The Special Needs Patient in Orthodontics
**Dr Daniel Fernandes - Orthodontics**
University of Western Australia
School of Dentistry
THE UNIVERSITY OF
WESTERN AUSTRALIA
**FACULTY OF**
Medicine and Dentistry
**Dr Daniel Fernandes - Orthodontics**
University of Western Australia
School of Dentistry
**FACULTY OF**
Medicine and Dentistry
![]()
Line-art diagram of the Vitruvian Man, featuring a nude male figure with outstretched arms and legs inscribed within a circle and square. This illustration is used to represent proportionality and symmetry.
# The Special Needs Patient in Orthodontics
- Rationale for treating disabled patients
- Who is prepared to treat them?
- Preparing the child for treatment
- Drawing up a general treatment direction
- Choosing the suitable management modality
- Adapting traditional orthodontics to the Special Needs Patient
- The ethical dilemma revisited
Becker, A. and Chaushu, S. (2004)
Australian Society of Orthodontics Meeting
The Special Needs Patient in Orthodontics
- Rationale for treating disabled patients
- Who is prepared to treat them?
- Preparing the child for treatment
- Drawing up a general treatment direction
- Choosing the suitable management modality
- Adapting traditional orthodontics to the Special Needs Patient
- The ethical dilemma revisited
Becker, A. and Chaushu, S. (2004)
Australian Society of Orthodontics Meeting
**Rationale for treating disabled patients**
Dental disability
Medically necessary care
Persons with special care needs
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
#### Rationale for Treating Disabled Patients
- Dental disability
- Medically necessary care
- Persons with special care needs
**Definition of Dental Disability**
Dental caries, periodontal disease, and other oral conditions if left untreated can limit substantially a child’s development and an individuals participation in life activities
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
Dental caries, periodontal disease, and other oral conditions if left untreated can limit substantially a child's development and an individual's participation in life activities.
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Clinical photo: A close-up of a child's face showing visible dental caries, specifically two decayed front teeth.
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Clinical photo showing a close-up of the anterior dentition in a child, illustrating significant dental caries affecting both the maxillary and mandibular primary teeth.
**Definition of Dental Disability**
A person should be considered to have a dental disability if they have pain, infection, or a lack of a functional dentition:
1. Restricts nutritional intake adequate for growth and energy needs.
2. Delays or otherwise alters growth and development; or
3. Inhibits participation in life activities
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
A person should be considered to have a dental disability if they have pain, infection, or a lack of a functional dentition:
1. Restricts nutritional intake adequate for growth and energy needs.
2. Delays or otherwise alters growth and development; or
3. Inhibits participation in life activities.
# Definition of Medically Necessary Care
Medically necessary care is the **reasonable and appropriate** diagnostic, preventive and treatment services and follow-up care **(including supplies, appliances and devices)** as determined by qualified, appropriate health care providers in treating any condition, disease, injury or congenital or developmental malformation.
---
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
Medically necessary care is the **reasonable and appropriate** diagnostic, preventive and treatment services and follow-up care **(including supplies, appliances and devices)** as determined by qualified, appropriate health care providers in treating any condition, disease, injury or congenital or developmental malformation.
**Definition of Medically Necessary Care**
Medically necessary care includes all health care services that directly support the delivery of dental/oral health care that in the judgment of the attending dentist, are necessary for the provision of optimal quality therapeutic and preventive oral care to the patients with medical, physical or behavioral conditions.
(cont.)
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
Medically necessary care includes all health care services that directly support the delivery of dental/oral health care that in the judgment of the attending dentist, are necessary for the provision of optimal quality therapeutic and preventive oral care to the patients with medical, physical or behavioral conditions.
Definition of Medically Necessary Care
**Definition**: Medically Necessary Care
**Services Included (but not limited to)**:
- Sedation
- General anesthesia
- Utilization of surgical facilities
*Source: Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005*
**Services Included (but not limited to):**
- Sedation
- General anesthesia
- Utilization of surgical facilities
Definition of Medically Necessary Care
**Dental care is medically necessary for the purpose of preventing, controlling and eliminating orofacial infection, pain and disease and correcting facial disfiguration or dysfunction.**
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
**Dental care is medically necessary for the purpose of preventing, controlling and eliminating orofacial infection, pain and disease and correcting facial disfiguration or dysfunction.**
# Definition of Persons with Special Health Care Needs
Persons are considered to have special care needs if they have a **physical**, **developmental**, **mental**, **sensory**, **behavioral**, **cognitive**, or **emotional impairment or limiting condition** that requires **medical management**, **health care intervention**, and/or use of **specialized services or programs**.
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
Persons are considered to have special care needs if they have a **physical**, **developmental**, **mental**, **sensory**, **behavioral**, **cognitive**, or **emotional impairment or limiting condition** that requires **medical management**, **health care intervention**, and/or use of **specialized services or programs**.
**Definition of Persons with Special**
**Health Care Needs**
**The condition may be developmental or **
**acquired and may cause limitations in **
**performing daily self-maintenance activities or **
**substantial limitations in a major life activity.**
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
The condition may be developmental or acquired and may cause limitations in performing daily self-maintenance activities or substantial limitations in a major life activity.
**Definition of Persons with Special Health Care Needs**
Health care for special needs patients is beyond that considered routine and requires specialized, knowledge, increased awareness and attention and accommodation.
Pediatric Dentistry, Vol. 26 No. 7 Reference Manual 2004-2005
Health care for special needs patients is beyond that considered routine and requires specialized knowledge, increased awareness and attention and accommodation.
