y) (SD) 9.4 (1.4) 9.3(0.8) 0.590
Female (%) 51.6 31.8 0.017 Initial mean ICON 54.9 (16.6) 54.0 (14.8) .43
Mean ICON (SD) unweighted components (SD)
Esthetics (1-10) 5.3(1.8) 5.2 (1.7) 0.469 Final mean ICON 33.6 (16.1)* 54.2 (16.9) \31
Crowding (0-5) 0.6 (1.3) 0.4 (1.6) 0.414 (SD)
Spacing (0-5) 0.2 (0.5) 0.4 (0.7) 0.006 lmprovement % 38.8 0.9
Crossbite (0-1) 0.6 (0.5) 0.2 (0.4) 0.000
*P \0.0001 (initial vs final; interceptive vs control).
Open bite (0-4) 0.3 (1.0) 0.2 (0.6) 0.277
Overbite (0-3) 0.6 (0.8) 1.0 (0.9) 0.008
Buccal AP (0-2) 1.1 (0.8) 1.2 (0.5) 0.500
sets of casts averaged 27.2 months (6 16.3) in the
AP, Anteroposterior relationship treated group and 24.4 months (6 3.6) in the control;
these were not different. At the second time point, the
unpaired t tests with Bonferroni adjustments for multi- mean ICON scores were 33.6 (6 16.1) for the treated
ple comparisons. Since 7 tests were performed, the level group and 54.2 (6 16.9) for the untreated controls.
of significance was set at P \0.007 (ie, P \0.05/7). This represented a 38.8% improvement for the former
ICON scores were compared between groups and at (P \0.0001) and no change for the latter. Based on
the 2 time points with 2-way analysis of variance (AN- the ICON acceptability cut point of \31, both groups
OVA) and post-hoc comparisons with the Kruskal- would be judged unacceptable, but the treated cohort
Wallis test if P \0.05. Initial need was determined by was borderline.
using the weighted ICON score threshold of .43, and The distributions of the initial complexity grades
end-of-study acceptability was determined with the (Fig 1) were not different between the groups (chi-
\31 threshold. The prevalences of subjects in the initial square: P 5 0.186). Figure 2 gives a comparison of
complexity grades and improvement categories were the distributions of improvement grades between the 2
also calculated, and these distributions were compared groups. The difference between these was highly signif-
between groups by using the chi-square statistic. Un- icant (chi-square, P \0.0001). Whereas most subjects
weighted ICON component scores were compared be- were categorized as ‘‘not improved or worse’’ in the un-
tween initial and final casts, and differences were treated control group (89.4%), the treated group had
assessed with multiple t tests with Bonferroni adjust- 36.1% in that category. This reduction was reflected
ments and significance set at P \0.007. by roughly equivalent increases in the ‘‘minimal,’’
‘‘moderate,’’ and ‘‘substantial’’ improvement categories
for the treated subjects (22.6%, 21.1%, and 17.3%, re-
RESULTS spectively) compared with the controls (7.9%, 1.8%,
Initially, the subjects in the interceptive and control and 0.9%, respectively).
groups had mean chronological ages of 9.4 years (6 Improvements in the various ICON categories are
1.4) and 9.3 years (6 0.8), respectively (Table I). These shown in Figures 3 and 4. The untreated controls had
were not different. However, although the treated group no improvement in any component and a statistically
was about equally divided by sex (51.6% female), the significant worsening of maxillary crowding (P 5
control group was predominantly male (31.8% female). 0.007). In contrast, the treated sample showed statisti-
These were statistically different (P 5 0.017). As as- cally highly significant improvements in the esthetic
sessed by the unweighted ICON component scores, and crossbite components (P \0.0001), with significant
the malocclusions in the 2 groups were largely well improvements in the maxillary-crowding and open-bite
matched, with moderate esthetics scores, minimal max- components (0.001 \ P \0.007).
illary crowding or spacing and openbite or overbite, and
moderate buccal anteroposterior occlusal relationships.
