Background
Reading/Links
To get the most advantage of this program, it is highly recommended to have reviewed the following information:
Ackerman-Proffit classification:
Computer Module, Level 2: Systematic Description of Malocclusion.
Interaction with orthodontists:
Computer Module, Level 4: Interaction with Orthodontic Specialists.
Orthodontic diagnosis:
The Development of a Problem List. Contemporary Orthodontics, 3rd ed., pp. 148-195.
Your Next Patient Is Here
After you enter dental practice, a common service to be rendered to the community where you will be practicing is to evaluate the orthodontic needs of a growing patient. Not far in the future, at your busy practice your assistant will be saying:
“Doctor, your next patient is here. She is an 11-year-old named Melissa, and her parents want to know if she needs orthodontic treatment” (video 1).
Orthodontic diagnosis requires a broad overview of the patient’s situation. The essence of the problem-oriented approach is the development of a comprehensive database of pertinent information so that no problems will be overlooked.
Let’s start developing the diagnostic database by going over to meet your new young patient (video 2). You can learn something about her general health and stage of maturity just by watching her walk into the clinic—and you should take the opportunity to do so.
: Patient coming to the dental clinic.
: Coming in and meeting the doctor.
Interview
Interview: Initial Questions
The first step in evaluating the patient is an interview with the patient and parent. The objective is to understand the patient’s overall situation and evaluate specific orthodontic concerns. The specific goals are to establish the
- Patient’s chief complaint: why are they seeking consultation?
- Medical and dental history
- Physical growth status
- Motivation, expectations, and other sociobehavioral factors
So let’s interview your patient and her mother (video).
Video
Chief Complaint
The first step in the interview is to establish the patient’s chief complaint, the reason for seeking this consultation. This usually is done best by direct questions:
- Tell me what bothers you about your face or your teeth?
- Do you think you need braces? Why? (video 1)
It is important to remember that what the dentist thinks is the major problem may not be what the patient/parent are concerned about (video 2). The major reasons for orthodontic treatment, of course, are to overcome some combination of psychosocial concerns related to dental and facial appearance, concerns about dental/jaw function, and health concerns.
You need to know “where they’re coming from,” in the “why are they here?” sense of that phrase.
: Video Clip 1, Melissa chief complaint.
: Video Clip 2, Mother chief complaint.
Medical and Dental History
Young patients interested in orthodontic treatment, like your patient Melissa, often are healthy and have a noncontributory medical history (video). But on occasion positive findings in the medical history can have relevance to orthodontic treatment, as in the following:
- Allergy to metal, especially nickel allergy, can be important if the patient will need fixed orthodontic appliances.
- Other allergies can affect growth and treatment response.
- Patients with actual or potential heart problems, such as those related to a history of rheumatic fever, need antibiotic coverage during banding and debanding (but not for noninvasive orthodontic procedures like changing an arch wire).
- Juvenile arthritis, if it affects the TM joints, can create severe growth problems—and involvement of the TM joints is likely in a child who has multiple affected joints, so this would be an immediate matter of concern in a child with any arthritic joints.
- Some children with small stature are treated with growth hormone, which can have implications for growth modification possibilities and treatment timing.
- Other medications can affect treatment, so all should be noted carefully.
Video
Orofacial Trauma
“Have you ever injured your teeth, jaws, or face?” (video)
Your patient and mother are reporting a negative history of orofacial trauma, but remember that children frequently sustain injury to their primary and permanent teeth and to their jaws. Twenty-five percent of 17-year-olds in the United States are reported to have sustained some type of trauma to the teeth and face in the past.
Let’s review why orofacial trauma is important in relation to orthodontic treatment.
Video
Trauma to the Teeth
First, think about trauma to the teeth. Why is a history of trauma to the teeth important?