# **Who is Prepared to Treat Them?**
**Australian Dental Association**
– Ask for a dentist skilled/experienced in treating disabled patients
Pediatric Dentist or General Dentist or **Special Needs Dentist (Specialist) (Daniel Sundaresan in WA)**
Usually within a **Public Institution/Facility**
Advice Disability Services
**Who is Prepared to Treat Them?**
**Australian Dental Association**
- Ask for a dentist skilled/experienced in treating disabled patients
Pediatric Dentist or General Dentist or **Special Needs Dentist (Specialist) (Daniel Sundaresan in WA)**
Usually within a **Public Institution/Facility**
Advice Disability Services
**Orthodontics for Special Needs Patients**
**Jackson, E. F. (1967)**
Orthodontics and the retarded child,
American Journal of Orthodontics, 53, 596-605.
**Orthodontics for Special Needs Patients**
**Jackson, E. F. (1967)**
Orthodontics and the retarded child,
American Journal of Orthodontics, 53, 596-605.
# Orthodontics for the handicapped child
As early as **1967** Jackson suggested methods for orthodontic treatment for patients with learning disabilities
Jackson, E. F. (1967)
*Orthodontics and the retarded child*,
American Journal of Orthodontics, **53**, 596-605.
**Orthodontics for the handicapped child**
As early as **1967** Jackson suggested methods for orthodontic treatment for patients with learning disabilities
Jackson, E. F. (1967)
*Orthodontics and the retarded child*,
American Journal of Orthodontics, **53**, 596-605.
# Orthodontics for Special Needs Patients
**Ackerman, A. and Wiltshire W. A. (1994)**
The occlusal status of disabled children, *Journal of the Dental Association of South Africa*, 49, 447-51.
**Orthodontics for Special Needs Patients**
**Ackerman, A. and Wiltshire W. A. (1994)**
The occlusal status of disabled children, *Journal of the Dental Association of South Africa*, 49, 447-51.
# The occlusal status of disabled **children**
The occlusal status of children of six schools for the handicapped was determined using the occlusal index (O.I.) of Summers. **The study showed 75%** required treatment **10.5%** had good occlusions and **15%** had slight malocclusions where treatment was not considered essential.
***
Ackerman, A. and Wiltshire W. A. (1994)
The occlusal status of disabled children,
*Journal of the Dental Association of South Africa*, **49**, 447-51.
**The occlusal status of disabled children**
The occlusal status of children of six schools for the handicapped was determined using the occlusal index (O.I.) of Summers. **The study showed 75%** required treatment **10.5%** had good occlusions and **15%** had slight malocclusions where treatment was not considered essential.
Ackerman, A. and Wiltshire W. A. (1994)
The occlusal status of disabled children,
*Journal of the Dental Association of South Africa*, **49**, 447-51.
# The occlusal status of disabled children
The study indicated that 40.6% of children were interested in receiving orthodontic treatment, but only **0.5%** were planning to seek it.
**Ackerman, A. and Wiltshire W. A. (1994)**
The occlusal status of disabled children, *Journal of the Dental Association of South Africa*, **49**, 447-51.
**The occlusal status of disabled children**
The study indicated that 40.6% of children were interested in receiving orthodontic treatment, but only **0.5%** were planning to seek it.
**Ackerman, A. and Wiltshire W. A. (1994)**
The occlusal status of disabled children, *Journal of the Dental Association of South Africa*, **49**, 447-51.
**Orthodontics for Special Needs Patients**
**Becker, A., and Shapira, J. (1996)**
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, 18, 55-67.
**Orthodontics for Special Needs Patients**
**Becker, A., and Shapira, J. (1996)**
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, 18, 55-67.
# Orthodontics for the handicapped child
In 1996 **Becker and Shapira** presented guidelines for the orthodontic treatment of the handicapped child. They discussed therapeutic modalities new and old that could be utilized in the treatment of the malocclusion of handicapped children.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
In 1996 **Becker and Shapira** presented guidelines for the orthodontic treatment of the handicapped child. They discussed therapeutic modalities new and old that could be utilized in the treatment of the malocclusion of handicapped children.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
Orthodontics for the handicapped child
**Four basic requirements an orthodontic patient must demonstrate:**
– **Motivation**
– **Oral hygiene**
– **Behaviour management**
– **Manual dexterity**
*In the context of these patients the parents or carers can supplement the requirements*
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, 18, 55-67.
**Orthodontics for the handicapped child**
**Four basic requirements an orthodontic patient must demonstrate:**
- **Motivation**
- **Oral hygiene**
- **Behaviour management**
- **Manual dexterity**
*In the context of these patients the parents or carers can supplement the requirements*
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, 18, 55-67.
**Orthodontics for the handicapped child**
General treatment principles still apply:
Clinical examination
Diagnostic records
Prioritized problem list
Treatment objectives
Treatment Plan
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
European Journal of Orthodontics, 18, 55-67.
**Orthodontics for the handicapped child**
General treatment principles still apply:
- Clinical examination
- Diagnostic records
- Prioritized problem list
- Treatment objectives
- Treatment Plan
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
European Journal of Orthodontics, 18, 55-67.
# Orthodontics for the handicapped child
***
**The Role of the Parent or Carer:**
Oral Hygiene
Caries prevention prophylaxis (diet control, fluoride application, etc.)
Appliance care
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics,* **18**, 55-67.
**The Role of the Parent or Carer:**
- Oral Hygiene
- Caries prevention prophylaxis (diet control, fluoride application, etc.)
- Appliance care
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics,* **18**, 55-67.