Statistical differences were found only in maxillary an- DISCUSSION
terior spacing (P \0.006) and crossbite (P \0.000). This study supports the hypothesis that a systematic
Table II shows that both groups had similar ICON program of interceptive orthodontic treatment during
scores when the first models were taken (54.9 and the mixed dentition is more effective than doing nothing
54.0, respectively). Based on the validated ICON as- to improve malocclusions over the near term. This
sessment of need (.43), both groups of subjects needed finding supports other studies that have reported similar
treatment. The intervals between the first and second improvements but has the added advantage of including
American Journal of Orthodontics and Dentofacial Orthopedics King and Brudvik 21
Volume 137, Number 1

Fig 1. Percent of subjects in the ICON initial complexity categories: easy, \29; mild, 29-50; moder-
ate, 51-63; difficult, 64-77; very difficult, .77. Interceptive and control distributions were not different
based on the chi-square statistic.

Fig 2. Percent of subjects in the ICON improvement categories: improvement scores 5 initial ICON
score – 4 x final ICON score. Greatly improved, .–1; substantially improved, –25 to –1; moderately
improved, –53 to –26; minimally improved, –85 to –54; not improved or worse, \–85. Based on the
chi-square statistic, the interceptive and control distributions were highly significantly different
(P \0.0001).

an untreated cohort with similar initial malocclusions to
address spontaneous improvement or worsening during
the transition from the deciduous to the permanent den-
tition.5,6,9,11 The untreated control group in this study
showed little change in overall ICON scores with
most subjects in the ICON ‘‘not improved or worse’’
category. This finding clearly supports the conclusion
that these malocclusions do not change in any signifi-
cant ways during the mixed dentition without interven-
tion. Conversely, the treated group had far fewer
patients in this ‘‘not improved or worse’’ category but
increases in the ‘‘minimal,’’ ‘‘moderate,’’ and
22 King and Brudvik American Journal of Orthodontics and Dentofacial Orthopedics
January 2010

Fig 3. Changes in ICON components in the untreated control group (unweighted). The initial scores
were statistically different from the final scores based on the t test (*P \0.007).

Fig 4. Changes in ICON components in the interceptive treatment group (unweighted). The pretreat-
ment scores were statistically different from the posttreatment scores based on the t test (*0.001 \
P \0.007; **P \0.0001).

‘‘substantial’’ improvement categories, suggesting that pothesis that interceptive orthodontic treatments often
interceptive treatment improves malocclusions to vary- require further treatment in the permanent dentition.
ing degrees. However, few patients in either group were When we considered the various components of
in the ‘‘greatly improved’’ category, supporting the hy- malocclusion, the untreated group experienced no
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 1
improvement in any category and a statistically signifi-
cant worsening of maxillary crowding, whereas the
treated group had improvements in esthetics, crossbite,
maxillary crowding, and anterior open bite. The deteri-
oration in maxillary crowding in the untreated sample
during the mixed dentition might have been caused by
a loss of arch perimeter caused by caries, since this
archival sample subjectively appeared to have more
interproximal caries, restorations, and early loss of
deciduous teeth than did the more contemporary treated
sample. This suggestion is supported by Norwegian
studies reporting declines in caries incidence during
the interval covered by the 2 groups in this study,14,15
with the extensive use of fluoride-based preventive
programs cited as the major factor contributing to the
decline during the late 1960s and early 1970s.16
This comparison did not consider the long-term sta-
bility of interceptive orthodontic corrections. Without
such a comparison, it is impossible to know the extent
to which these partial corrections have any lasting ben-
efit, or how they compare over the long term with com-
prehensive treatment. Preferably, a randomized
controlled trial designed to compare interceptive with
comprehensive treatment over the long term would be
required, but such a study has not yet been reported.