- Increased overjet with protrusion of maxillary incisors is a significant predisposing factor for trauma to the teeth. Note that the patient in image 1 traumatized her maxillary left central incisor in the past. That’s more likely if 10 mm of overjet is present, as for her. One reason for beginning orthodontic treatment early (in the mixed dentition), though not a major one for most patients, is to reduce the chance of injury to protruding incisors.
- Previous trauma to the permanent incisors, even minor, can produce devitalization of the pulp of the injured tooth. The patient shown in image 2 has history of traumatic injuries in her incisors due to seizures. A negative pulp response was obtained from the maxillary right central incisor, and a periapical radiograph of her maxillary incisors reveals external root resorption, which of course would be exacerbated by orthodontic tooth movement.
- Severe displacement of the incisors can cause extensive damage to the periodontal ligament, and as that heals, ankylosis of the tooth is quite possible. Ankylosis (image 3) leads to gradual infraocclusion and arrested development of the alveolar process. Remember, an ankylosed tooth cannot be moved orthodontically. Often the best plan is to extract it before it drops well below the plane of the other teeth to minimize the size of the eventual alveolar defect in that area.
 Image 1, increased overjet: Increased overjet with protrusion of incisors increases the chance of trauma to the protruding teeth. |  Image 2, nonvital pulp: A history of dental trauma also increases the chance of external root resorption that would preclude orthodontic tooth movement. |
 Image 3, ankylosed incisor: Ankylosed permanent incisors due to previous trauma. As these teeth fail to erupt, an anterior open bite is developing. |
Trauma to the Face and Jaws
Why is a history of trauma to the face and jaws important?
- The condylar neck of the mandible in childhood is vulnerable when there is a blow to the face, and a fracture of this area can result in a growth deficit that causes facial asymmetry as the injured side lags behind. A condylar fracture often goes undiagnosed. Remember that this is the most likely cause of a mandibular asymmetry with deficient growth of one side, even if the child and family don’t remember the traumatic event.
- At age 5, the patient in images 1 and 2 suffered a subcondylar fracture of his left condyle in a car accident. Note in the panoramic radiograph that the condylar fragment is displaced. It will remodel and regenerate in most instances. A removable appliance was fabricated to reposition his mandible and guide jaw movement during healing, to maximize the chance of normal growth afterward.
- When the mandible can’t translate after an injury (remember, the condyle must be able to move out of the fossa to grow), there’s a major growth problem. The patient in images 3 and 4 suffered a subcondylar fracture as an infant. The asymmetric and reduced growth noted at age 9 is severe enough to require early mandibular surgery to improve the skeletal problem.
 Image 1, panoramic and frontal cephalometric radiograph, subcondylar: A subcondylar fracture on the left can be seen in the panoramic radiograph taken soon after the accident. Note the displacement of the fractured condyle. |  Image 2, subcondylar fracture: Following the accident, a removable appliance was fabricated, to reposition his mandible and facilitate growth on the affected side. |
 Image 3, old fracture, asymmetric growth: Young patient with reduced mandibular growth as a result of early mandibular fracture and restriction of translation of the condyles. Early orthognathic surgery (at age 9) was indicated. |  Image 4, old fracture, early mandibular advancement: Cephalometric radiographs before/after mandibular advancement at age 9. Additional surgery later probably will be required—subsequent normal growth cannot be expected. |
Physical Growth Status
The child’s physical growth status (where is he or she relative to the adolescent growth spurt?) is an important factor in determining the timing of orthodontic treatment. How do you evaluate that in an interview? The appropriate questions:
- How rapidly have you grown recently? (video)
- Have your clothes sizes changed?
- (For girls) Have you reached menarche?
In addition, of course, you would look for signs of sexual maturation. Before sexual maturity, continuing growth of the face and jaws can be expected; after it, much less growth is anticipated.
