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Justification for Orthodontic Treatment

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    Advice for PCTs, LHBs and SHAs

    The Justification for

    Orthodontic Treatment

    This document has been produced by the British Orthodontic Society

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    This document has been produced by the Clinical

    Standards Committee of the British Orthodontic

    Society. It seeks to provide information for

    purchasers and other interested parties about the

    specialty of orthodontics. It is divided into eight

    sections covering modern orthodontic practice.

    1. What is Orthodontics? page 4

    2. Prevalence of orthodontic page 4

    problems

    3. Why do people need braces? page 5

    4. Health gains from orthodontic page 7

    treatment

    5. Risks of orthodontic treatment page 10

    6. Demand for orthodontic page 11

    treatment

    7. What is the best time to carry page 11

    out orthodontic treatment?

    8. Providers of orthodontic care page 12

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    The Justification forOrthodontic Treatment

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    Orthodontics comes from the Greek words orthos,

    meaning correct or straight and odontes, meaning

    teeth. It is a specialised branch of dentistry concerned

    with the development and management of deviations

    from the normal position of the teeth, jaws and face(malocclusions). A malocclusion is not a disease but

    simply a marked variation from what is considered to be

    the normal position of teeth. Orthodontic treatment can

    improve both the function and appearance of the mouth

    and face. Appliances (braces) can be fixed or removable

    and are used to straighten the teeth and encourage

    growth and development. The main aims of orthodontic

    care are to produce a healthy, functional bite, creating

    greater resistance to disease and improving personalappearance. This contributes to the mental, as well as the

    physical, well being of the individual.

    The photographs show how the treatment of dental

    malocclusions, often using fixed appliances, can greatly

    improve the aesthetics and function of an individuals

    dentition. These dramatic improvements are known to

    have significant psycho-social benefits to the patient.

    People with obviously unsightly teeth are very keen to

    have them changed. Crowded teeth can be potentially

    unhealthy and often provoke teasing or ridicule. Once

    straightened, teeth are often less prone to being damaged

    and the improvement to facial appearance can be

    dramatic.

    2. Prevalence of orthodontic problems

    The 2003 Childrens Dental Health survey1 found that

    approximately one third of children would benefit greatly

    from orthodontic treatment. Indicators of treatment need

    and outcome have been developed and validated by the

    whole orthodontic profession to assess the efficacy and

    appropriateness of care. The most widely used are the

    Index of Orthodontic Treatment Need (IOTN)2 and the

    Peer Assessment Rating (PAR)3.

    The IOTN is divided into two parts called the dental

    health component (DHC) and the aesthetic index (AI).

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    1. What is Orthodontics?

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    The DHC is used to quantify the impact of a particular

    malocclusion upon the long-term dental health of an

    individual whereas the AI provides an assessment of the

    socio-psychological impact through appearance. They

    are used to categorise malocclusion into five groupings

    measured from 1 to 5 with the most severe being 5. It

    is generally accepted that IOTN groups 4 & 5 wouldgreatly benefit from orthodontic treatment as well as

    some individuals from IOTN 3 when the AI is high at 6 or

    more. The main flaw of this index system is that it fails to

    evaluate the childs perception of need. This may lead to

    the denial of treatment of children with a genuine socio-

    dental need4.

    Holmes5 found that 38.5% of 12 year olds would greatly

    benefit from orthodontic treatment. The most commonsevere problems in a normal population are detailed:

    3. Why do people need braces?

    Evidence suggests that correcting the following tooth/

    jaw anomalies with orthodontic appliances will benefit the

    patients long-term dental health:-

    Crowding: Teeth may be poorly aligned because

    the teeth are too large for the mouth. Poor biting

    relationships and unsightly appearance may all result from

    crowding of the teeth. The upper canine teeth are one of

    the most frequent culprits.

    Deep (traumatic) overbite:Extreme (vertical) overlap

    of the top and bottom front teeth can lead to themcontacting the roof of the mouth causing significant tissue

    damage and gum stripping. In some patients, this can

    contribute to excessive tooth wear and early tooth loss in

    adulthood.

