PRACTICE

1
IN BRIEF
This series of articles is designed to aid in the orthodontic evaluation of patients
Not every malocclusion needs orthodontic treatment
Not every patient is suitable for treatment
Understanding the treatment benefit for the patient is important
GDPs have an important role to play in assessing the need for orthodontic treatment

VERIFIABL
Orthodontics. Part 1: Who needs orthodontics? E CPD

D.Roberts-Harry1 and J. Sandy2

There are various reasons for offering patients orthodontic treatment. Some of these
include improved aesthetics, occlusal function and the long-term dental health.

Orthodontics comes from the Greek words

With these different definitions of what
‘orthos’ meaning normal, correct, or straight
ORTHODONTICS con- stitutes malocclusion, there is, not
and ‘dontos’ meaning teeth. Orthodontics is
surprisingly a degree of confusion as to what
1. Who needs concerned with correcting or improving the
should be treated and what should not.
orthodontics? position of teeth and correcting any malocclu-
Although some tooth posi- tions can produce
2. Patient assessment sion. What then do we mean by occlusion and
tooth and soft tissue trauma, it is important to
and examination I malocclusion? Surprisingly the answer is not
remember that malocclusion is not a disease
3. Patient assessment straightforward. There have been various
but simply a variation in the nor- mal position
and examination II attempts to describe occlusion using terms
of teeth. Essentially, there are three principal
such as ideal, anatomic (based on tooth
4. Treatment planning reasons for carrying out orthodontic
morpholo- gy), average, aesthetic, adequate,
5. Appliance choices treatment:
normally functioning and occlusion unlikely
6. Risks in to impair dental health.
orthodontic To improve dento facial appearance
treatment To correct the occlusal function of the teeth
7. Fact and
fantasy in
orthodontics
8. Extractions
in
orthodonti
cs
9. Anchorage control
and distal
movement
10. Impacted teeth

1*
Consultant Orthodontist, Orthodontic
Department, Leeds Dental Institute,
Clarendon Way, Leeds LS2 9LU; 2Professor
in Orthodontics, Division of Child
➠

Dental Health, University of Bristol Dental

School, Lower Maudlin Street, Bristol
BS1 2LY Fig. 1a A child with a Class Fig.
II division
1b The 1same
malocclusion and
child as in very
Fig. 1a poo
*Correspondence to: D. Roberts-
Harry E-mail:

robertsharry@btinternet.com
Refereed Paper
doi:10.1038/sj.bdj.4810592
© British Dental Journal 2003; 195:
433–437

BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 1

2003
 PRACTIC

➠
Fig. 2a Same child as in Fig.
Fig. 2b
1 after orthodontic
Occlusion treatment
of the same patient as in

3. To eliminate occlusion that could damage the

Table 1 Features children most dislike or are teased about (Shaw et al.1)
FeatureDisliked appearance or teased ( ) long-term health of the teeth and
periodontium

DENTO FACIAL APPEARANCE

Teeth Clothes Ears Weight Brace
60.7 Nose Improving the appearance of the teeth is without
Height 53.8 question the main reason why most orthodontic
51.7
41.5 treatment is undertaken. Although it might be
33.3 tempting to dismiss this as a trivial need, there
29.3 is little doubt that a poor dental appearance can
25.3 have a profound psychosocial effect on children.
Figure 1 illustrates such a case with a child who
has a substantial aesthetic need for treatment.
The case is shown before (Fig. 1a, b) and after
(Fig 2a, b) orthodontic treatment. Few would
question that there has been an improvement in
both the dental and facial appearance of this
child. Indeed, orthodontic treatment can have a
beneficial psychosocial effect. For example
Shaw et al.1 found that children were teased
more about their teeth than anything else, such
as the clothes they wear or their weight and
height (Table 1).

OCCLUSAL FUNCTION
Fig. 3 This patient has a severe anterior open bite with contact only on the molars
Teeth, which do not occlude properly, can
make eating difficult and may predispose to
temporo- mandibular joint (TMJ) dysfunction.
However, the association with TMJ
dysfunction and mal- occlusion is a
controversial subject and will be discussed in
more detail in a later section. Indi- viduals
who have poor occlusion, such as shown in
Figure 3, may find it difficult and embarrass-
ing to eat because they cannot bite through
food using their incisors. They can only chew
food using their posterior teeth.
Fig. 4 Class II Division 1 with an increased overjet. The anterior teeth are at risk of potential trauma with an overjet of 10 mm or g
DENTAL HEALTH
Surprisingly there is no strong association
between dental irregularity and dental caries
or periodontal disease. It seems that dietary
factors are much more important than the
alignment of the teeth in the aetiology of
caries. Although straight teeth may be easier