Why is it important to evaluate physical growth status? Young patients, those who still have significant growth remaining, can be treated using growth modification. The patient in images 1 and 2 has a Class II malocclusion due to mandibular deficiency, and the patient in images 3 and 4 has a concave profile and a Class III malocclusion due primarily to a shift from centric relation to maximum intercuspation (if the Class III is mostly due to a shift, it’s called pseudo-Class III). For both, treatment during active growth offers the best possibility to correct the skeletal and dental discrepancy. The Class III patient needs treatment as soon as possible because the constant forward shift can displace erupting teeth and make the malocclusion worse. The Class II patient is best treated during the adolescent growth spurt and must be evaluated relative to his level of physical maturity rather than his dental age.
Video, Physical Growth Status
 Image 1, Class II malocclusion: Class II div I malocclusion in a boy entering the adolescent growth spurt, which is the ideal time for treatment. |  Image 2, Class II growth modification: Growth modification treatment during active growth: progress note the improved jaw relationship after 12 months of headgear treatment and braces in the anterior teeth. |
 Image 3, pseudo-Class III malocclusion: Young patient with anterior crossbite due to forward shift. |  Image 4, crossbite/forward shift correction: Crossbite/shift correction by relieving incisor interferences. |
Motivation, Expectations, and Compliance
As the final step in the interview, it is important to explore two related but different factors: the motivation for treatment, and what the patient/parents expect as a result of treatment. Why? Because both relate strongly to cooperation with treatment and therefore to the chance of a successful treatment outcome.
Melissa shows genuine interest for treatment and demonstrates now that she understands a lot of what it is like to wear orthodontic appliances when she talks about her friends wearing braces (video). This suggests that she would cooperate with treatment.
Increased patient compliance has been associated with:
- more severe malocclusions and a greater desire to have treatment
- positive parental attitude regarding the value of effective orthodontics
- whether or not the child likes the dentist
The patients in images 1 and 2 really wanted treatment and were very motivated to use extraoral appliances like the face mask or headgear. The patient in image 2 had a personal diary in which she recorded the hours she wore her headgear.
Cooperation is likely to be much better if the child genuinely wants treatment, rather that just putting up with it to please a parent. Indifferent patients, of course, are not likely to cooperate, and occasionally a child overtly refuses to cooperate with treatment, often because it is being forced on him or her by the parents and becomes a focus of adolescent rebellion. Sometimes orthodontic treatment has to be delayed until the patient is ready to accept it.
Video, Motivations and Expectations
 Image 1, Face mask to treat maxillary deficiency: This young patient was very conscious of her facial appearance and was highly motivated to cooperate with reverse pull headgear (face mask) to bring her upper jaw and teeth forward. |  Image 2, Headgear to treat skeletal Class II: This girl wanted her protruding teeth corrected and cooperated very well with headgear. |
Summary of Interview
So what did we learn about Melissa from the interview?
- She and her parents think she needs orthodontic treatment, and their primary concern is the protrusive appearance of the teeth.
- There’s nothing significant in the history—no history of trauma, no allergies/habits, no medications.
- She has obvious secondary sexual characteristics and reports recent growth, so she’s entering the adolescent growth spurt even though she’s only 11.
- Her expectations are realistic, and she appears to be motivated to be a cooperative patient.
Now we are ready to perform the clinical exam.
Video
Clinical Evaluation
Step 1: Oral Health
In the clinical examination, look at the patient from general to particular (video, image 1). It’s a serious error to characterize the dental occlusion while overlooking a jaw discrepancy, developmental syndrome, periodontal problem, or systemic disease. It helps to have a mental checklist to avoid overlooking things. If you don’t see it, usually it’s because you are not looking for it.
This is the suggested checklist—look at these four things, in this order:
- Oral health
- Jaw function
- Facial proportions
- Dental relationships
For the prospective orthodontic patient, what are you looking for in the category of oral health? The same things you would be in any dental patient. Is there any oral pathology? What is the periodontal status? Is caries present? Are there missing teeth, tooth discoloration, enamel fractures, and or enamel defects?
Remember that even if the question is only whether the patient needs orthodontic treatment, any active disease or problem in the soft and hard tissues must be under control before any recommended orthodontic treatment can begin.