Randomized controlled trials designed to examine
1-phase vs 2-phase treatment of Class II malocclusions
indicate that early intervention has a short-term benefit
over no treatment but offers no advantage over 1-phase
treatment at adolescence.17,18 However, these studies
did not have groups receiving only phase-1 treatment,
so they could not address the long-term stability of early
treatment alone. Because interceptive orthodontic treat-
ment has limited goals aimed at reducing, rather than
eliminating, features of malocclusion, it is considered
to be partial treatment by most orthodontists; our data
support that conclusion. If producing an ideal occlusion
lessens the risk of relapse as some contend, one might
predict that comprehensive treatment would have
greater stability. However, the question of how the qual-
ity of outcome influences posttreatment stability is de-
batable, with some evidence suggesting that, over the
long term, excellent results tend to deteriorate, whereas
average results tend to improve.19
The comparison groups were well matched with re-
spect to the main outcomes for testing the hypothesis:
age, need, complexity, and treatment duration. How-
ever, there were some lack of comparability in less rel-
evant features that might reflect clinician and patient
biases in favor of early treatment for some population
subgroups and malocclusions as well as differences in
dental health between the years covered by the 2 groups.
Comparison of initial complexity data suggests slightly
King and Brudvik 23
more mild-to-moderate malocclusions in the control
group and more difficult-to-very-difficult cases in the
treated group. This seems reasonable, since one expects
that there would be parental pressure to begin treatment
early for children with more significant impairments.20
Since mixed dentition treatment was an exclusion crite-
rion for the control group in this study, some subjects
with the most severe problems requiring early treatment
might have been excluded from the control sample. This
also might explain the curious finding of more boys in
the control sample, since demand for orthodontic treat-
ment is known to be higher for girls.21
Matching also was generally good with respect to
the various components of malocclusion with differ-
ences only in more maxillary spacing and fewer cross-
bites in the controls. Many clinicians, including the
orthodontic faculty at the University of Bergen, treat
crossbites during the mixed dentition because younger
patients are thought to respond better to treatment; early
treatment also prevents the risk of asymmetric facial
growth and gingival damage.22-24 Despite recent reports
that do not strongly support many of these beliefs, this
practice is common worldwide.25,26 This could explain
why these patients were found less frequently in our un-
treated sample. A greater amount of initial maxillary
spacing in the untreated sample might reflect greater
incisor flaring in this group. The tendency for higher
overbite scores in this group further supports this inter-
pretation. Despite good matching on several important
criteria for testing the main hypothesis, the failure to
achieve perfect matching in all categories examined is
a limitation of this study, since some of these might
be confounders in data interpretation.
The wider use of interceptive orthodontic treatment
has been proposed as a public health measure for reduc-
ing the burden of malocclusions in developing coun-
tries3 and for increasing access to orthodontic services
for underserved populations (low-income, ethnic minor-
ities, and geographically isolated subgroups).1 The
rationale for this derives from the hypothesis that ortho-
dontists can more readily provide shorter, simpler inter-
ceptive and preventive treatments to low-income
families compared with the alternative of more expen-
sive and longer comprehensive treatments. Cost-effec-
tiveness analyses are necessary to demonstrate the
economic value of this strategy compared with compre-
hensive treatment in the permanent dentition. A Finnish
study found that the cost was lower in 1-stage treatments
started in the permanent dentition compared with
2-stage treatments started in the mixed dentition.27
However, no studies have compared mixed dentition in-
terceptive treatment alone vs comprehensive permanent
dentition treatment alone. Nevertheless, data from
24 King and Brudvik
a decision analysis designed to evaluate potential sav-
ings by reducing the proportion of children offered
free orthodontic treatment through the National Health
Service in Denmark suggest that this reduction actually
results in increased consumption of resources overall.28
This finding lends support to the idea that a comprehen-
sive strategy designed to increase access to interceptive
orthodontic services might be more cost-effective over-
all than the competing one of focusing primarily on com-
prehensive treatment in the permanent dentition for the
most difficult malocclusions.