2 BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25

 PRACTIC
to clean than crooked ones, patient motivation
and dental

BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 3

2003
 PRACTIC
hygiene seems to be the overriding factor in pre-
venting gingivitis and periodontitis. That said,
few of the studies that have investigated the link
between crowding and periodontal disease have
been longitudinal, over a long term and included
older adults. It would appear that aligned teeth
confer no benefit to those who clean their teeth
well because they can keep their teeth clean
regardless of any irregularity. Similarly, align-
ment will not help bad brushers. If there is poor
tooth brushing, periodontal diseases will devel-
op no matter how straight the teeth are. Howev-
er, having straight teeth may help moderate
brushers, although there is no firm evidence to
support or refute this statement. This is an area
that requires further study.
Some malocclusions may damage both the
teeth and soft tissues if they are left untreated. It
is well known that the more prominent the upper
incisors are the more prone they are to trauma2,3
(Table 2).
When the overjet is 9 mm or more the risk of
damaging the upper incisors increases to over
40 . Reducing a large overjet is not only bene-
ficial from an aesthetic point of view but min-
imises the risk of trauma and long-term com-
plications to the dentition. Fig. 4 shows a
child with a large overjet and it is not difficult
to imagine the likely dental trauma that would
result if he or she fell over.
Fig. 5a Anterior crossbite in a 60-year-old man
occluding in the intercuspal position
Fig. 5c The patient in fixed appliances in order
to correct the displacement and the position of his
upper anterior teeth
4 BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25
Table 2 Relation between size of overjet and prevalence of traumatised anterior teet
Overjet (mm)Incidence
5 22
9 24
>9 44
Certain other occlusal relationships are
also liable to cause long-term problems.
Figure 5a and b show a case where there is an
anterior cross-bite with an associated
mandibular dis- placement in a 60-year-old
man. The constant attrition of the lower
incisors against the upper when the patient
bites together, have produced some
substantial wear. If allowed to continue then
the long-term prognosis for these teeth is
extremely poor. In order to preserve the teeth,
the patient accepted fixed appliance treatment
that eliminated the cross bite and helped
prevent further wear Figure 5c and d.
Another example of problems caused by an
anterior cross bite is shown in Figure 6. A trau-
matic anterior occlusion produced a displacing
force on the lower incisors with apical migration
of the gingival attachment as a consequence. Pro-
vided this situation is remedied early (Fig. 7) the
soft tissue damage stops and as the rest of the
gingivae matures the situation often resolves
Fig. 5b Shows the retruded contact position of the
patient. To reach full intercuspation the mandible displaces
forward and this movement is probably associated with
the wear on the incisors
Fig. 5d After correction and space reorganisation the
patient is wearing a prosthesis to replace the missing
lateral incisors
 PRACTIC

vidual will receive from this will depend on the

Fig. 6 A traumatic anterior occlusion is displacing the lower right central incisor
Fig. 7 The same patient as in Fig. 6, but the cross bite has been corrected social
an improvement in the gingival condition
severity of the presenting malocclusion as well
as the patients own perception of the problem.
Some individuals can have a marked degree of
dento-facial deformity and be unconcerned with
their appearance. Although a practitioner may
suggest treatment for such an individual,
patientslabially
should not
and bethere
talkedisinto
antreatment and dehiscence
associated
must be left to make the final decision them-
selves. Mild malocclusions should be treated
with caution. Not only will the net improvement
in the appearance of the teeth be small, but also
as nearly all teeth move to some degree after
ortho- dontic treatment the risk of relapse in
these cases is high. Whilst minor movements
after the cor- rection of severe malocclusions
will still produce a substantial net overall
improvement for the patients, the same is not
true of minor problems. Many practitioners will
have encountered the parent who can spot a 5-
degree rotation of an upper lateral incisor from
fifty metres and is con- vinced this will be the
with adeath
removable
of their appliance and there
child. Regardless has been
of how
insistent the parent or child is, the practitioner
should approach such problems

Table 3 Index of Treatment Need

Dental health componentTreatment need

1 No need Little need

2 Moderate need Great need
3 Very great need
4
spontaneously and no long-term problems 5
usu- ally develop.
Deep overbites can occasionally cause strip-
ping of the soft tissues as shown in Figure 8a Aesthetic component Treatment need

and b. This is a case where there is little aes-

1
thetic need for treatment but because of the 2 Little need
deep overbite there is substantial damage to 3
the soft tissues. Clearly if this is allowed to 4
continue there is a risk of early loss of the 5
lower incisors that would produce a difficult 6
7
restorative problem. Moderate need
8
9
WHO SHOULD BE TREATED? 10
Dental irregularity alone is not an indication Great need
for treatment. Most orthodontic treatment is
carried out for aesthetic reasons and the
benefit an indi-

Fig. 8a This malocclusion has an extremely deep bite

which can be associated with potential periodontal Fig. 8b The same patient as in Fig. 8a, but not in
problems occlusion. The deep bite has resulted in labial
stripping of the periodontium on the lower right
central incisor
BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 5
2003
PRACTIC

with care and only carry out the treatment if it

is in the best interests of the patient. It is
essential that the patient and parent are fully
aware of the limi- tations of treatment and that
long term, ie perma- nent retention is currently
the only way to ensure long-term alignment of
the teeth.
In order to assess the need for orthodontic
treatment, various indices have been developed.
The one used most commonly in the United Fig. 9 The Index of Treatment Need for this patient
is 2. Although this is low, the level of expertise required to treat it is high
King- dom is the Index of Orthodontic Treatment
Need (IOTN).4 This index attempts to rank
malocclu- sion, in order, from worst to best. It
comprises two parts, an aesthetic component and
a dental health component (Table 3). The
aesthetic component consists of a series of ten
photographs ranging from most to least attractive.
takes no account of the degree of treatment
The idea is to match the patient’s malocclusion
diffi- culty. For example, class II division 2
as closely as possible
malocclu- sions are notoriously difficult to
with one of the photographs. It is unlikely that a treat yet they might have a low IOTN. Figure 9
perfect match will be found but the practitioner illustrates such a case. The IOTN of this patient
should use his or her best guess to match to the is only 2 but it is a difficult case to manage and
nearest equivalent photograph. The dental health treatment requires a high level of expertise.
component consists of a series of occlusal traits
that could affect the long-term dental health of
the teeth. Various features are graded from 1–5 1. Shaw W C, Meek S C, Jones D S. Nicknames, teasing,
(least severe — worst). The worst feature of the harassment and the salience of dental features among
presenting malocclusion is matched to the list and school children. Br J Orthod 1980; 7: 75-80.
2. Office of Population Censuses and Surveys (1994).
given the appropriate score. Children’s dental health in the United Kingdom 1993.
Many hospital orthodontic services will not London: HMSO 0116916079.
accept patients in categories 1–3 of the dental 3. Office of Population Censuses and Surveys (1985).
Children’s dental health in the United Kingdom 1983.
health component or grade 6 or less of the aes-
London: HMSO 0116911360.
thetic component of the IOTN unless they are 4. Brook P, Shaw W C. The development of an
suit- able for undergraduate teaching purposes. index of orthodontic treatment priority. Eur J Orthod
Whilst the IOTN is a useful guide in 1989; 11: 309-320.
prioritising treatment and determining
treatment need it
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6 BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25