**Orthodontics for the handicapped child**
**The role of the orthodontist:**
1. There is the need **to aim for realistic treatment goals**, which must be **adapted to the individual patient’s needs and capabilities** (Willard and Nowak, 1981)
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
**Orthodontics for the handicapped child**
**The role of the orthodontist:**
1. There is the need **to aim for realistic treatment goals**, which must be **adapted to the individual patient’s needs and capabilities** (Willard and Nowak, 1981)
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
Orthodontics for the handicapped child
The role of the orthodontist:
2. It is advisable to use a **bold simplified** appliance design to make activation **bold independent of the patient (Becker 1993)**
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
**Orthodontics for the handicapped child**
The role of the orthodontist:
2. It is advisable to use a **bold simplified** appliance design to make activation **bold independent of the patient (Becker 1993)**
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
# Orthodontics for the handicapped child
**The role of the orthodontist:**
3. Conscious sedation is a pharmacologically induced state of relaxation in which the patient remains conscious, but with significant alteration of mood and co-operativeness throughout the dental treatment. This has played an increasingly important part in the orthodontic treatment of handicapped children.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
**The role of the orthodontist:**
3. Conscious sedation is a pharmacologically induced state of relaxation in which the patient remains conscious, but with significant alteration of mood and co-operativeness throughout the dental treatment. This has played an increasingly important part in the orthodontic treatment of handicapped children.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
![]()
Clinical photo: A medical professional in blue scrubs holds up a clear, circular breathing mask connected to a black tube. The image illustrates the concept of conscious sedation equipment used during orthodontic treatment for handicapped children.
Orthodontics for the handicapped child
The role of the orthodontist:
**4.** **Strategic extractions that will allow spontaneous corrective movements of adjacent teeth.** This will often minimize the need for and extent of mechanotherapy.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
**Orthodontics for the handicapped child**
The role of the orthodontist:
4. **Strategic extractions that will allow spontaneous corrective movements of adjacent teeth.** This will often minimize the need for and extent of mechanotherapy.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
![]()
Radiograph:
Orthodontics for the handicapped child
The role of the orthodontist:
5. The use of **en bloc** (all of the teeth moved as a unit) **extra-oral** removable appliances for growth modification (**full-time**).
Where the parents cooperate with this appliance, the results may be truly dramatic.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
**Orthodontics for the handicapped child**
The role of the orthodontist:
5. The use of **en bloc** (all of the teeth moved as a unit) **extra-oral** removable appliances for growth modification (**full-time**).
Where the parents cooperate with this appliance, the results may be truly dramatic.
Becker, A., and Shapira, J. (1996)
Orthodontics for the handicapped child,
*European Journal of Orthodontics*, **18**, 55-67.
![]()
Clinical photo: A clear acrylic extra-oral removable orthodontic appliance featuring metal clasps and a wire component, shown alongside its application on a child's face. This visual illustrates the en bloc growth modification device described in the text.
**Orthodontics for Special Needs Patients**
**S. M. Chadwick and C. Asher-McDade (1997)**
The orthodontic management of patients with
profound learning disability,
*British Journal of Orthodontics*, **24**, 117-125.
**Orthodontics for Special Needs Patients**
**S. M. Chadwick and C. Asher-McDade (1997)**
The orthodontic management of patients with
profound learning disability,
*British Journal of Orthodontics*, **24**, 117-125.
**The orthodontic management of patients with profound learning disability**
Patient selection
Treatment planning
Clinical management
S. M. Chadwick and C. Asher-McDade (1997)
*The orthodontic management of patients with profound learning disability*,
*British Journal of Orthodontics*, **24**, 117–125.
**The orthodontic management of patients with profound learning disability**
- Patient selection
- Treatment planning
- Clinical management
S. M. Chadwick and C. Asher-McDade (1997)
*The orthodontic management of patients with profound learning disability*,
*British Journal of Orthodontics*, **24**, 117–125.
The orthodontic management of patients with profound learning disability
Due the need to provide routine dental care of many of these patients under general anesthetic (GA). **Close coordination of these procedures with orthodontic treatment is recommended.** Increases the GA time, but otherwise would not place the patient under any additional risk.
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, 24, 117-125.
**The orthodontic management of patients with profound learning disability**
Due the need to provide routine dental care of many of these patients under general anesthetic (GA). **Close coordination of these procedures with orthodontic treatment is recommended.** Increases the GA time, but otherwise would not place the patient under any additional risk.
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, 24, 117-125.
![]()
Clinical photo: A frontal view of a young patient with dark hair and bangs, whose eyes are pixelated for privacy. The figure illustrates the physical appearance of a child likely requiring the orthodontic management discussed in the slide text.
![]()
The orthodontic management of patients with **profound learning disability**
Elective procedures on patients with a learning disability raise bold moral and ethical questions.
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, **24**, 117-125.
**The orthodontic management of patients with profound learning disability**
Elective procedures on patients with a learning disability raise bold moral and ethical questions.
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, **24**, 117-125.
**The orthodontic management of patients with profound learning disability**
There may be considerable pressure from parents/carers for some form of treatment to improve the patient’s “quality of life.” **The risks of orthodontic treatment must be carefully explained to allow the parents/carers to provide informed consent.**
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, **24**, 117-125.
**The orthodontic management of patients with profound learning disability**
There may be considerable pressure from parents/carers for some form of treatment to improve the patient’s “quality of life.” **The risks of orthodontic treatment must be carefully explained to allow the parents/carers to provide informed consent.**
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, **24**, 117-125.
**The orthodontic management of patients with profound learning disability**
Elective procedures for patients with learning disability are not limited to dental treatment. Similar ethical and moral questions have been raised concerning elective surgery for patients with Downs Syndrome in order to improve their speech and appearance.