The use of the ICON as the measure of the effective-
ness of interceptive orthodontic treatment ignores possi-
ble psychological and quality-of-life benefits that can be
derived from these approaches. These factors are often
cited as justifications for orthodontic treatment. This
study supported the effectiveness of interceptive treat-
ments at improving esthetics but did not address quality
of life. According to several reports in the literature, the
decision to seek orthodontic care is based on the desire
to improve dental esthetics, self-esteem, and social ac-
ceptance, not necessarily on the degree of malocclusion
severity.29,30 In a study evaluating the psychosocial ef-
fects of early treatment, self-concept improved, and
negative social experiences declined, suggesting that
improved self-esteem might be an important benefit of
interceptive orthodontic treatment.31
The unweighted ICON component data seem to sug-
gest that some types of interceptive treatments are more
effective than others. This is lost in the summary ICON
data, when the weightings are applied, and the contribu-
tions from the individual components are masked. In the
ICON validation, certain component scores (eg, es-
thetics) were weighted much more highly by the experts
than others. Therefore, these components tend to drive
the summary results. Also, the ICON scores compo-
nents of malocclusion, not the effectiveness of certain
treatment approaches. For the latter, it would be more
appropriate to actually measure the various features of
malocclusion that are addressed by certain types of in-
terceptive treatment (eg, overjet by headgear).
CONCLUSIONS
1. Interceptive orthodontic treatment initially im-
proves malocclusions with reductions in complex-
ity and need compared with doing nothing.
2. Interceptive orthodontic treatment often requires
follow-up treatment in the permanent dentition.
We thank Kirsten Thunold for collecting the study
models in the untreated control sample.
American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
REFERENCES
1. King GJ, Hall CV, Milgrom P, Grembowski DE. Early orthodon-
tic treatment as a means to increase access for children enrolled
in Medicaid in Washington state. J Am Dent Assoc 2006;137:
86-94.
2. Kerosuo H. The role of prevention and simple interceptive mea-
sures in reducing the need for orthodontic treatment. Med Princ
Pract 2002;11 Suppl. 1:16-21.
3. Onyeaso CO. Need for preventive/interceptive orthodontic treat-
ment among 7-10-year-old children in Ibadan, Nigeria: an epide-
miological survey. Odontostomatol Trop 2004;27:15-9.
4. Karaiskos N, Wiltshire WA, Odlum O, Brothwell D, Hassard TH.
Preventive and interceptive orthodontic treatment needs of an in-
ner-city group of 6- and 9-year-old Canadian children. J Can Dent
Assoc 2005;71:649.
5. al Nimri K. Richardson A. Interceptive orthodontics in the real
world of community dentistry. Int J Pediatr Dent 2000;10:
99-108.
6. Vakiparta MK, Kerosuo HM, Nystrom ME, Heikinheimo KA.
Orthodontic treatment need from eight to 12 years of age in an
early treatment oriented public health care system: a prospective
study. Angle Orthod 2005;75:344-9.
7. Richmond S, Shaw WC, Roberts CT, Andrews M. The PAR index
(peer assessment rating): methods to determine outcome of ortho-
dontic treatment in terms of improvement and standards. Eur J Or-
thod 1992;14:180-7.
8. Daniels C, Richmond S. The development of the index of com-
plexity, outcome and need (ICON). J Orthod 2000;27:149-62.
9. Mirabelli JT, Huang GJ, Siu CH, King GJ, Omnell L. The effec-
tiveness of phase I orthodontic treatment in a Medicaid popula-
tion. Am J Orthod Dentofacial Orthop 2005;127:592-8.
10. Han H, Davidson WM. A useful insight into 2 occlusal indexes:
HLD(Md) and HLD(CalMod). Am J Orthod Dentofacial Orthop
2001;120:247-53.
11. Theis JE, Huang GJ, King GJ, Omnell ML. Eligibility for publicly
funded orthodontic treatment determined by the handicapping la-
biolingual deviation index. Am J Orthod Dentofacial Orthop
2005;128:708-15.