    Increased overjet: Upper front teeth that protrude

    beyond normal contact with the lower teeth often

    indicate a poor bite of back teeth and can indicate

    unevenness in jaw growth. Thumb and finger sucking

    habits can also cause prominence of the upper incisor

    teeth and increase the risk of trauma and permanent

    Dental Feature Prevalencein

    Population(%)

    CLEFT LIP ANDPALATE

    0.3%

    IMP ACTED TEETH 8.5%

    HYPODONTIA(missing teeth)

    1.8%

    REVERSE OVERJET(lower teeth in frontof upper teeth)

    2.1%

    LARGE OVERJETS (topteeth stick out)

    8.8%

    CROSSBITE ANDDEVIATION OF JAWSON CLOSING

    3.0%

    DEEP OVERBITE(lower teeth bite onpalate)

    4.3%

    SEVERE CROWDINGOF TEETH

    9.0%

    OPEN BITE (teeth donot meet)

    0.7%

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    damage to the front teeth. A systematic review of the

    available evidence on this topic found that individuals

    with an increased overjet had more than double the risk

    of injury6.

    Open Bite: An open bite results when the upper and

    lower front teeth do not touch when biting together. Thisleads to all the chewing pressures being placed on the

    back teeth, which may cause these teeth to wear down

    quicker. It may also make the patients biting less efficient,

    which may cause social problems especially at meal times.

    Spacing: If teeth have either not developed or are

    missing, or smaller than average in size, unsightly spaces

    may occur between the teeth. This is a less common

    problem though when compared with patients who havesignificant crowding of their teeth. Some malocclusions

    have a greater adverse effect on quality of life than other

    types. Individuals with four or more missing teeth have

    been shown to have poorer quality of life scores7.

    Crossbite: This occurs when the upper front teeth bite

    inside the lower teeth i.e. towards the tongue. This can

    lead to one or more of the lower incisor teeth becoming

    mobile with early receding of the gums. It can also occur

    on the back teeth and is best corrected at an early age

    e.g. 8-10 years, due to biting and chewing difficulties as a

    result of the deviated bite and associated displacement of

    the lower jaw.

    Reverse overjet or lower jaw protrusion:

    Approximately 3 - 5% of the population have a lower

    jaw that is significantly longer than their upper jaw. Thiscauses them to bite their lower front teeth ahead of the

    upper front teeth thus creating a total crossbite of the

    teeth. It can also lead to significant wearing down of the

    tips of the upper front teeth.

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    4. Health gains from orthodontic treatment

    Improved dental health and resistance to

    dental disease: Clinical experience suggests that

    poorly aligned teeth reduces the potential for natural

    tooth cleansing and increases the risk of tooth decay.

    Malocclusion could thereby contribute to bothdental decay and periodontal disease, which would

    damage the long-term health of the teeth and gums

    as it makes it harder for the patient to take care of

    their teeth properly8. However, the evidence linking

    periodontal (gum) disease and crowding of the teeth

    is conflicting. Some studies have found no associations

    between crowded teeth and periodontal destruction9.

    Others have shown that mal-aligned teeth may have

    more plaque retention than straight teeth but socio-economic group, gender, tooth size and tooth surface

    have greater influences10. Studies seem to indicate that

    malocclusion has little impact on diseases of the teeth

    or supporting structures as the presence or absence of

    dental plaque is the major determinant of the health of

    the hard and soft tissues of the mouth. Straight teeth

    may be easier to clean than crooked ones but patient

    motivation and dental hygiene seems to be the over-

    riding influencing factor in preventing gum disease9.

    Having straighter teeth may help moderate tooth

    brushers to be more efficient with their oral care.

    Improvements in the overall function of

    the dentition: Teeth which do not bite together

    properly, can make eating difficult. Individuals

    who have a poor occlusion can find it difficult and

    embarrassing to eat because of their poor control of

    either biting through food or poor chewing ability

    on their back teeth. Adults with severe malocclusion

    often report difficulties in chewing, swallowing or

    speech. Studies have found no causative association

    between orthodontic treatment and jaw joint (TMJ)

    problems11, 12. In the main, speech is little affected

    by malocclusion. However, if a patient cannot attain

    contact between their front teeth, this may contribute

    to the production of a speech lisp.