 PRACTIC

BRITISH DENTAL JOURNAL VOLUME 195 NO. 8 OCTOBER 25 7

2003
 PRACTICE

2
IN BRIEF
Careful patient assessment is the most important part of treatment
The extra-oral examination is conducted first
The skeletal relationship must be assessed three-dimensionally
The teeth lie in a position of soft tissue balance
Habits such as thumb sucking can induce a malocclusion
There is no proven association between TMJ dysfunction and orthodontics

VERIFIABLE CPD PAPE

Orthodontics. Part 2: Patient assessment

and examination I
D. Roberts-Harry1 and J. Sandy2

The patient assessment forms the essential basis of orthodontic treatment. This is
divided into an extra-oral and intra-oral examination. The extra-oral examination is
carried out first as this can fundamentally influence the treatment options. The skeletal
pattern, soft tissue form and the presence or absence of habits must all be
taken into account.

The most important part of orthodontic treat- Skeletal pattern

ORTHODONTICS ment is the patient assessment. Once a Patients are three-dimensional and therefore
1. Who needs particu- lar treatment strategy is started the skeletal pattern must be assessed in
orthodontics? subsequent changes are often difficult. If it is anterior- posterior (A-P), vertical and
decided that extractions are needed and since transverse relation- ships. Although the soft
2. Patient assessment the process is irreversible, they must be tissues can tip the crowns of the teeth the
carefully considered in the treatment planning skeletal pattern funda- mentally determines
1* 3. and
Consultant
examination
Patient assessment
Orthodontist,
I
Orthodontic process. Inappropri- ate orthodontic treatment their apical root position. The relative size of
andLeeds
Department, examination II
Dental Institute,
9LU; 2Professor
can produce adverse results and it is essential the mandible and maxilla to each other will
4. Treatment
Clarendon Way, Leeds LS2planning
in Orthodontics, Division of Child that full examination of skeletal form, soft determine the skeletal pattern. The smaller the
5.Health,
Dental Appliance
Universitychoices
of Bristol Dental tissue relationships and occlusal features are mandible or the larger the maxil- la the more
6.Lower
School, RisksMaudlin
in Street, Bristol performed prior to under- taking treatment. It the patient will be Class II. Converse- ly with
BS1 2LYorthodontic
*Correspondence to: D. Roberts- is sensible to carry out the assessment in a a bigger mandible or smaller maxilla the
treatment
Harry E-mail: logical order so that none of the steps are patient will be more Class III. The bigger the
7. Fact and
robertsharry@btinternet.com missed. A simple assessment should include size discrepancy between the maxilla and
fantasy in the following: mandible, the more difficult treatment
Refereed Paper
orthodontics
doi:10.1038/sj.bdj.4810659 becomes and the less likely it is that
8. Extractions
© British Dental Journal 2003; • Medical history orthodontics alone will be able to correct the
195: in malocclusion. Although some orthodontic
489–493
• Patient’s complaint
orthodonti • Extra-oral examination appliances have a small orthopaedic effect,
cs • Intra-oral examination treatment is generally most easily accom-
9. Anchorage control • Radiographs plished on patients with a normal skeletal pat-
and distal • Orthodontic indices tern and a normal relationship of the maxilla
movement • Justification for treatment to the mandible.
10. Impacted teeth • Treatment aims
• Treatment plan Anterior-posterior (AP)
Although precise skeletal relationships can be
This section concentrates on the extra- and determined using a lateral cephalostat radi-
intra-oral examination of the patient. ograph, many practices do not have this
facility and it is important to be able to assess
EXTRA-ORAL EXAMINATION the skele- tal relationships clinically.
It is helpful to follow the examination To assess the AP skeletal pattern the
sequence outlined: patient has to be postured carefully with the
head in a neutral horizontal position
• Skeletal pattern (Frankfort Plane hor- izontal to the floor).
• Soft tissues Different head postures can mask the true
• Temporomandibular joint examination relationship. If the head is tipped back the
BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 4
chin tends to
PRACTIC
come further
forward and
makes the
patient appear
to be more
Class III.

4 BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8

PRACTIC

Fig. 1
A tracing of
a lateral cephalostat radiograph identifying soft tissue points A and B

Conversely, if the head is tipped down the

chin moves back and the patient appears to be
more Class II. Sit the patient upright in the
dental chair and ask them to occlude gently
on their posterior teeth. Ask them to gaze at a
distant point; this will usually bring them into
a fairly neutral horizontal head position. Look
at the patient in profile and identify the most Fig. 2 Shows a patient with a skeletal III pattern where a
con- cave points on the soft tissue profile of
the upper and lower lips (Fig. 1).
The point on the upper lip is called soft tis-
sue A point and on the lower lip soft tissue B
point. In a patient with a class I skeletal
pattern B point is situated approximately 1 underlying skeletal pattern. Obviously the soft
mm behind A point. The further back B point tissue thickness may vary and mask the A–P
is, the more the pattern is skeletal II and the skeletal pattern to some degree but generally
more anterior, the more skeletal III it the thickness of the upper and lower lips is sim-
becomes. Figure 2 shows a patient with a ilar. The underlying skeletal pattern is therefore
skeletal III pattern where the outline of the often reflected in the soft tissue pattern. The
hard tissues has been superim- posed on the more severe the skeletal pattern is the more dif-
photograph. This demonstrates that although ficult treatment of the resulting malocclusion
we are examining the soft tissue outline this becomes. Figure 3a and b, shows an adult with
also gives an indication of the an obvious skeletal III pattern and a malocclu-
➠

Fig. 3b Malocclusions of the same patient in F

Fig. 3a Profile of an adult
whichwho has an the
is beyond obvious
scopeskeletal III pattern
of orthodontics alo

BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 4

 PRACTIC

sion that is clearly beyond the scope of ortho-

dontic treatment alone.

