Straight talking

Specialist Robbie Lawson offers advice on managing key risks in orthodontic treatment

MEDIA articles and robust advertising by aligner companies have increased public awareness of orthodontics, and many general practitioners now offer a range of treatments.

Orthodontics is a lengthy, reactive process that requires longitudinal training to ensure good outcomes. Ideally, it would be carried out only once, with the resulting occlusion maintained throughout life with a robust retention regime.

Adolescent treatment

Optimal results are usually achieved in adolescence when growth can assist treatment objectives, the dentition is less likely to be restored or worn, and the periodontal support is not compromised. The periodontal adaptation to tooth movement is better, with less risk of dehiscence and gingival recession.

Our first priority is therefore to identify orthodontic treatment need during adolescence and direct the patient towards optimal comprehensive treatment when the best, non-compromised outcomes are a possibility.

We should all recognise normal occlusal development and be able to identify deviations. Symmetry and patterns in development are of more importance than chronological age. Specifically, we should be palpating for canines from the age of 10, as late ectopic canine management can require otherwise avoidable surgical intervention.

We should all have a working knowledge of the Index of Orthodontic Treatment Need. Grades 4 and 5 have an established need for treatment and will attract NHS funding in all UK countries. Malocclusions in grade 3 have a borderline need, and will only attract NHS funding if the malocclusion is less attractive, scoring higher on aesthetic need. Treatment of grades 1 and 2 will have little or no long-term dental health or aesthetic improvement, as minor improvements are very difficult to maintain long term.

In most cases, comprehensive orthodontic treatment in a growing adolescent should result in a class I mutually protected functional occlusion with good alignment, no spaces, level occlusal planes and optimal crown and root angulation and inclination. If you have the skills, training and experience to reliably achieve this, it would be appropriate to treat the case. Otherwise, refer the patient to a specialist orthodontic colleague. All adolescent patients should understand the need for excellent oral hygiene and restriction of cariogenic foods to prevent decalcification. Caries risk should be controlled before considering treatment.

Adult treatment

Many patients seek treatment as an adult. This may be because they did not access treatment as an adolescent, or because of the inevitable dental changes that accompany aging. There is also now greater awareness of orthodontic treatment possibilities. Dentists are often targeted by direct marketing from aligner providers and dental laboratories offering indirect bonding and laboratory driven treatment plans, extolling the ease of the clinical process and the potential financial returns. As educated scientists and clinicians, we should view these claims with a robust degree of scrutiny.

There are a small number of cases where simple alignment with round wire appliances in one or both arches is appropriate. However, many will require occlusal changes and three dimensional control on individual teeth to ensure aesthetically acceptable and stable results. Always be clear with patients about your level of expertise and remember that the term orthodontist can only be used by GDC-registered specialists.

There are a number of specific challenges to consider in the orthodontic treatment of adults. Firstly, there will be no growth to help in the treatment of a malocclusion. Unless surgery is considered, the skeletal pattern must be accepted and considered. In a class II, mild crowding case, alignment of upper teeth on a non-extraction basis will inevitably increase the upper incisor prominence, possibly affecting the competence of the lips at rest. This commonly occurs where the practitioner has failed to fully diagnose the underlying malocclusion before embarking on a simple alignment treatment plan.

The periodontal support may be compromised. Moving teeth with a reduced, but healthy periodontium presents biomechanical challenges, but if executed carefully it should not risk further significant bone loss. However, if there is active disease, the loss of alveolar bone during orthodontic treatment can be marked. Always carry out BPE assessment before treatment and consider specialist periodontal referral if indicated. Expansion or proclination, often accompanying non-extraction treatment, risk gingival recession, especially in patients with a thin biotype.

The heavily restored or worn dentition may be at risk in adult patients. The new, often transient occlusal contact that occurs during treatment may lead to enamel fracture or failure of restorations, especially in a patient with parafunction.

Simple aligner treatment or round wire orthodontics may be appropriate in class I cases with normal overbite, in mild crowding of less than 3-4 mm per arch, or mild spacing. There should be no significant tooth movements requiring the 3D control afforded by rectangular wire mechanics.

Even if an adequate outcome can be achieved with aligners or round wire appliances, better aesthetics and stability can often be achieved with more sophisticated appliances and specialist skills. Often asymmetric torque angulations produce less aesthetic outcomes and dissatisfied patients.

Beware of getting involved in treatments that are easier to sell than they are to successfully finish to the patient’s contentment.

Retention

Retention is not a problem in orthodontics – it is THE problem in orthodontics. Teeth will tend to relapse until the supporting tissues have reorganised after 12-15 months. Thereafter there will be age and functional related changes, lifelong. Minimise the relapse potential through careful planning and treatment delivery to achieve the best occlusal outcome, respecting the alveolar trough, periodontium and soft-tissue envelope of stability. All teeth have the potential to change position unpredictably. It is therefore very risky to retain only a few anterior teeth with a bonded retainer alone.

Lifelong wear of full arch removable retainers is essential to predictably retain optimal outcomes. Patients should be clearly informed of this commitment and the need for periodic retainer replacement before treatment. GDPs should routinely ask patients if they have had orthodontic treatment and reinforce the need to continue wearing retainers.

Consent

Risks of orthodontic treatment should be discussed from the outset. Iatrogenic problems such as decalcification and root resorption should be highlighted along with any patient-specific risks such as recession, dark triangles or the need to modify misshapen teeth. Initial consent should be comprehensive, robust and written. The patient should have a chance to read, consider and discuss the risks, commitment and outcome objectives before starting treatment. Consent should be ongoing, with discussion of progress, problems and risks as they develop. Treatment time estimates should be realistic. A patient who is promised a smile in six months will not be happy if their expectations are not met in 12.

Success will come from correct diagnosis, identifying patient expectations, and aligning these with treatment possibilities, risks and limitations in a robust, informed and candid manner.

Key points

  • Treating malocclusion in adolescence is usually preferable to treating as an adult.
  • Recognise normal occlusal development and deviations from this.
  • Palpate for canines from age 10.
  • Understand IOTN and refer/treat when appropriate.
  • Beware of risks of adult orthodontics.
  • Beware of risks of limited objective treatments not meeting patient expectations in time and outcome.
  • Prepare patients for a lifetime of removable retainers.
  • Consent should be robust and ongoing.

Robbie Lawson is a specialist orthodontist

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