    Prevention of trauma to prominent teeth: The

    risk of trauma/injury to upper incisors has been shown

    to increase to 45% for children with significantly

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    protruding upper front teeth13. These malocclusions

    score a Dental Health Component of 5, indicating

    a great need for treatment. Such trauma to the

    mouth of an untreated child can result in a fracture

    of the tooth and/or damage of the tooths nerve

    (pulp). Prominent upper front teeth are an important

    and potentially harmful type of orthodontic problem.Providing early orthodontic treatment for young

    children (aged 7-9 years) with prominent upper front

    teeth is of questionable clinical significance. It may be

    prudent to delay treatment until early adolescence.

    However, important factors such as psychological

    impact and the reduction of associated accidents

    (trauma) to the protruding front teeth need to be

    evaluated on an individual basis14.

    Treatment of impacted (buried, partially

    erupted) teeth: Unerupted teeth may cause

    resorption (dissolving) of the roots of adjacent teeth.

    Cyst formation can also occur around unerupted

    wisdom or canine teeth. Extra (supernumerary) teeth

    may also give rise to problems and prevent the normal

    eruption of a permanent tooth. Unerupted or partially

    erupted wisdom teeth can often be left alone in the

    mouth if they are not giving the patient any problems.

    Improvement in dental/facial aesthetics: Often

    resulting in improved self-esteem and other psycho-

    social aspects of the individual. Until recently, this

    aspect has been harder to measure and quantify. A

    number of studies over the years have confirmed that

    a severe malocclusion can be a social handicap. Social

    responses, conditioned by appearance of the teeth,

    can severely affect an individuals whole adaptationto life. This can lead to the concept of a patients

    malocclusion being handicapping.

    One of the most significant effects of a malocclusion

    is its psycho-social impact on the individual patient.

    There is little doubt that a poor dental appearance

    can have a profound psycho-social effect on children.

    Shaw et al. (1980) found that children were teased

    more about their teeth than anything else e.g. clothes,

    weight, ears. A persons dental appearance can have a

    significant effect on how they feel about themselves15.

    Children and adolescents with poor teeth can often

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    become targets for teasing and harassment from other

    children. This results in these patients being unsure

    of themselves in social interaction and having lower

    self-esteem.

    Adolescents who complete orthodontic treatment

    report fewer oral health impacts on their daily life

    activities than those who had never had treatment.

    Groups of children who need orthodontic treatment

    exhibit significantly higher impacts on their emotional

    and social well-being16. Malocclusion has a negative

    impact on the oral health related quality of life of

    adolescents. Children aged between 11 and 14 years

    old with malocclusion demonstrate significantly more

    impacts i.e. worse quality of life, compared with a

    minimal malocclusion group based on the IOTN17

    .Johal et al. (2006) investigated the impact that

    a malocclusion has on a childs quality of life by

    assessing the effect of an increased overjet (>6mm)

    or spaced front teeth. These groups of children also

    had more significant social and emotional issues than

    children with well-aligned teeth18. Their research also

    found that both these occlusal traits had a significant

    negative impact on the quality of life of their parents

    and other family members.

    Shaw et al. (2007) carried out a major multi-

    disciplinary longitudinal study in Cardiff back in 1981

    of an initial sample of 1,018 11-12 year olds. A 20-year

    follow-up study looked at the dental and psycho-social

    status of individuals who received, or did not receive,

    orthodontics as teenagers19. Unfortunately, only a third

    (n=337) of the original sample could be re-examined

    in 2001 due to a 67% dropout rate. Those patientswith a prior need for orthodontic treatment, who had

    treatment completed as a child, demonstrated better

    tooth alignment, better self-esteem and satisfaction

    with life scores. However, orthodontics seemed to

    have little positive effect on psychological health

    and quality of life in adulthood. Unfortunately, this

    long-term study suffered with problems of an archaic

    treatment regime (mainly removable appliances being

    used), antique methodology and short retention

    regime. Its relevance to 21st century orthodontics is

    therefore debatable.

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    In summary, it appears that both psycho-social and

    functional handicaps can produce a significant need for

    orthodontic treatment in addition to the dental health

    benefits described.

    The benefits of orthodontic treatment include an

    improvement in dental health, function, appearance andself-esteem. These perceived benefits are described in

    more detail below. Prospective patients (and their parents)

    seem to be confident of the gains that they expect to

    achieve by undergoing a course of orthodontic treatment.