Vertical dimension
This dimension gives some indication of the
degree of overbite. The vertical dimension is 50
usually measured in terms of facial height and
the shorter the anterior facial height the more
likely it is that the patient will have a deep
over- bite. Conversely the longer the facial
height the more the patient is likely to have an 50
Fig. 4 Assessment of
anterior open bite. Deep overbites associated
facial proportions. The upper and lower anterior face heights should be approximately e
with a short anterior facial height and open
bites with long face heights are difficult to
correct with ortho- dontics alone. The greater
the skeletal difference the more likely it is
that the patient will need a combination of
orthodontics and orthognathic surgery to
correct the occlusion and the underly- ing
skeletal discrepancy.
➠

Fig. 6 Occlusion of the patient shown in Figure 5. The reduced lower anter
Fig. 5 Profile of a patient with a much reduced lower anterior facial height

Conversely, if the lower anterior facial height is greater

There are various ways of measuring the
vertical dimension, one of the most common
is to measure the Frankfort Mandibular Planes
Angle. This is not a very easy clinical angle to
measure and the problem is compounded by
the fact that not many clinicians can identify
the Frankfort Plane correctly. A more
practical way of assessing this is simply to
measure the vertical dimension as indicated in
Figure 4.
The lower anterior facial height is the dis-
tance from the base of the chin to the base of
the nose. The upper anterior facial height is
the distance from the base of the nose to a
point roughly between the eyebrows. These
dimensions can be measured with a ruler
although the index finger and thumb will do
almost as well. The lower and upper facial
heights are usually equal. If the lower anterior
facial height is reduced, as illustrated in Fig-
ure 5, this can result in a deep overbite that
can be difficult to correct (Fig. 6).

4 BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8

 PRACTIC
this dimension, look at the patient head-on and
t assess whether there is any asym-
h
a
n

5
0


t
h
i
s

c
a
n

p
r
o
d
u
c
e

a
n

a
n
t
e
r
i
o
r

o
p
e
n
-

b
i
t
e

(
F
i
g
.

7
)
.

Transverse dimension
T
o

a
s
s
e
s
s
BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 4

Fig. 7 Anterior open bites are often associated with an increase in lower anterior face h

Fig. 8 A centre line shift where the lower centre line is to the left
Fig. 9 Teeth are
in soft tissue balance between the tongue and the lips
Fig. 10 These diagrams show how partial reduction of the overjet does not allow the lip to cover the upper incisors. The upper incis
4 BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8
PRACTIC
metry in the facial mid-line. If there appears to
be any mandibular asymmetry this may be
reflected in the position of the teeth as shown
in Fig. 8. If there is asymmetry it is important
to distinguish between false and true asymme-
try. A false asymmetry arises when occlusal
interferences force the patient to displace the
mandible laterally producing a cross-bite in
the anterior or buccal region. If the displace-
ment is eliminated then the mandible will
return to a centric position. A true asymmetry
arises as a consequence of unequal facial
growth on the left or right side of the jaws. In
these cases elimination of any occlusal cross-
bites (which can be very difficult) is unlikely to
improve the facial asymmetry.
SOFT TISSUE EXAMINATION
The soft tissues comprise the lips, cheeks and
tongue and these guide the crowns of the teeth
into position as they erupt. Ultimately, the teeth
will lie in a position of soft tissue balance
between the tongue on one side and the lips and
cheeks on the other (Fig. 9).
In patients with a Class I incisor relation-
ship the soft tissues rarely play an important
part unless there is an anterior open-bite. The
anterior open-bite may be caused by a digit
sucking habit, a large lower anterior facial
height, localised failure of eruption of the
teeth, proclination of the incisors or to an
endogenous tongue thrust. The latter cause is
very rare and is usually identified by a large
thrusting tongue that seems to permanently sit
between the upper and lower incisors. This
type of anterior open-bite is extremely diffi-
cult to correct. It is usually possible to reduce
it, but on completion of treatment the tongue
invariably pushes between the teeth and they
move apart once again.
An important aspect of lip position is seen
in patients with an increased overjet. If the
upper incisor prominence is reduced, stability
usually depends on the lower lip covering the
upper incisors in order to prevent the overjet
increasing post-treatment. Therefore, careful
examination of the position of the lower lip in
relation to the upper incisors is important. If
the lower lip does not cover the upper incisors
sufficiently after treatment, relapse of the
overjet may occur. Similarly, if the overjet is
to be reduced, full reduction is very important
in order to give the lip the best possible
chance of stabilising the incisors. Figure 10
illustrates the point; partial reduction of the
overjet does not allow the lip to cover the
upper incisors and they are likely to return to
their pre-treatment position.
Whilst many young children have incompe-
tent lips, this is often just a normal stage of
development. As they pass through puberty, the
lip length increases relative to the size of the
face and the degree of lip competence gradually
improves (Fig. 11).1
Lip incompetence can be caused by either a
lack of lip tissue or an adverse skeletal pattern.
If
PRACTIC
Overlap (mm)
-5 0
5 10
Fig. 11 Lip length is thought to increase as children pass through the pubertal growth spurt. This will aid retention of
the skeletal pattern is unfavourable in either
the vertical or anterior-posterior position then
even with normal lip length the soft tissues
are still widely separated.
HABITS
Digit sucking is a well-known factor in pro-
ducing anterior open-bite, proclined upper
incisors and buccal cross-bites. If the habit
ceases while the child is still growing then the
incisors are very likely to return to their nor-
mal position. However, once the teenage years
are passed and facial growth slows down,
spontaneous resolution becomes increasingly
unlikely. If the habit persists into adult life it
may be necessary to use appliance treatment to
correct the habit induced anterior open-bite.
Buccal cross-bite possibly produced by digit
sucking habits, rarely resolve spontaneously
on cessation of the habit because of occlusal
interferences. These buccal cross-bites often
BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8
1520
Age (years)
need to be corrected with active appliance
treatment.
TEMPORO-MANDIBULAR JOINT PROBLEMS
A comprehensive review of the literature by
Luther2,3 failed to demonstrate any conclusive
association between TMJ dysfunction, maloc-
clusion and orthodontic treatment. However, it
is important that the joints are palpated and
assessed for signs and symptoms of TMJ dys-
function. Patients who present with TMJ pain
seeking an orthodontic solution to correct the
problems should be treated with caution.
1. Vig P S, Cohen A M. Vertical growth of the lips: a
serial cephalometric study. Am J Orthod 1979; 75:
405-415.
2. Luther F. Orthodontics and the tempromandibular joint:
where are we now? Part 1. Orthodontic treatment
and temporomandibular disorders. Angle Orthod 1998;
68: 305-318.
3. Luther F. Orthodontics and the temporomandibular
joint: where are we now? Part 2. Functional
occlusion, malocclusion, and TMD. Angle Orthod 1998;
68: 305-318.
4
 PRACTICE