**S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, British Journal of Orthodontics, 24, 117-125.**
**The orthodontic management of patients with profound learning disability**
Elective procedures for patients with learning disability are not limited to dental treatment. Similar ethical and moral questions have been raised concerning elective surgery for patients with Downs Syndrome in order to improve their speech and appearance.
**S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, British Journal of Orthodontics, 24, 117-125.**
**The orthodontic management of patients with profound learning disability**
Following orthodontic treatment for patients with learning disabilities an improvement in the parent-child relationship has been reported, but an improvement in "**quality of life**" or social acceptability is difficult to quantify, particularly if the patients themselves are not able to express their **feelings**.
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, 24, 117-125.
**The orthodontic management of patients with profound learning disability**
Following orthodontic treatment for patients with learning disabilities an improvement in the parent-child relationship has been reported, but an improvement in "**quality of life**" or social acceptability is difficult to quantify, particularly if the patients themselves are not able to express their **feelings**.
S. M. Chadwick and C. Asher-McDade (1997)
The orthodontic management of patients with profound learning disability, *British Journal of Orthodontics*, 24, 117-125.
**Orthodontics for Special Needs Patients**
**Chaushu, S. and Becker A. (2000)**
Behaviour management needs for the children with disabilities,
*European Journal of Orthodontics*, **22**, 143-149.
Chaushu, S. and Becker A. (2000)
Behaviour management needs for the children with disabilities, *European Journal of Orthodontics*, **22**, 143-149.
# **Behaviour management needs for the children with disabilities**
This investigation studied the modes of behaviour management used in the orthodontic treatment of disabled children, and the preferred criteria.
**Chaushu, S. and Becker A. (2000)**
*Behaviour management needs for the children with disabilities*, European Journal of Orthodontics, **22**, 143-149.
**Behaviour management needs for the children with disabilities**
This investigation studied the modes of behaviour management used in the orthodontic treatment of disabled children, and the preferred criteria.
**Chaushu, S. and Becker A. (2000)**
*Behaviour management needs for the children with disabilities*, European Journal of Orthodontics, **22**, 143-149.
# Behaviour management needs for the children with disabilities
**Five specific factors, frequently seen in disabled children, gag reflex, drooling, uncontrollable movements, inability to remain still, and the need for additional procedures**, were graded and a scoring system was devised to include these factors within the assessment.
Chaushu, S. and Becker A. (2000)
*Behaviour management needs for the children with disabilities*
*European Journal of Orthodontics*, 22, 143–149.
**Five specific factors, frequently seen in disabled children, gag reflex, drooling, uncontrollable movements, inability to remain still, and the need for additional procedures**, were graded and a scoring system was devised to include these factors within the assessment.
Chaushu, S. and Becker A. (2000)
*Behaviour management needs for the children with disabilities*
*European Journal of Orthodontics*, 22, 143–149.
# Behaviour management needs for the children with disabilities
The scoring system may be used to evaluate new patients and to assist in a choice of the **selection of an appropriate behavioral management mode.**
Chaushu, S. and Becker A. (2000)
Behaviour management needs for the children with disabilities, *European Journal of Orthodontics*, **22**, 143-149.
The scoring system may be used to evaluate new patients and to assist in a choice of the **selection of an appropriate behavioral management mode.**
Chaushu, S. and Becker A. (2000)
Behaviour management needs for the children with disabilities, *European Journal of Orthodontics*, **22**, 143-149.
**Orthodontics for Special Needs Patients**
**Becker A., Shapira J. and Chaushu, S. (2000)**
*Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.*
*European Journal of Orthodontics, 22, 225-8.*
***Orthodontics for Special Needs Patients***
*Becker A., Shapira J. and Chaushu, S. (2000)*
*Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.*
*European Journal of Orthodontics, 22, 225-8.*
**Orthodontics for Special Needs Patients**
**Becker A., Shapira J. and Chaushu, S. (2000)**
*Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.*
*European Journal of Orthodontics, 22, 225-8.*
***Orthodontics for Special Needs Patients***
*Becker A., Shapira J. and Chaushu, S. (2000)*
*Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.*
*European Journal of Orthodontics, 22, 225-8.*
Orthodontic treatment for disabled children: **motivation**, **expectation**, and **satisfaction**.
Orthodontic treatment for disabled children: **motivation**, **expectation**, and **satisfaction**.
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
**The** parents expected improvement in the child’s appearance with a concomitant improvement in his/her social acceptance.
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
European Journal of Orthodontics, **22**, 151-158.
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
**The** parents expected improvement in the child’s appearance with a concomitant improvement in his/her social acceptance.
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
European Journal of Orthodontics, **22**, 151-158.
Orthodontic treatment for disabled children: **_motivation_**, **_expectation_**, and **_satisfaction_**.
**_These expectations from the treatment_** were found to be **_exaggerated_**, with only a minority of the parents claiming a marked improvement in their **_child’s everyday functioning_**, or a significant **_social improvement_**.
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: **_motivation_**, **_expectation_**, and **_satisfaction_**.
_European Journal of Orthodontics_, **22**, 151-158.
Orthodontic treatment for disabled children: **_motivation_**, **_expectation_**, and **_satisfaction_**.
**_These expectations from the treatment_** were found to be **_exaggerated_**, with only a minority of the parents claiming a marked improvement in their **_child’s everyday functioning_**, or a significant **_social improvement_**.
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: **_motivation_**, **_expectation_**, and **_satisfaction_**.
_European Journal of Orthodontics_, **22**, 151-158.
# Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
**Nevertheless** most of the parents were **satisfied with treatment**, and reported that 17 of the children themselves, who were aware of a change, considered it an improvement. A majority of the children understood the reasons for treatment, in the most general of terms.
Becker A., Shapira J. and Chaushu, S. (2000)
*Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.*
*European Journal of Orthodontics, 22, 151-158.*
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
**Nevertheless** most of the parents were **satisfied with treatment**, and reported that 17 of the children themselves, who were aware of a change, considered it an improvement. A majority of the children understood the reasons for treatment, in the most general of terms.
Becker A., Shapira J. and Chaushu, S. (2000)
*Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.*
*European Journal of Orthodontics, 22, 151-158.*
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
**With only one exception**, **the parents stated that they would repeat the procedure**, given **the same set of circumstances**, and all of them would recommend it for other disabled children.
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
*European Journal of Orthodontics*, 22, 151-158.
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
**With only one exception**, **the parents stated that they would repeat the procedure**, given **the same set of circumstances**, and all of them would recommend it for other disabled children.
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
*European Journal of Orthodontics*, 22, 151-158.
**Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.**
It may be concluded that even though orthodontic treatment in this group of patients does not yield the desired social influence, **the individual benefits from the treatment are worthwhile.**
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
*European Journal of Orthodontics*, **22**, 151-158.
**Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.**
It may be concluded that even though orthodontic treatment in this group of patients does not yield the desired social influence, **the individual benefits from the treatment are worthwhile.**
Becker A., Shapira J. and Chaushu, S. (2000)
Orthodontic treatment for disabled children: motivation, expectation, and satisfaction.
*European Journal of Orthodontics*, **22**, 151-158.
**Orthodontics for Special Needs Patients**
**Chaushu, S., Zeltser R. and Becker A.**
**(2000)**
Safe orthodontic banding for children with disabilities during general anesthesia, *European Journal of Orthodontics*, **22**, 225-8.
**Orthodontics for Special Needs Patients**
**Chaushu, S., Zeltser R. and Becker A.**
**(2000)**
Safe orthodontic banding for children with disabilities during general anesthesia, *European Journal of Orthodontics*, **22**, 225-8.
**Safe orthodontic banding for children with disabilities during general anesthesia**
General anesthesia (GA) may be employed to overcome management difficulties in the orthodontic treatment of disabled children. **This report introduces the application of rubber dam as a useful aid for a high quality bonding and as an effective safeguard in bonding of brackets**
Chaushu, S., Zeltser R. and Becker A. (2000)
Safe orthodontic banding for children with disabilities during general anesthesia,
*European Journal of Orthodontics*, **22**, 225-8.
**Safe orthodontic banding for children with disabilities during general anesthesia**
General anesthesia (GA) may be employed to overcome management difficulties in the orthodontic treatment of disabled children. **This report introduces the application of rubber dam as a useful aid for a high quality bonding and as an effective safeguard in bonding of brackets**
Chaushu, S., Zeltser R. and Becker A. (2000)
Safe orthodontic banding for children with disabilities during general anesthesia,
*European Journal of Orthodontics*, **22**, 225-8.
Safe orthodontic banding for children with disabilities during general anesthesia
This report introduces
the
application of rubber dam as a
useful aid for a high quality
bonding and as an effective
safeguard in bonding of brackets in
(GA), in the handicapped in
particular.
Chaushu, S., Zeltser R. and Becker A. (2000)
Safe orthodontic banding for children with disabilities during general anesthesia,
European Journal of Orthodontics, 22, 225-8.
Safe orthodontic banding for children with disabilities during general anesthesia
This report introduces
the
application of rubber dam as a
useful aid for a high quality
bonding and as an effective
safeguard in bonding of brackets in
(GA), in the handicapped in
particular.
Chaushu, S., Zeltser R. and Becker A. (2000)
Safe orthodontic banding for children with disabilities during general anesthesia,
European Journal of Orthodontics, 22, 225-8.
![]()
Clinical photo: A healthcare professional wearing blue scrubs holds up a clear, circular medical device (likely a laryngeal mask airway or similar intubation tool) attached to a black tube. The image illustrates the equipment used for general anesthesia, which is the context of the slide's report on safe orthodontic banding.
# **Safe orthodontic banding for children with disabilities during general anesthesia**
Additional procedures, such as extractions or exposure of impacted teeth may be carried out only after removal of the rubber dam, but before archwire placement, wherever possible.
Chaushu, S., Zeltser R. and Becker A. (2000)
Safe orthodontic banding for children with disabilities during general anesthesia, *European Journal of Orthodontics*, 22, 225-8.
**Safe orthodontic banding for children with disabilities during general anesthesia**
Additional procedures, such as extractions or exposure of impacted teeth may be carried out only after removal of the rubber dam, but before archwire placement, wherever possible.
Chaushu, S., Zeltser R. and Becker A. (2000)
Safe orthodontic banding for children with disabilities during general anesthesia, *European Journal of Orthodontics*, 22, 225-8.
Orthodontics for Special Needs Patients
**Chaushu, S., Gozal, D. and Becker A. (2002)**
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, 24, 81-89.
Orthodontics for Special Needs Patients
**Chaushu, S., Gozal, D. and Becker A. (2002)**
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, 24, 81-89.
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities
**Intravenous (IV) sedation has become established as an important and preferred alternative to general anesthesia (GA), in order to overcome difficulties in patient management encountered in the delivery of routine dental treatment of the disabled.**
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, **24**, 81-89.
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities
**Intravenous (IV) sedation has become established as an important and preferred alternative to general anesthesia (GA), in order to overcome difficulties in patient management encountered in the delivery of routine dental treatment of the disabled.**
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, **24**, 81-89.