Video, clinical exam
 Image 2, lateral / frontal intraoral views: Melissa, age 11, frontal/lateral intraoral views. Whether or not the questions relate to malocclusion, a careful examination of oral health is the first step in evaluation. |  Image 3, occlusal intraoral views: Melissa, age 11, occlusal intraoral views. Caries? Gingivitis/bleeding on probing? Attached gingiva? |
Step 2: Evaluation of Jaw Function and Habits
The key questions in evaluation of jaw function:
- What is the maximum voluntary opening?
- Normal lateral/forward movements?
- TMJ sounds?
- Tenderness on palpation?
- History of pain and habits?
The answers should be recorded on an appropriate clinical form (image 1).
The most important single indicator of joint function is the amount of maximum opening (video 1). If any joint has reasonably normal motion, there is not a great deal wrong with it. If the mandible moves normally, the TM joint is unlikely to be significantly impaired.
It also is important to palpate the muscles of mastication and TM joints and to note any joint sounds or pain. In a patient with limitation of motion, looks for a scar in the chin as a sign of previous orofacial trauma that may have not have been thought to be important at the time.
Find out if the patient has any oral habits like thumb sucking (video 2) or nail biting or a forward posture of the tongue. Both can disturb the development of the orofacial complex.
Video 1, Opening
Video 2, Sucking habit?
Step 3: Evaluation of Facial Proportions and Esthetics
A critically important step in the clinical examination is the evaluation of facial proportions and esthetics. The goal is to detect disproportions and asymmetries that are major contributors to facial esthetic problems. Start by looking at your patient in the frontal view to evaluate the transverse proportions (image 1). Remember that a small degree of bilateral asymmetry exists in essentially all normal individuals. One way to show this is by creating an image of what the face would look like with the right and left sides duplicated (image 2). This “normal asymmetry” should be distinguished from a chin or nose that deviates enough to produce an esthetic problem. The guideline is that a deviation of more than 3-4 mm is enough to be noticed and therefore potentially a problem.
The relationship of height to width establishes the overall facial type. Robin Williams (relatively wide) and Dustin Hoffman (relatively narrow) illustrate the different types within the normal range (image 3). The width of the dental arches, not surprisingly, is related to the width of the face.
The relationship of the midline of each dental arch to the facial midline also should be noted during the clinical examination (image 4). Melissa’s dental and skeletal midlines are exactly coincident. It’s not enough to just note whether the midline of the upper and lower arches coincide—you need to know how the dentition fits into the face.
It is important to note the relationship of the dentition to the lips when a patient smiles (video). A video clip of the patient’s smile rapidly is becoming a standard part of the diagnostic records for orthodontics, as it becomes easy to include video in the digital record file for the patient. Melissa’s smile exposes all of her upper incisors and some gingiva, which is normal at her age but makes the upper incisor protrusion quite apparent.
Video, smile animation
 Image 1, Melissa, frontal view: Melissa, frontal view. |  Image 2, Melissa, frontal facial composite views: Melissa, actual view (left) and composite faces with 2 right and 2 left sides (center, right) showing normal asymmetry. |
 Image 3, Facial types: Facial types: extremes of normal. |  Image 4, Melissa, dental / skeletal midlines: Melissa, dental / skeletal midlines. |
Evaluation of Facial Proportions and Esthetics (cont’d.)
The next step in examining facial proportions is to look at your patient from the profile view. The goal now is to evaluate the anteroposterior jaw relationship, the vertical jaw relationship, and the lip prominence.
Let’s start by evaluating the relative prominence of the mandible to the maxilla. Put the patient in natural head position (relaxed, looking into the distance) (image 1). Then visualize where the maxilla is positioned in relation to the forehead. Normally we would see it slightly in front. Now what about the mandible? Locate the most anterior point of the chin and see how it relates to the forehead and the maxilla. Melissa’s chin is behind that line, so she has moderate mandibular deficiency. That’s why her profile is convex (image 2).