12. Richmond S, Shaw WC, O’Brien KD, Buchanan IB, Jones R,
Stephens CD, et al. The development of the PAR index (peer as-
sessment rating): reliability and validity. Eur J Orthod 1992;14:
125-39.
13. Dahlberg G. Statistical methods for medical and biological stu-
dents. New York: Interscience Publications; 1940.
14. Gimmestad AL, Holst D, Fylkesnes K. Changes in restorative car-
ies treatment in 15-year-olds in Oslo, Norway, 1979-1996. Com-
munity Dent Oral Epidemiol 2003;31:246-51.
15. Birkeland JM, Haugejorden O. Caries decline before fluoride
toothpaste was available: earlier and greater decline in the rural
north than in southwestern Norway. Acta Odontol Scand 2001;
59:7-13.
16. von der Fehr FR, Haugejorden O. The start of caries decline and
related fluoride use in Norway. Eur J Oral Sci 1997;105:21-6.
17. Tulloch JF, Phillips C, Proffit WR. Benefit of early Class II treat-
ment: progress report of a two-phase randomized clinical trial.
Am J Orthod Dentofacial Orthop 1998;113:62-72.
18. King GJ, McGorray SP, Wheeler TT, Dolce C, Taylor M. Compar-
ison of peer assessment ratings (PAR) from 1-phase and 2-phase
treatment protocols for Class II malocclusions. Am J Orthod Den-
tofacial Orthop 2003;123:489-96.
19. Nett BC, Huang GJ. Long-term posttreatment changes measured
by the American Board of Orthodontics objective grading system.
Am J Orthod Dentofacial Orthop 2005;127:444-50.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 1
20. Tung AW, Kiyak HA. Psychological influences on the timing of
orthodontic treatment. Am J Orthod Dentofacial Orthop 1998;
113:29-39.
21. Wheeler TT, McGorray SP, Yurkiewicz L, Keeling SD, King GJ.
Orthodontic treatment demand and need in third and fourth grade
schoolchildren. Am J Orthod Dentofacial Orthop 1994;106:
22-33.
22. Thilander B, Wahlund S, Lennartsson B. The effect of early inter-
ceptive treatment in children with posterior cross-bite. Eur J Or-
thod 1984;6:25-34.
23. Ninou S, Stephens C. The early treatment of posterior crossbites:
a review of continuing controversies. Dent Update 1994;21:420-6.
24. Valencia RM. Treatment of unilateral buccal crossbites in the pri-
mary, early mixed, and permanent dentitions: case reports. J Clin
Pediatr Dent 2007;31:214-8.
25. Petren S, Bondemark L, Soderfeldt B. A systematic review con-
cerning early orthodontic treatment of unilateral posterior cross-
bite. Angle Orthod 2003;73:588-96.
King and Brudvik 25
26. Farella M, Michelotti A, Iodice G, Milani S, Martina R. Unilateral
posterior crossbite is not associated with TMJ clicking in young
adolescents. J Dent Res 2007;86:137-41.
27. Jarvinen S, Widstrom E. Determinants of costs of orthodontic
treatment in the Finnish public health service. Swed Dent J
2002;26:41-9.
28. Mavreas D, Melsen B. Financial consequences of reducing treat-
ment availability in a publicly-funded orthodontic service. A de-
cision analysis problem. Br J Orthod 1995;22:47-51.
29. Dann CT, Phillips C, Broder HL, Tulloch JF. Self-concept, Class II
malocclusion, and early treatment. Angle Orthod 1995;65:411-6.
30. Pratelli P, Gelbier S, Gibbons DE. Parental perceptions and atti-
tudes on orthodontic care. Br J Orthod 1998;25:41-6.
31. O’Brien K, Wright J, Conboy F, Chadwick S, Connolly I, Cook P,
et al. Effectiveness of early orthodontic treatment with the Twin-
block appliance: a multicenter, randomized, controlled trial. Part
2: psychosocial effects. Am J Orthod Dentofacial Orthop 2003;
124:488-94.