    The benefits of orthodontic treatment often go beyond

    improving a persons dental health. People may feel they

    look better, which can contribute to self-esteem and ones

    overall quality of life20.

    5. Risks of orthodontic treatment

    In the vast majority of well-planned cases, the benefits

    of orthodontic treatment outweigh the possible

    disadvantages. Patient education and the selection of

    appropriate treatment plans for individuals reduce this risk

    considerably. The most important aspect of orthodontic

    care is to have an extremely high standard of oral hygiene

    before and during orthodontic treatment21.

    i. Early tooth decay: poor oral hygiene (tooth

    brushing) can lead to damage of the teeth around

    orthodontic braces. Early tooth decay (decalcification) will

    occur when plaque accumulates around a fixed brace in

    the presence of frequent sugar intake. Thorough dietary

    advice, excellent oral hygiene and the use of fluoride

    supplements are used routinely by orthodontists tominimise this risk.

    ii. Root Resorption:mild loss of tooth root tissue

    (dissolving) is very commonly seen as a consequence of

    tooth movement but this does not cause any long-term

    problems for the vast majority of patients.

    iii. Loss of Periodontal Support: if a patients oral

    hygiene is poor during treatment, orthodontics may

    exacerbate gingival inflammation and susceptibility to

    periodontal (gum) disease. Patients who have undergone

    orthodontic treatment do not have any increased pre-

    disposition to developing periodontal disease22.

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    6. Demand for orthodontic treatment

    Orthodontics has played an increasing role in dentistry

    over recent years and this trend is likely to continue in

    the future. Recent surveys of the long-term effects of

    orthodontic treatment reveal that the vast majority of

    individuals who have undergone orthodontic treatmentfeel that they benefited from the treatment and are

    pleased with the result. Many patients will demonstrate

    dramatic changes in their dental and facial appearance.

    It is well known that not all patients with malocclusion,

    even those with extreme deviations from normal, seek

    orthodontic treatment. The perceived need for treatment

    is influenced by both social and cultural factors and

    currently the demand for treatment greatly exceeds theresources available. There has been a marked increase in

    demand from both children and adults seeking treatment

    since the 1980s as a result of more dental awareness

    by the public in conjunction with an increased social

    acceptance of fixed braces.

    7. What is the best time to carry outorthodontic treatment?

    Each year, in excess of 130,000 patients (most of whom

    are children under the age of 18 years) have braces fitted

    under the NHS in England & Wales. There is a wide range

    of opinion on the best time to start orthodontic treatment

    but the vast majority is carried out on children who have

    lost all their baby (deciduous) teeth and have most of

    their adult teeth (except for wisdom teeth) present inthe mouth. This means that the earliest the majority

    of children commence their orthodontic treatment is

    between 11-12 years of age.

    Orthodontic treatment provided whilst many baby teeth

    are still present in the mouth, i.e. at age 7-9 years, is

    regarded as early or interceptive treatment. A common

    example of this type of orthodontic treatment is in

    cases with anterior and/or lateral crossbites with jawdisplacement on mouth closure23, 24. Simple expansion

    appliances (removable or fixed types) are usually

    employed to deal with this clinical situation over a

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    few months. Another example of valid interceptive

    orthodontic treatment is where the timely removal of

    a baby tooth can enable the spontaneous (natural)

    correction of a dental centreline shift or allows an off-

    track (ectopic) adult tooth to erupt into its correct

    position in the mouth without the need for braces.

    Most UK orthodontists do not favour early treatment

    to correct increased overjets, deep overbites or severe

    dental crowding and prefer to carry out this treatment

    at the more ideal age of 10-12 years or later. Early

    treatment for increased overjets is commonplace in

    the USA and mainland Europe. It is described as two

    phase treatment as it involves a period of early active

    treatment with a functional or removable appliance

    followed by a second phase with fixed braces once allthe adult teeth are present in the mouth. This compares

    with one phase treatment of adult teeth where the

    functional and fixed brace treatments are combined

    thereby reducing the overall treatment time and possibly

    cost. The optimal timing for treatment of children with

    increased overjets remains controversial25 and needs to

    be based on individual indications for each child. Good

    communication skills can identify specific children whose

    psychological well being can be improved by early

    treatment26.

