08


• Clinical risk reduction


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


STRAIGHT M


EDIA 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


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