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities**
**The study describes the use of IV sedation to enable the performance of certain complex orthodontic and surgical procedures, which require strict control of the oral environment for prolonged periods.**
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, 24, 81-89.
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities**
**The study describes the use of IV sedation to enable the performance of certain complex orthodontic and surgical procedures, which require strict control of the oral environment for prolonged periods.**
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, 24, 81-89.
**Intravenous sedation: an adjunct to enable
orthodontic treatment for children with disabilities**
**The use of IV sedation provided a**
**satisfactory management modality in these**
**patients,** who had previously been referred
**for GA.**
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, **24**, 81-89.
**Intravenous sedation: an adjunct to enable
orthodontic treatment for children with disabilities**
**The use of IV sedation provided a**
**satisfactory management modality in these**
**patients,** who had previously been referred
**for GA.**
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, **24**, 81-89.
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities**
The parents reported complete satisfaction and general agreement that the same modality would again be welcomed.
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, **24**, 81-89.
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities**
The parents reported complete satisfaction and general agreement that the same modality would again be welcomed.
Chaushu, S., Gozal, D. and Becker A. (2002)
Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.
*European Journal of Orthodontics*, **24**, 81-89.
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities**
IV sedation significantly reduces the use of GA and makes treatment more readily available to a larger number of disabled patients.
**Chaushu, S., Gozal, D. and Becker A. (2002)**
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.**
*European Journal of Orthodontics, 24, 81-89.*
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities**
IV sedation significantly reduces the use of GA and makes treatment more readily available to a larger number of disabled patients.
**Chaushu, S., Gozal, D. and Becker A. (2002)**
**Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities.**
*European Journal of Orthodontics, 24, 81-89.*
# The Ethical Dilemma
**First Do No Harm**
### Medically Necessary Treatment
Medically necessary care is the reasonable and appropriate diagnostic, preventive and treatment services (including supplies, appliances and devices) and follow-up care as determined by qualified, appropriate health care providers in treating any condition, disease, injury or congenital or developmental malformation.
Dentally
#### The Ethical Dilemma
**First Do No Harm**
##### Medically Necessary Treatment
Medically necessary care is the reasonable and appropriate diagnostic, preventive and treatment services (including supplies, appliances and devices) and follow-up care as determined by qualified, appropriate health care providers in treating any condition, disease, injury or congenital or developmental malformation.
Dentally
# **The Ethical Dilemma Revisited**
Dental care is medically necessary for the purpose of preventing, controlling and eliminating orofacial infection, pain and disease and correcting facial disfiguration or dysfunction.
#### The Ethical Dilemma Revisited
Dental care is medically necessary for the purpose of preventing, controlling and eliminating orofacial infection, pain and disease and correcting facial disfiguration or dysfunction.
**Phoebe**
* Female
* Developmental learning disorder
* Moderate to severe skeletal malocclusion
- Female
- Developmental learning disorder
- Moderate to severe skeletal malocclusion
![]()
Clinical photo of a female patient exhibiting moderate to severe skeletal malocclusion, characterized by the lower jaw protruding forward relative to the upper jaw.
![]()
Clinical photo: A frontal view of a young female patient with dark hair and a pink shirt, illustrating the context of developmental learning disorder and moderate to severe skeletal malocclusion.
![]()
Clinical photo showing the right lateral profile of a female patient, illustrating moderate to severe skeletal malocclusion.
# Phoebe
![]()
Radiograph: A lateral cephalometric view of a patient's skull displaying the skeletal profile, nasal cavity, and maxillary/mandibular dental arches.
![]()
Radiograph:
PR
DR PETER READMAN
BDSc (Hons), MDS, FRCDS
Paediatric Dentist
353 Canning Highway
Bicton WA 6157
Tel (08) 9139 8200
Fax (08) 9139 8211
Unit 2, 187 Scarborough Beach Road
Mount Hawthorn WA 6016
Tel (08) 9441 3922
Fax (08) 9443 6199
2 November 2004
MOBILE: 0417 910 122
Dr Mike Razza
Booragoon Orthodontics
Suite 4
Gateways Building
BOORAGOON 6154
Dear Mike,
RE: Phoebe [REDACTED]
DOB: 21 MAR 1992
Our ref: [REDACTED]
PO Box [REDACTED]
BROOME 6725
I would like to update your records in regards to Phoebe's recent dental treatment while visiting Perth in the past few days. As you are aware, Phoebe is one of your Broome patients who was referred for extraction of her retained and partially ankylosed primary molars. During this opportunity under general anaesthesia, impressions were taken for a rapid maxillary expansion appliance (RME) which was fitted on Monday 1 November 2004.
The dental treatment provided under general anaesthesia included:
**20th October 2004**
* EUA
* Intraoral Radiographic examination
* Scale, prophylaxis and fluoride treatment
* 7 x Dental extractions of retained primary teeth (teeth 55, 53, 63, 65, 75, 84, 85)
* 5 x Fissure sealants (teeth 16, 26, 37, 46, 47)
* Impressions for study models
* Impressions for RME
The RME was then inserted on Monday 1 November 2004 at Southbank Clinic under sedation. Post insert instructions where also give with the RME key and further discussed with Phoebe's father (**REDACTED**).
Mike, the fees which I charged in regards to her Orthodontic treatment so far are:
* Study Models ($90)
* Impressions/cementation/insert of RME ($280),
I would therefore be grateful if you could charge Phoebe independently in regards to the fabrication of the RME and other Orthodontic costs. I have tried to keep this quite reasonable on my behalf so as not to complicate the cost of Orthodontic treatment. Please find enclosed in this correspondence study models and Lab fee document.