Another important aspect is the prominence of the lips and their relationship to each other (image 3). Note that Melissa’s lower lip is behind a line from the nose to the chin and well related to her chin (only slightly forward from the chin). So she doesn’t have protrusion of her lower teeth relative to the mandible that compensates for the skeletal mandibular deficiency.
Last but not least, look at the vertical proportions of her face. The easiest way to do this is to check to see if the facial thirds are proportional. The distances from the hairline to the bridge of the nose, bridge of nose to base of nose, and base of nose to chin should be very close to the same. Do you see any disproportions?
It also helps to visualize the mandibular plane (image 3) and relate it to the true vertical line. If the lower face is long, the mandibular plane angle usually is steep—so if you see a high mandibular plane angle, you should look again at lower face height. For Melissa, both the facial thirds and mandibular plane angle appear to be close to normal.
 Image 1, Profile convex: Profile evaluation in natural head position |  Image 2, Lip posture: Lip position in reference to natural head position |
 Image 3, Vertical thirds: Vertical thirds proportion and mandibular plane inclination |
Step 4: Evaluation of Crowding/Alignment
Now evaluate the dental relationships, starting with the alignment of the teeth and the amount of space within each dental arch (image 1). At a quick look you can estimate the amount of crowding present. Is it mild (<2 mm), moderate (2-4 mm), or severe (>4 mm)? Look carefully at Melissa’s mandibular arch, where are the permanent canines related to the first primary molars? … No first primary molars present! space between canines and second primary molars nearly closed! So it looks as if at least moderate, probably severe crowding is likely. In the maxillary arch, in contrast, even though the incisors are somewhat crowded, it looks as if there should be enough (or nearly enough) room for the permanent teeth.
Mixed dentition space analysis at this point would quantify the space available for the permanent teeth. To interpret it, remember that you have to look again at the profile and evaluate lip protrusion (image 2). Is there excessive separation of her lips at rest? Is there any strain in bringing her lips together? How prominent are the lips relative to nasolabial and mentolabial concavities?
Since Melissa’s upper lip is a little protrusive, space analysis might understate her upper arch crowding. The lower lip isn’t at all protrusive relative to the chin, perhaps is a little retrusive, so crowding in the lower arch is fully expressed or even a little overstated by space analysis.
The bottom line: She’s short of space in both arches, and some of the potential crowding in the upper arch is concealed by protrusion of the upper incisors.
| Image 1, occlusal views: Melissa, mild maxillary, moderate to severe mandibular crowding. |  Image 2, profile: Melissa, profile: reasonably normal lip prominence, mandibular deficiency. |
Evaluation of Occlusion
Then (image 1) look at the occlusal relationships in the three planes of space:
- transverse (posterior crossbites),
- anteroposterior (overjet, molar and canine relationships), and
- vertical (overbite or open bite).
The objectives are to accurately describe the occlusion and then distinguish between skeletal and dental contributions to malocclusion.
Melissa has no posterior crossbite, so the transverse relationships are acceptable. She has 8 mm overjet, well above the normal 1-3 mm. Her overbite is 1-2 mm, normal. Her molars are Class I, but the canines are nearly Class II.
In her case the Class I molar relation was created by the mesial drift of her mandibular molars after premature loss of the first primary molars (image 2). Reference to her profile (image 3) confirms mandibular deficiency, so this is a skeletal Class II problem.
| Image 1, occlusal views: Melissa, 8 mm overjet and 2 mm overbite, Class I molars but Class II canines. |  Image 2, posterior drift: Mesial drift of molars after early loss of mandibular primary first molar. |
| Image 3, profile: Melissa, profile: lack of chin prominence = mandibular deficiency. |
Give Your Recommendations
Which Diagnostic Records Are Needed?
After interviewing your patient and performing the clinical evaluation, you should be thinking about whether any diagnostic records are needed to provide more information before you give your recommendations about orthodontic treatment.