3
IN BRIEF
Careful patient assessment is the most important part of treatment
The intra-oral examination is conducted after the extra-oral assessment
The degree of occlusal discrepancy influences the treatment options
The dental health and patient motivation determine if appliance therapy can be used

VERIFIABLE CPD PAPE

Orthodontics. Part 3: Patient assessment

and examination II
D. Roberts-Harry1 and J. Sandy2

The intra-oral assessment examines the oral health, individual tooth positions and
inter-occlusal relationships. When this has been completed in conjunction with the
extra-oral examination, a treatment plan can then be formulated.

INTRA-ORAL EXAMINATION tionable dental health should be confined to

ORTHODONTICS There are various systems available to assess extractions and spontaneous alignment of the
1. Who this aspect but the following sequence is both teeth only. Figure 2 illustrates a case where
needs practi- cal and thorough: there is an obvious need for orthodontic
orthodontic treatment but this was precluded by the
s? • Dental health patient's extremely poor oral hygiene.
3. Patient assessment • Lower arch Minor apical root resorption is a common
and examination II • Upper arch consequence of orthodontic tooth movement.
4. Treatment planning • Teeth in occlusion However, this resorption can occasionally be
1*
Consultant Orthodontist, Orthodontic • Radiographs severe. Tooth movement in the presence of
5. Appliance
Department, choices
Leeds Dental Institute, api- cal pathology is known to accelerate
6. Risks
Clarendon in LS2 9LU; 2Professor
Way, Leeds
orthodontic
in Orthodontics, Division of Child Dental health resorption and should be dealt with prior to
Dental Health, University of Bristol Dental Even individuals with severe malocclusions commencing treatment.
treatment
School, Lower Maudlin Street, Bristol should not have active orthodontic treatment
BS17. 2LYFact and
*Correspondence to:in
D. Roberts- in the presence of dental disease. Orthodontic Lower arch
fantasy
Harry E-mail: appliances accumulate plaque and if the The lower arch should be examined and
orthodontics
robertsharry@btinternet.com patient has a poor diet and tooth brushing then planned in the first instance. Whatever
8. Extractions treatment is car- ried out in the lower arch
irre- versible damage can result as
in demonstrated in Figure 1. Although the often determines the treatment to be carried
orthodonti out in the upper. Examine the teeth for any
patient has straight teeth there is considerable
cs tipping, rotations and crowd- ing. Teeth which
decalcification and it could be argued is worse
9. Anchorage control off as a consequence of treat- ment. Clearly are tipped mesially are much more amenable
and distal this could have serious medico- legal to treatment, both with remov- able and fixed
movement complications, particularly if the clinician appliances than teeth which are distally
10. Impacted teeth fails to write in the notes that appropriate tipped. They also respond much better to
dental health advice has been given extractions and spontaneous alignment than
Decalcification around orthodontic appliances other teeth. The presence or absence of
is a recognised hazard and will occur in the rotations is important because rotated teeth
pres- ence of poor oral hygiene and a cariogenic are most easily treated with fixed appliances.
diet. Not only will decalcification occur around The more crowded the teeth are the more
the brackets but tooth movement in the presence likely it is that extractions will be needed in
of active gingivitis or periodontal disease will order to correct the malocclu- sion. A method
accelerate any bone loss. Attempting to move of assessing crowding is given in Figure 3.
Firstly, measure the size of the teeth
teeth in the presence of active dental disease can and add these together (length A). Then measure
Refereed Paper 563–565 have disastrous consequences and must be avoided.
doi:10.1038/sj.bdj.4810724
© British Dental Journal 2003; Therefore, treatment for patients with ques-
195:

BRITISH DENTAL JOURNAL VOLUME 195 NO. 10 NOVEMBER 22 5

from the
mid-line to PRACTIC
the distal of
the canine
with a pair
of dividers.
Measure
from the
distal of the
canine to the
mesial of
the first
permanent

5 BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8

PRACTICE

Upper arch
This is examined in a similar way to the lower
arch. Additional points to note in the mixed
den- tition are the presence of a mid-line
diastema and the position of the upper
canines.
Fig. 1 Decalcification attributable to fixed appliances and a patient with poor oral hygiene
A mid-line throughout
diastema is commonlytreatment
seen in the
mixed dentition. The aetiological factors to be
considered are:

• Normal (physiological) development

• Fraenum
• Small teeth
• Missing teeth
• Midline supernumerary

Fig. 2 This patient has a reasonable need for orthodontic treatment,

but the poor oral hygiene and gingival condition precludes this

molar. Add these together to give you the
approximate arch length (length B). Subtract
B from A to give you the degree of crowding.
This must be repeated for both sides of the
arch.
The degree of crowing influences the need
for extractions. Although one should not be
dog- matic and several other factors influence
the planning of extractions, as a general rule pable in the buccal sulcus by 10 years of age.
the greater the crowding the more likely
extractions are necessary. Table 1 gives an
outline of the relation between degree of
crowding and need for extractions.
Table 1 Relationship between crowding and
Degree of crowdingNeed for extractions
< 5 mmNo
5–10 mm Possibly
> 10 mmYes
Physiologic spacing usually disappears as the
occlusion matures, especially when the upper
permanent canines erupt and no treatment apart
from observation is needed. Fraenectomies are
rarely indicated and generally do not need to be
removed unless the fraenum is particularly large
and fleshy.
The upper permanent canine should be pal-
If not, and the deciduous canine is firm,
parallax radiography should be undertaken to
determine where the permanent tooth is. If the
tooth is palatally positioned then the
deciduous canines on both sides should be
extractions
removed. This will help guide the permanent
tooth into a more favourable path of eruption
and prevent any centre line shift caused by a
unilateral deciduous extraction. It is essential
that this palpation be carried out on all
patients in this age group. Very often
impacting canines are missed and the patient
not referred for treatment until 15 or 16 years
of age. Not only is this negligent, but the
patient may then need to undergo a lengthy
course of treatment at a socially difficult time.

Teeth in occlusion
The overjet and overbite should be measured
and the incisor classification assessed. The
British Standards Institute (BS EN21942 Part 1
(1992) Glossary of Dental terms) defines the
incisor classification as follows:

BRITISH DENTAL JOURNAL VOLUME 195 NO. 10 NOVEMBER 22 5

 1

2
Fig. 3 Assessment of crowding. The widths of all the teeth anterior to the molars are measured and subtracted from the sum o

1+2+3+4+5A 1+2 = B
B – A = Degree of crowding

564 BRITISH DENTAL JOURNAL VOLUME 195 NO. 10 NOVEMBER 22 2003

 PRACTICE

The centre line should be measured by

plac- ing a ruler down the patient's facial mid-
line and measuring how far away from this
the centre lines deviate (Fig. 4). This can then
be marked in the notes as shown in Figure 5.
The buccal occlusion is assessed next, par-
ticularly the molar relationship. This is impor-
tant because when assessing the treatment, it
has to be decided whether the buccal
occlusion is to be accepted or whether it
should be cor- rected as part of the treatment
plan. The canine and molar relationships
Fig. 5 Method for recording deviations in the centre
should line where
be recorded theI,lower
as class is to the right by 1mm and the upper to the left by 2 mm
II or III
Finally, the presence of any anterior or
pos- terior cross-bites should be assessed and
if there is a cross-bite, the clinician should
• Class I. The lower incisor edges occlude with check to see whether there is any mandibular
or lie immediately below the cingulum dis- placement associated with it. This is
plateau (middle part of) the upper central important because any displacement will
incisors. mask the posi- tion of the teeth and give a
• Class II. The lower incisor edges lie posterior misleading indica- tion of the inter-occlusal
to the cingulum plateau of the upper central relationships. Figure 6 shows a child who has Fig. 4 Measurement of centre line deviation
incisors. There are two divisions: an apparently severe class III incisor
Division 1 — there is an increase in the relationship. However, he can get his teeth
overjet and the upper central incisors are into an edge-to-edge relationship and in this
usually proclined. position the occlusion does not appear to be
Division 2 — the upper central incisors are so severe. The amount of procli- nation of the
retroclined. The overjet is usually minimal but upper incisors needed to correct the incisor
may be increased. relationship was quite mild and easily
• Class III. The lower incisor edges lie anterior accomplished using a removable appli- ance
to the cingulum plateau of the upper central (Fig. 7 and 8).
incisors. The overjet is reduced or reversed.

Fig. 6 Class III malocclusion with a displacement anteriorly. The patient can achieve an edge to edge incisor relation in the retru

Fig. 7 Upper removable appliance used to correct the anterior cross bite

Fig. 8 The corrected incisor position for the patient

BRITISH DENTAL JOURNAL VOLUME 195 NO. 10 NOVEMBER 22 5

 Prologue
Ashok Karad

CURRENT STATUS OF ORTHODONTIC

PROFESSION

associated new risks and uncertainties; individual

Advances in diagnostic technology, changing training, diagnostic acu-
treatment concepts and philosophies, appliance design
innova- tions and subsequent exponential growth of
practices to include diverse patient populations have
transformed the face of orthodontics over the past
several years. It was towards the end of the nineteenth
century the great evolutionary process in orthodontics
commenced. A clearer conception of orthodontic
problems was gained principally through the careful
application of fundamental principles by such
dedicated workers as Farrar, Guildford, Jackson, Case
and Angle. Angle’s final achievement, the edgewise
appliance, was the culmina- tion of many years of
effort and many different appli- ance designs
attempting to position the teeth according to his ‘line
of occlusion’. Since the time modern ortho- dontics
gathered momentum under the leadership of Edward H
Angle more than 100 years back, basic and clinical
research and innovative technology have been
instrumental in getting the orthodontic profession to its
present level.
Orthodontics is a dynamic and changing field. Ad-
vances in science and technology are taking place at
a rapid pace. As newer technologies are being intro-
duced, their integration into a busy practice can take
a lot of time, energy and money. A few of these new
technologies include temporary anchorage devices
(TADs), the use of fixed appliances with fully
custom- ized bracket prescriptions, cone beam
computed to- mography (CBCT), sophisticated
treatment planning for patients in need of
orthognathic surgeries, peri- odontal bone
engineering, new protocols for improved treatment
efficiency, interdisciplinary treatment for complex
dentofacial problems, corticotomies to accel- erate
tooth movement, control of adverse effects of
orthodontic treatment, laser surgery, and lingual ortho-
dontics. However, there is very little standardization
across orthodontic practices on the degree of expo-
sure to new techniques. For example, some clinicians
take routine 3-D radiographs on each and every pa-
tient, while others advocate them only as deemed
necessary, and some do not consider them at all.
Many of these newer techniques are being
gradually
incorporated into private practices. As these new
technol- ogies do not always provide solutions to
complex prob- lems in patients, and are likely to bring
men and therapeutic skills of the orthodontic
professional become critical.