Mike, should you require any further information please contact the Bicton Rooms in regards the Phoebe's management.
Kind regards,
**Dr Peter Readman**
PR
DR PETER READMAN
BDSc (Hons), MDS, FRCDS
Paediatric Dentist
353 Canning Highway
Bicton WA 6157
Tel (08) 9139 8200
Fax (08) 9139 8211
Unit 2, 187 Scarborough Beach Road
Mount Hawthorn WA 6016
Tel (08) 9441 3922
Fax (08) 9443 6199
2 November 2004
MOBILE: 0417 910 122
Dr Mike Razza
Booragoon Orthodontics
Suite 4
Gateways Building
BOORAGOON 6154
Dear Mike,
RE: Phoebe [REDACTED]
DOB: 21 MAR 1992
Our ref: [REDACTED]
PO Box [REDACTED]
BROOME 6725
I would like to update your records in regards to Phoebe's recent dental treatment while visiting Perth in the past few days. As you are aware, Phoebe is one of your Broome patients who was referred for extraction of her retained and partially ankylosed primary molars. During this opportunity under general anaesthesia, impressions were taken for a rapid maxillary expansion appliance (RME) which was fitted on Monday 1 November 2004.
The dental treatment provided under general anaesthesia included:
**20th October 2004**
- EUA
- Intraoral Radiographic examination
- Scale, prophylaxis and fluoride treatment
- 7 x Dental extractions of retained primary teeth (teeth 55, 53, 63, 65, 75, 84, 85)
- 5 x Fissure sealants (teeth 16, 26, 37, 46, 47)
- Impressions for study models
- Impressions for RME
The RME was then inserted on Monday 1 November 2004 at Southbank Clinic under sedation. Post insert instructions where also give with the RME key and further discussed with Phoebe's father (**REDACTED**).
Mike, the fees which I charged in regards to her Orthodontic treatment so far are:
- Study Models ($90)
- Impressions/cementation/insert of RME ($280),
I would therefore be grateful if you could charge Phoebe independently in regards to the fabrication of the RME and other Orthodontic costs. I have tried to keep this quite reasonable on my behalf so as not to complicate the cost of Orthodontic treatment. Please find enclosed in this correspondence study models and Lab fee document.
Mike, should you require any further information please contact the Bicton Rooms in regards the Phoebe's management.
Kind regards,
**Dr Peter Readman**
![]()
A handwritten signature of Dr Peter Readman, which serves as the formal closing for the medical correspondence regarding patient Phoebe's treatment.
# Phoebe
* GA - **Diagnostic records, restorations, fit** bands for rapid maxillary expansion appliance and impression for appliance fabrication.
* GA - insertion of RME
* Maintained expansion longer than average
* No sedation required to remove appliance
- GA - **Diagnostic records, restorations, fit** bands for rapid maxillary expansion appliance and impression for appliance fabrication.
- GA - insertion of RME
- Maintained expansion longer than average
- No sedation required to remove appliance
<img title="Information about a multiple missing teeth dental patient">Nicholas is a patient with **Downs Syndrome**. He has **moderate to severe dental malocclusion** and **multiple missing teeth**.
Downs Syndrome
Moderate to severe dental malocclusion
Multiple missing teeth
Nicholas is a patient with **Downs Syndrome**. He has **moderate to severe dental malocclusion** and **multiple missing teeth**.
- Downs Syndrome
- Moderate to severe dental malocclusion
- Multiple missing teeth
<ul>
<li>Nicholas</li>
<li>GA sedation</li>
<li>Deciduous teeth extraction</li>
<li>Required dental restorations</li>
<li>Reassess</li>
</ul>
- Nicholas
- GA sedation
- Deciduous teeth extraction
- Required dental restorations
- Reassess
# Nicholas
![]()
Radiograph: This cropped image displays a panoramic dental X-ray (orthopantomogram) showing the patient's maxilla and mandible. It visualizes the full arch of teeth, including molars, premolars, canines, and incisors, along with the underlying jawbone structure.
null
**Nicholas**
**Nicholas**
![]()
Radiograph:
Nicholas
Nicholas
![]()
Radiograph:
Patrick
post RME
Patrick
post RME
![]()
Clinical photo: A frontal portrait of a young male with short brown hair against a blue background, featuring an oval redaction over the eyes.
![]()
Clinical photo of a male patient's face post-RME (rapid maxillary expansion), showing the midface and smile.
![]()
Clinical photo: A lateral view of a patient's head and neck, likely taken for orthodontic assessment or surgical planning. The subject has short brown hair and is shown in profile against a solid blue background.
Patrick
post RME
Patrick
post RME
![]()
Clinical photo showing the maxillary and mandibular posterior teeth in occlusion, illustrating a post-treatment dental arch. The image highlights the alignment of the upper and lower molars and premolars following Rapid Maxillary Expansion (RME).
![]()
Clinical photo of the anterior dentition showing a severe anterior crossbite, where the maxillary central incisors are positioned labial to the mandibular incisors. The image is labeled 'Patrick post RME', indicating the patient's condition after rapid maxillary expansion.
![]()
Clinical photo of the patient's dental arches showing a Class I molar relationship with good overjet and overbite following rapid maxillary expansion (RME). The image highlights the alignment of the upper and lower teeth in occlusion.
![]()
Clinical photo of a maxillary occlusal view showing the upper dental arch and hard palate following rapid maxillary expansion (RME). The image displays the alignment of the teeth within the widened palatal vault.
![]()
Clinical photo of the mandibular arch showing the lower teeth and tongue, illustrating the post-treatment result after RME.