    8. Providers of orthodontic care

    In the United Kingdom (UK), orthodontic care is provided

    within the state funded NHS at no direct cost to the

    patient or their parents. All Specialist Orthodontists areDentists but only about 3% of Dentists are Orthodontists.

    An Orthodontist is a specialist in the diagnosis, prevention

    and treatment of dental irregularities and facial growth

    anomalies. An Orthodontic Specialist must complete

    an initial 5-year dental undergraduate programme at a

    University Dental School and then successfully complete

    an additional 3-year post-graduate programme of

    advanced education in orthodontics. By the completion

    of their specialist training, trainees will have undertakena Masters Degree and the Membership in Orthodontics

    from one of the Royal Colleges. Currently, hospital and

    university trainees complete two years of additional

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    training before they can become eligible to apply for

    consultant posts.

    At present, there are approximately 1200 orthodontic

    specialists in the UK. These are made up of specialist

    practitioners, hospital consultants and community

    orthodontists. Compared with the rest of the developedworld, the UK is severely short of qualified orthodontists.

    The UK is 15th out of 17 European countries in terms of

    orthodontic provision with 1 orthodontist per 73,000

    population - only Spain and Turkey are worse off.

    Germany and Austria top the table with 1 per 30,000

    - the average is 1 in 55,000. Many other European

    countries utilise orthodontic therapists to work along

    side orthodontists as part of the orthodontic team. The

    number of funded training places and the very recentintroduction of orthodontic therapists in the UK will

    influence the future availability of orthodontic care.

    There is a wealth of evidence to show that orthodontic

    treatment is more likely to achieve a pleasing, successful

    result if fixed appliances rather than removable appliances

    are used27-30 and if the operator has had some post-

    graduate training in orthodontics31, 32. The likelihood that

    orthodontic treatment will benefit a patient is increased

    if a malocclusion is severe28 and if appliance therapy is

    planned and carried out by an experienced orthodontist29.

    However, the likelihood of either a health or psycho-social

    gain is reduced if the malocclusion is mild and treatment

    is undertaken by an inexperienced operator33.

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    References

    1. Lader D, Chadwick B, Chestnutt I, Harker R. et al. Childrens dental health in the United Kingdom 2003.Summary Report Office for National Statistics: March 2005.

    2. Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. European Journal ofOrthodontics, 1989; 11: 309-320.

    3. Richmond S, Shaw WC, OBrien KD, Buchanan IB. et al. The development of the PAR index: reliability andvalidity. European Journal of Orthodontics, 1992; 14: 125-139.

    4. De Oliveira CM, Sheiham A, Tsakos G and OBrien KD. Oral health-related quality of life and the IOTNindex as predictors of childrens perceived needs and acceptance for orthodontic treatment. British DentalJournal, 2008; 204: E12.

    5. Holmes A. The Prevalence of Orthodontic Treatment Need. British Journal of Orthodontics, 1992; 19:177-182.

    6. Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of the relationship betweenoverjet size and traumatic dental injuries. European Journal of Orthodontics, 1999; 21: 503-515.

    7. Wong AT, McMillan AS, McGrath C. Oral health-related quality of life and severe hypodontia. Journal ofOral Rehabilitation, 2006; 33: 869-873.

    8. Roberts-Harry D, Sandy J. Orthodontics. Part 1: Who needs orthodontics? British Dental Journal, 2003;195: 433-437.

    9. Geiger A, Wasserman B, Turgeon L. Relationship of occlusion and periodontal disease. Part 8:Relationship of crowding and spacing to periodontal destruction and gingival inflammation. Journal ofPeriodontology, 1974; 45: 43-49.

    10. Davies T, Shaw W, Worthing H. et al. The effect of orthodontic treatment on plaque and gingivitis.American Journal of Orthodontics & Dentofacial Orthopedics, 1988; 93: 423-428.

    11. Sadowsky C. Risk of orthodontic treatment for producing temporo-mandibular disorders: A literaturereview. American Journal of Orthodontics & Dentofacial Orthopedics, 1992; 101: 79-83.