Diagnosis in orthodontics, like in other disciplines of DIAGNOSIS AND IMAGING

dentistry and medicine, is a scientific procedure to
gener- ate objective, relevant and accurate information
of pa- tient’s problem and its synthesis that helps the
clinician to plan appropriate treatment strategy. Is this
diagnostic process driven by innovations? Until 1931,
orthodontic diagnosis was performed using clinical
examination, study models and facial photographs.
However, after the introduction of Broadbent–Bolton
cephalometer in 1931, the orthodontic profession
witnessed several cephalomet- ric analyses,
significantly contributing to the extensive study of
human craniofacial growth and its impact on the way
diagnoses were established. Both lateral and frontal
cephalometric analyses enabled the clinician to
identify various components contributing to the
development of sagittal, vertical and transverse
problems in the dentofa- cial complex. This further
enhanced the ability of both the orthodontist and the
maxillofacial surgeon to treat patients with skeletal
problems to produce outstanding results that are
aesthetic and functionally efficient.
Diagnostic capabilities in orthodontics have been im-
proved drastically along with advances in computer
tech- nology. Current concepts in the multifaceted
aspects of diagnosis have been based on an in-depth
analysis of soft tissues and their considerations in
treatment planning. Aes- thetic needs of patients are
always on the rise in both medi- cal and dental fields,
and orthodontics is no exception. With a great majority
of patients visiting orthodontic offices for enhancement
of appearance, the goal of maximizing facial aesthetics
has forced the orthodontist to revisit funda- mental
concepts of art and beauty. Contemporary ortho- dontics
has certainly made valuable progress in considering
both aesthetics and function as priorities in orthodontic
treatment. This has resulted in a major emphasis shift
for- merly based on the dental and skeletal components
to the one that is currently based on the soft tissue
aspects.
Recent advances in imaging technology have further
provided clinicians with a documented view of
craniofacial and dental structures before, during and after
treatment, enhancing the clinician’s diagnostic
capabilities and also
xxi
xxii Prologue
facilitating the patient’s understanding of a problem and
outcome of the treatment procedure. This certainly made
a significant impact on doctor–patient interaction,
making the patient a partner in the treatment planning
process. This new technology is digital, resolving the
limitations of fi lm photographs and radiographic records
offering nu- merous options to the practitioner.
Cone-beam computed tomography represents a
significant advantage in imaging capabilities, replacing
conventional two-dimensional radiographic images
with three-dimensional data sets, with only a small
increase in radiation. Three-dimensional images of the
craniofacial anatomy of a patient can be used with
advanced applica- tion software for diagnosis and
development of treat- ment plans.
RESEARCH
The ANDinMATERIAL
rapid advances orthodontic SCIENCE
research and the
sophis- tication at the molecular level of science have
generated enormous body of literature and new
knowledge in the last 10 years. This has resulted in a
new terminology and lan- guage, quite often little
understood by the practising ortho- dontist. To
understand the mechanism, by which various orthodontic
treatment procedures can be explained, the clinician is
required to have a sound knowledge of biologi- cal
aspects. As the focus of current continuing education
programs is on training the mind and intellect, as well as
superior manual skills, it is equally important to acquire
the methodological skills to assess the treatment
outcomes of alternative treatment strategies. Evidence-
based approach ensures that clinical decisions are based
on the best avail- able information, derived from
integrating relevant clinical research, basic sciences and
clinical experience.
Orthodontists are dependent on a variety of devices
that are made from a large array of biomaterials possess-
ing qualities of nontoxicity, high purity, good strength,
hydrolytic stability, sterilizability, etc. The end of the
nine- teenth century was marked by the scarcity of
adequate orthodontic materials suitable for orthodontic
work. This was followed by major developments in
metallurgy, ana- lytic and organic chemistry and metal
treatment, as well as the emergence of new plastic, all
leading to the first mass-produced orthodontic
consumables way back in the 1960s. Technological
advances in biomaterials such as metals, ceramics and
organic polymers, as well as their combinations, have also
graced the profession over the last few years. The
orthodontic practitioner today has a much more powerful
and sophisticated array of appli- ances, better materials
and a much greater understand- ing of the issues of
biocompatibility. Improvements of the morphology,
structure and mechanical properties of ad- hesives and
bonding with conventional and acid-etching technique,
archwires, elastomeric modules, and ceramic and metal
brackets have significantly contributed to in- creased
treatment effi ciency and reduced chair time.
CLINICAL
Several ORTHODONTICS
fundamental conceptual AND
changes and newer
PRACTICE
trends MANAGEMENT
in the orthodontic profession clearly signify
alterations of traditional emphasis that have gradually
emerged over the past decade or so. The existing
clinical practice has emphasized the broader scope of
various orthodontic procedures to encompass children
in pri- mary and mixed dentition through adolescence
and also including all aspects of adult orthodontic
treatment. Orthodontic treatment was universally
considered to be easier when it was limited to children
and adolescent patients since these patients tend to have
intact, non- worn dentitions associated with optimal
periodontal health. Levelling and alignment of teeth
and good oc- clusal interdigitation were the primary
treatment goals. However, function does not improve
automatically if the teeth are simply aligned within the
dental arches with the molars in Angle Class I
relationship. Recognizing that orthodontic procedures
are meant to be therapeutic and not just cosmetic, these
goals were later redefined to in- clude functional
aspects of occlusion to improve the posttreatment
health of the patient’s stomatognathic system with
lasting effect.
Traditionally, the correction of sagittal discrepancy was
considered a common goal for both the patient and the
orthodontist. However, a large proportion of clinical
situ- ations are not a single entity and are often
associated with significant skeletal and dental
imbalances in all three planes of space – sagittal,
vertical and transverse. The current thinking makes
every specialist familiar with and be able to critically
analyse biologic, biomechanic, diagnostic and
therapeutic concepts in clinical ortho- dontics. This has
drawn clinician’s attention to the fact that an emphasis
should be placed on careful and com- plete diagnosis
of various components of malocclusion and their
interaction, appropriate treatment mechanics based on
sound biomechanical principles, a continued
diagnostic monitoring during treatment and a careful
step-by-step accomplishment of the treatment
objectives. Lack of compliance in all age groups,
especially in the adolescent population, has been a
matter of concern for the practising orthodontists,
having significant impact on the treatment outcome.
The serious consequences of poor patient compliance
have been well appreciated by most clinicians, which
have shown its increasing trend over the years.
Recognizing this aspect of clinical practice, the current
orthodontic practice incorporates treatment designs
and appliance systems that depend minimally on
patient cooperation. This has led to the emergence of
many new techniques and a variety of appliances
available
to the clinician to treat the noncompliant patient.
Anchorage control in fixed orthodontic treatment is
considered one of the most important factors
influencing treatment results. For planning efficient
treatment me- chanics and to avoid undesirable or
detrimental effects on anchor units, it is critical to have
a secure and stable anchorage. Compromised
anchorage, especially in adult malocclusions
characterized by missing teeth, poor peri- odontal
health, etc. is often recognized as the limiting factor in
achieving optimal results. With the limited an- chorage
potential in such cases and acceptance prob- lems
associated with conventional intraoral and extra- oral
aids, several implant anchorage systems have been
introduced to provide absolute orthodontic
anchorage. These exciting innovations that are
developing at a rapid pace are constantly offering
new treatment options for previously untreatable
clinical situations.

