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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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