    12. Luther F. Orthodontics and the TMJ: Where are we now? Angle Orthodontist, 1998; 68: 295-318.

    13. Todd J, Dodd T. Childrens dental health in the United Kingdom. London: Office of Population Censusand Surveys, 1985.

    14. Harrison JE, OBrien KD, Worthington HV. Orthodontic treatment for prominent upper front teeth inchildren. Cochrane Database of Systematic Reviews, 2007; Issue 3.

    15. Shaw WC, Meek SC, Jones DS. Nicknames, teasing harassment and the salience of dental featuresamong school children. British Journal of Orthodontics, 1980; 7: 75-80.

    16. De Oliveira CM, Sheiham A. The relationship between normative orthodontic treatment need and oralhealth-related quality of life. Community Dentistry Oral Epidemiology, 2003; 31: 426-436.

    17. OBrien C, Benson PE, Marshman Z. Evaluation of a quality of life measure for children withmaloccluson. Journal of Orthodontics, 2007; 34: 185-193.

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    18. Johal A, Cheung MYH, Marcenes W. The impact of two different malocclusion traits on quality of life.British Dental Journal, 2007; 202: E6.

    19. Shaw WC, Richmond S, Kenealy PM, Kingdon A, Worthongton H. A 20-year cohort study of healthgain from orthodontic treatment: Psychological outcome. American Journal of Orthodontics & DentofacialOrthopedics, 2007; 132: 146-157.

    20. Turpin DL. Orthodontic treatment and self-esteem (Editorial)American Journal of Orthodontics & Dentofacial Orthopedics, 2007; 131: 571-572.

    21. Travess H, Robert-Harry D, Sandy J. Orthodontics. Part 6: Risks in orthodontic treatment. British DentalJournal, 2004; 196: 71-77.

    22. Sadowsky C, BeGole EA. Long term effects of orthodontic treatment on periodontal health. AmericanJournal of Orthodontics, 1981; 80: 156-172.

    23. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database of SystematicReviews, 2001; Issue 1.

    24. Pietil I, Pietil T, Pirttiniemi P. et al. Orthodontists views on indications for and timing of orthodontictreatment in Finnish public oral care. European Journal of Orthodontics, 2008; 30: 46-51.

    25. Tulloch JFC, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class IItreatment. American Journal of Orthodontics & Dentofacial Orthopedics, 2004; 125: 657-667.

    26. OBrien K. et al. Effectiveness of early orthodontic treatment with the Twin-Block appliance: a multi-center, randomized, controlled trial. Part 2: Psychosocial effects. American Journal of Orthodontics &Dentofacial Orthopedics, 2003; 124: 488-494.

    27. Jones ML. The Barry Project a three-dimensional assessment of occlusal treatment change in aconsecutively referred sample: Crowding and arch dimensions. British Journal of Orthodontics, 1990; 17:269-285.

    28. Richmond S, Shaw WC, Stephens CD, Webb WG, Roberts CT, Andrews M. Orthodontic standards in theGeneral Dental Service of England and Wales: a critical appraisal of standards. British Dental Journal, 1993;174: 315-327.

    29. OBrien KD, Shaw WC, Roberts CT. The use of occlusal indices in assessing the provision of orthodontictreatment by the hospital orthodontic services of England and Wales. British Journal of Orthodontics, 1993;20: 25-35.

    30. Turbill EA, Richmond, Wright JL. A closer look at General Dental Service orthodontics in England andWales I: Factors influencing effectiveness. British Dental Journal, 1999a: 187: 211-216.

    31. Fox NA, Richmond S, Wright JL, Daniels CP. Factors affecting the outcome of orthodontic treatmentwithin the General Dental Services. British Journal of Orthodontics, 1997; 24: 217-221.

    32. Turbill EA, Richmond, Wright JL. A closer look at General Dental Service orthodontics in England andWales II: What determines appliance selection? British Dental Journal, 1999b: 187: 271-274.

    33. Mitchell L. 2007 Chapter 1.6 The effectiveness of treatment, page 5, in An Introduction to

    Orthodontics 3rd edition, Oxford University Press, England.

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    Produced by the Clinical Standards Committee of theBritish Orthodontic Society 2008

    British Orthodontic Society12 Bridewell Place London EC4V 6AP

    Email: ann.wright@bos.org.uk www.bos.org.uk Telephone: 020 7353 8680 Fax: 020 7353 8682Registered Charity No: 1073464