For this patient, which diagnostic records do you really need to provide an opinion?
- No further records needed
- Panoramic radiograph ✓
- Cephalometric radiograph
- Dental casts plus radiographs
Correct
That is correct, you need a panoramic radiograph. In the mixed dentition, a panoramic radiograph is the screening tool to evaluate pathology (for an orthodontic opinion, especially missing teeth and supernumerary teeth) and gain further insight into the timing of treatment.
Incorrect
No, that’s incorrect. You really need, and should obtain, a panoramic radiograph to offer an informed opinion. In the mixed dentition, a panoramic radiograph is the screening tool to evaluate pathology (for an orthodontic opinion, especially missing teeth and supernumerary teeth) and gain further insight into the timing of treatment. The other records would be part of the complete set of records needed to plan orthodontic treatment but aren’t needed to give the parents a recommendation about treatment.
Which Diagnostic Records Are Needed? (cont’d.)
Let’s review Melissa’s panoramic radiograph. She doesn’t have any pathologies, missing teeth, or supernumerary teeth. Look where the unerupted teeth are, and think further about whether there is enough space for them. The crowding in the lower arch looks pretty severe, doesn’t it?
How long will it be before the second premolars would be ready to erupt? You’d judge that by the amount of root development: They’re about a year away, given that they have half or less of their root formation, and normally would erupt when 2/3 of the root is formed.
Using the panoramic radiograph as a visual aid to explain space problems to the parents is an excellent way to help them understand. It doesn’t require a lot of training to see that space for the second premolars just isn’t going to be there.
Orthodontic Problems?
From your findings during the interview and the clinical evaluation, which of the following need to be discussed with Melissa and her parents?
a. Melissa’s concerns about her teeth and appearance
b. Facial proportions and esthetics
c. Alignment and space
d. Dental relationships
e. Radiographic findings
- a, c, and e
- b, c, and d
- b, d, and e
- a, b, c, e
- all of the above ✓
Correct
That’s right, your findings relative to all these areas should be discussed.
Incorrect
No, that’s incorrect. Your findings relative to all these areas should be discussed.
Orthodontic Problems? (cont’d.)
What should you tell them about each area?
- Melissa’s concerns are appropriate: The protrusive appearance of her front teeth can cause problems in social interactions.
- One reason that her upper teeth appear protrusive is a problem with the growth of her lower jaw. It hasn’t grown forward as much as it should.
- The crowding in the lower arch is worse than it appears clinically. This needs to be explained to the parents with the aid of the panorex, showing the lack of space for the succedaneous teeth.
- All the upper teeth are too far forward relative to the lower teeth. This is part of the reason that she will need braces on all her teeth, not just the protruding front ones.
- Melissa has a healthy mouth, which is necessary before you can have orthodontic treatment, so she is in good shape to go ahead with treatment if she wants it.
To Refer or Not To Refer?
Would you refer Melissa to an orthodontist?
- Yes ✓
- No
Correct
That’s correct, referring Melissa to an orthodontist is recommended.
Incorrect
No, that’s probably not good professional judgment. She certainly is a candidate for orthodontics, and her problems are severe enough to require extensive and prolonged treatment. Referring Melissa to an orthodontist is recommended.
To Refer or Not To Refer? (cont’d.)
Melissa is a candidate for orthodontics for three reasons:
-
the skeletal component of her Class II malocclusion,
-
the severity of the crowding, which is at least borderline for extraction, and
-
the excessive lip support in the upper arch, decreased lip support in the lower arch, and lip incompetence (lip separation at rest).
She will need comprehensive treatment with a complete fixed orthodontic appliance.
When Would You Refer Her?
When would you refer her?
- Now ✓
- When menarche makes it definite that she is in the adolescent growth spurt
- In another 12 months or so, when the premolars erupt
- Between ages 12 and 13, depending on her level of maturity
Correct
That is correct, now is the right time to refer.