For generations, most specialists have concentrated
exclusively on their own speciality. The boundaries be-
tween various dental disciplines have become more and
more sharply drawn over the last few years. Recently,
an increased awareness of malocclusion, aesthetic
appli- ances and functional benefits of orthodontics
have all played an important role in making
orthodontic treat- ment popular in adult population.
With the explosive growth and advances in various
dental disciplines, there has, on the contrary, been a
drawing together on the level of maximizing treatment
results in adult compromised dentition by combining
orthodontic, periodontic and restorative principles and
ways of thinking. Adult orth- odontic patients have
different problems like excessive tooth wear, missing
teeth, restored teeth, periodontally compromised teeth,
etc. which demand some alteration in treatment
strategy. The most efficient and effective care in such
individuals is coordinated by an interdisci- plinary
team where providers of the critical elements of the
care have special training, expertise and experience. In
addition, these team members comprising essentially of
orthodontist, periodontist and restorative dentist have
learned to benefit from one another’s expertise.
Stability of the orthodontic result, an area of great
concern to every clinician, at least partially depends on
the way the cases have been finished. In current
scenario marked by advances in treatment
mechanics, there is hardly a separate stage of
complicated wire bending to fine-tune the tooth
positions; rather, it is a gradual pro- gression towards fi
nishing. In the management of a routine orthodontic
case, the clinician defi nes finishing goals at the
beginning of treatment and continues to fo- cus on
them till the fi nishing stage, in order to achieve them
with appropriate treatment mechanics. Finishing goals
are essentially defi ned for optimal aesthetics, good
function of the stomatognathic system, normal peri-
odontal health and long-term posttreatment stability.
In the past, every orthodontist spent years for
learning how to be an excellent clinician, with less
effort on under- standing the business principles of
practice. In an effort to grow and prosper, most
orthodontic practices today plan on treating more
number of patients, which cannot be accomplished with
traditional methods of management. Recognizing that
extraordinary service, profi tability and high level of
patient satisfaction are key elements in man- aging an
ideal orthodontic practice, attempts are being made to
modify or discard the systems that are not effi cient and
effective. Modern orthodontic practices are try- ing to
adopt a management style that can optimize avail- able
technology, can refine work systems, has effective staff
management principles and has efficient treatment
proto- cols for high-quality treatment results and
service.
Prologue xxiii
APPLIANCE INNOVATIONS
Innovations in orthodontic appliance systems,
archwires, bonding and imaging have dramatically
improved clini- cal efficiency, patient acceptance,
profitability and level of patient satisfaction. Over the
years, the orthodontic bracket design has undergone a
series of evolutionary changes from the initial brackets
used by Dr Angle, to the twin bracket, to the
preadjusted edgewise bracket introduced by Dr Larry
Andrews and now to the self- ligating brackets.
Preadjusted edgewise appliances in their current
variations are probably the most significant
advancement in orthodontic appliance design providing
great benefits to orthodontists in all stages of treatment,
especially during finishing and detailing. Self-ligating
brackets is a magnificent step forward in the effi cient
and effective treatment of orthodontic patients.
Lingual orthodontic therapy is now much more
widely used for its undisputable aesthetic,
biomechanical and therapeutic advantages. In the past,
some patient-related problems like tissue irritation,
speech difficulties and oc- clusal interferences and
certain operator-related prob- lems like bonding,
archwire placement and ligation were associated with
lingual appliance system. However, con- tinued
research in this field over the last few years has led to
several improvements in the original lingual appli-
ance, and a variety of new lingual appliance systems
are now available. The current lingual appliances are
much more refined to address these associated
problems and offer great promise in clinical practice.
The develop- ment of newer brackets, introduction of
superelastic archwires and refi nements in laboratory
procedures have all contributed to the way lingual
orthodontics is practiced today, making it easier and
more comfortable for both doctors and patients. With
the advances in com- puter technology like Computer
Aided Designing and Manufacturing, one signifi cant
development that is making its presence felt is the use
of mass- produced customized orthodontic appliances –
both labial and lingual. These innovations significantly
improve the con- venience and comfort for both
patients and orthodon- tists as they customize treatment
on an individual basis.
These changing trends in the profession are certainly
having a great impact on the way orthodontics is prac-
ticed today. Though basic and clinical research and in-
novative technology will continue to drive orthodontic
advances in the future, it is author’s firm belief that the
area that has great potential to influence the profession
in the future will be ‘individualized diagnosis and cus-
tomized care’ to ensure that all aspects of patient care
are carefully matched and optimized.