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: [email protected] www.bos.org.uk Telephone: 020 7353 8680 Fax: 020 7353 8682Registered Charity No: 1073464

Justification for Orthodontic Treatment

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Justification for Orthodontic Treatment