Incorrect
No, that’s wrong. Now is the right time to refer.
When Would You Refer Her? (cont’d.)
There are two reasons for referring her now:
- Treatment for patients with skeletal Class II malocclusion should start no later than the time of the adolescent growth spurt, although some children may benefit from earlier treatment.
Remember that it’s the stage of physical development that’s important, not the stage of dental development. Many girls now undergo adolescence at surprisingly early ages. Melissa may be only 11, but she already has secondary sexual characteristics that indicate the onset of puberty.The general rule is that treatment of skeletal problems is most effective and efficient if done during the adolescent growth spurt, so you always want to refer children by the beginning of adolescence. Get them to the orthodontist before they are sexually mature.
- Melissa also has problems in the transition from the late mixed dentition to the early permanent dentition, specifically the crowding in the lower arch and protrusion of upper incisors, which need to be addressed in the near future.
In short, she’s a candidate for treatment now for both growth modification and management of eruption of the teeth.
Referral Letter
In your referral letter, what would you tell the orthodontist about her problems?
- All the things included in the discussion with the parents ✓
- Only the positive findings from the patient’s evaluation
- That she has a Class II crowded malocclusion
- No referral letter with information is needed, the orthodontist will find out all the information
Correct
That is correct. Before seeing the child for the first time, there are a few things the orthodontist would like to know from you.
Incorrect
No, that is incorrect. All the things you discussed with the parent are things you should share with the orthodontist.
Referral Letter (cont’d.)
Before seeing the child for the first time, the orthodontist would like to know from you:
- Anything useful about the child/parent’s expectations, social setting, etc.
- What the orthodontic problems appear to be.
- Whether you have taken radiographs recently that would be useful during the orthodontic evaluation. If so, of course, copies of those radiographs are needed and should be sent in advance if possible.
- Your recommendations for treatment or recall in your practice. For Melissa, an appropriate referral letter might look like the one in the attached images, which show the sections of the letter (separated for greater enlargement and easier reading on the screen).
What Treatment Do You Expect?
What treatment do you expect the orthodontist to suggest?
a. No treatment at this time, he or she will wait for all the teeth to erupt
b. Orthodontic treatment soon using headgear or a functional appliance growth modification
c. Comprehensive orthodontic treatment with possible extractions when the permanent teeth erupt
d. Orthognathic surgery in the future
- a and c
- b and c ✓
- b and d
- a and d
- b, c, and d
Correct
That is correct. Because of her skeletal maturity relative to the eruption of the permanent teeth, growth modification treatment in the mixed dentition will be indicated in the near future. That could be either headgear to the maxillary arch or a functional appliance. It may be desirable to use a partial fixed appliance in the mixed dentition to reposition and align the incisors. If so, headgear might be the choice—and in fact, for Melissa it was (image 1).
After the permanent teeth are available, a second phase of comprehensive treatment to deal with the alignment/space problems definitely will be needed. Orthognathic surgery, however, is not needed for a patient with moderately severe problems like Melissa’s.
Incorrect
No, that’s incorrect. Because of her skeletal maturity relative to the eruption of the permanent teeth, growth modification treatment in the mixed dentition will be indicated in the near future. That could be either headgear to the maxillary arch or a functional appliance. It may be desirable to use a partial fixed appliance in the mixed dentition to reposition and align the incisors. If so, headgear might be the choice—and in fact, for Melissa it was (image 1).
After the permanent teeth are available, a second phase of comprehensive treatment to deal with the alignment/space problems definitely will be needed. Orthognathic surgery, however, is not needed for a patient with moderately severe problems like Melissa’s.
Length of Treatment
How long do you think Melissa’s orthodontic treatment will take? That’s almost surely something the parents will ask you, so you need to have an answer—what will you tell them?
- Less than 12 months
- 12-15 months
- 15-24 months
- More than 24 months ✓
Correct
That is correct, treatment for Melissa almost surely will take more than 2 years.
The first phase of treatment, still in the mixed dentition, needs to start now, but the second phase of treatment can’t start until the remaining permanent teeth erupt. That won’t be for at least a year (image), and phase 2 will take more than a year, so the total will be greater than 24 months.
Incorrect
No, that’s wrong. Treatment for Melissa almost surely will take more than 2 years.
The first phase of treatment, still in the mixed dentition, needs to start now, but the second phase of treatment can’t start until the remaining permanent teeth erupt. That won’t be for at least a year (image), and phase 2 will take more than a year, so the total will be greater than 24 months.
Feedback from the Orthodontist
What feedback do you expect the orthodontist to provide after he or she sees Melissa?
a. acknowledgment of the referral and thanks for it
b. summary of problems
c. recommendations for treatment
d. copies of photographs
e. copies of cephalometric radiographs
- all the above
- a, b, c, d
- a, b, c ✓
- only what I have asked for
Correct
That is correct. Let’s look at the specifics of what to expect from the referral.
Incorrect
No, that’s incorrect. Let’s look at the specifics of what to expect from the referral.
Feedback from the Orthodontist (cont’d.)
You should expect a letter acknowledging the referral, with a summary of the patient’s problems and the orthodontist’s recommendations for treatment. A copy of that letter, or one in simpler language providing the same information, goes to the parents. If the orthodontist took panoramic, bitewing, or periapical radiographs, you also should expect to receive copies of those.
You may or may not get copies of photographs, depending on whether you have told the orthodontist you want them. Unless you specifically request them, you won’t get copies of the cephalometric radiographs, simply because they are of minimal use in family practice—but you can have them if you want them.
A typical feedback letter is shown in the attached images (with the parts separated for greater enlargement on the computer screen).
Melissa’s Recall Schedule
While Melissa is in orthodontic treatment, on what schedule will you recall her for evaluation in your office?
- No need to see her during orthodontic treatment
- When the orthodontist indicates it
- Every 10-12 weeks
- Normal 6- or 12-month recall schedule as with any other young patient ✓
Correct
That’s correct. Melissa needs to be seen in a normal recall schedule like any of your other regular patients, to check for the development of caries or other problems, and to reinforce the importance of oral hygiene during orthodontic appliance wear (image).
If hygiene becomes a particular problem, the orthodontist may ask for your help, and then Melissa might need to be seen in your office more often. Other special problems—which Melissa does not have at this point—also could be the reason for a modified recall schedule when one of your patients is in orthodontic treatment.
Incorrect
That is incorrect. Melissa needs to be seen in a normal recall schedule like any of your other regular patients, to check for the development of caries or other problems, and to reinforce the importance of oral hygiene during orthodontic appliance wear (image).
If hygiene becomes a particular problem, the orthodontist may ask for your help, and then Melissa might need to be seen in your office more often. Other special problems—which Melissa does not have at this point—also could be the reason for a modified recall schedule when one of your patients is in orthodontic treatment.
Summary
Yes indeed. It will happen: In the near future you’ll be asked to look at a friend’s child or patient’s child to offer an opinion as to whether orthodontics is needed.
To answer such questions, you need to
- analyze the patient’s problems,
- decide whether orthodontic treatment is needed, and
- apply the triage method based on problem severity to make the decision as to whether a child has a problem that warrants consultation with an orthodontist.
Specifically, you need to
- interview the parent and patient, asking about their concerns, the medical/dental history, and growth status;
- perform a clinical exam with emphasis on facial symmetry/proportions and jaw relationships, then the dental alignment and occlusion; and
- obtain a panoramic radiograph in most circumstances, so that you can evaluate pathology, anomalies in eruption dental development, missing teeth, and supernumerary teeth.
Good communication in both directions is the key to good patient management when a patient from your practice goes to an orthodontist. It is important for the patient to have regular appointments with the primary dental health provider while undergoing orthodontics, to monitor oral health.