**Patrick**
```json
{"BOX_A": "Pre-treatment", "BOX_B": "Progress", "BOX_C": "Occlusion", "BOX_D": "Maxillary arch", "BOX_E": "Mandibular arch"}
```
**Patrick**
- **BOX_A**: Pre-treatment
- **BOX_B**: Progress
- **BOX_C**: Occlusion
- **BOX_D**: Maxillary arch
- **BOX_E**: Mandibular arch
![]()
Clinical photo showing a close-up of the maxillary and mandibular arches with fixed orthodontic appliances (brackets and wires) in place. The teeth exhibit crowding, particularly in the anterior region, illustrating the pre-treatment condition.
![]()
Clinical photo showing the patient's teeth fitted with metal braces and a blue archwire, illustrating the 'Progress' stage of orthodontic treatment.
![]()
Clinical photo showing the occlusion of both maxillary and mandibular arches fitted with fixed orthodontic appliances. The image captures the teeth in a closed bite position, illustrating the alignment of the brackets and archwires during treatment.
![]()
Clinical photo of a maxillary arch view showing the upper dental arch with brackets bonded to the teeth, illustrating an orthodontic appliance in place.
![]()
Clinical photo of the mandibular arch showing fixed orthodontic appliances, including brackets and an archwire bonded to the lower teeth.
Patrick
* **Rapid maxillary expansion**
* Full-fixed appliances
* Force modules and/or elastics for Class II correction
* No sedation
* Significant parental and family support and involvement
- **Rapid maxillary expansion**
- Full-fixed appliances
- Force modules and/or elastics for Class II correction
- No sedation
- Significant parental and family support and involvement
Patrick
Patrick
![]()
Clinical photo of a male patient with the eyes obscured by a tan oval, set against a blue background.
![]()
Clinical photo of a young male patient's face showing the anterior view, specifically highlighting dental alignment and facial features. The patient is smiling to expose the upper and lower teeth against a solid blue background.
![]()
Clinical photo showing a lateral view of a male patient's head and neck, displaying the profile of the face, nose, chin, and ear against a blue background.
Pattern/Goal: Extract speech-derived text from this medical image
## Extracted Speech Text
"Hello, this is Brian Allen. I'm going to describe the patient Patrick's current orthodontic status. Her age is 14 years and 4 months.
We have what I call a very modest or mild midline discrepancy. The lower midline was shifted to the right maybe 2 millimeters at presentation. It's now centered.
We have a very conservative non-technique or soft-tissue treatment approach. She wore a 0.018 inch lingual holding arch, which is visible in the intraoral images posted here.
The clinician noted that the alveolar bone has been addressed in the maxillary left second premolar and first molar area, where the alveolar bone has been very thin and labially resorbed from the previous orthodontic treatment and potential overinflated labial appliance, which has contributed to this general bone resorption.
Her treatment was straightforward, meaning she had a lot of anterior crossbite, with Class III malocclusion and no skeletal or environmental factor. Therefore, her treatment was really simplified, an orthognathic surgery was not required.
Hopefully, this is informative!"
---
## Figure Caption Extraction
"Hello, this is Brian Allen. I'm going to describe the patient Patrick's current orthodontic status. Her age is 14 years and 4 months.
We have what I call a very modest or mild midline discrepancy. The lower midline was shifted to the right maybe 2 millimeters at presentation. It's now centered.
We have a very conservative non-technique or soft-tissue treatment approach. She wore a 0.018 inch lingual holding arch, which is visible in the intraoral images posted here.
The clinician noted that the alveolar bone has been addressed in the maxillary left second premolar and first molar area, where the alveolar bone has been very thin and labially resorbed from the previous orthodontic treatment and potential overinflated labial appliance, which has contributed to this general bone resorption.
Her treatment was straightforward, meaning she had a lot of anterior crossbite, with Class III malocclusion and no skeletal or environmental factor. Therefore, her treatment was really simplified, an orthognathic surgery was not required.
Hopefully, this is informative!"
![]()
Clinical photo: This intraoral image displays the patient's dentition in occlusion, illustrating the corrected midline discrepancy and anterior crossbite mentioned in the case study.
![]()
Clinical photo: This intraoral image displays the patient's anterior teeth and gingiva, illustrating the corrected midline discrepancy where the lower incisors are now centered. It also shows the lingual holding arch appliance mentioned in the context.
![]()
Clinical photo: This intraoral image displays the patient's dentition in occlusion, illustrating a mild midline discrepancy where the lower midline is shifted to the right. It demonstrates the result of the described conservative treatment approach involving a lingual holding arch.
![]()
Clinical photo showing an intraoral view of the patient's maxillary arch. The image displays the upper teeth and alveolar ridge, illustrating the specific area where the clinician noted thin and labially resorbed bone in the left second premolar and first molar region.
![]()
Clinical photo: An intraoral view of the patient's mandibular arch displaying a fixed lingual holding arch appliance. The image illustrates the conservative non-technique approach mentioned in the context, showing the wire positioned behind the lower anterior teeth.
**Nathan**
**Nathan**
![]()
Clinical photo of a young boy with visible dental abnormalities, including missing or malformed central incisors.
![]()
Clinical photo of a young boy with light brown hair and freckles, displaying two visible upper front teeth.
![]()
Clinical photo: A profile view of a young boy with short brown hair, showing the side of his face and ear against a blue background.
<nih>
1. Nathan
2. Dummy
3. Side X-Ray
4. X-Ray
5. NB: Doping 2019
6. 15-MONTH 2016
</nih>
1. Nathan
2. Dummy
3. Side X-Ray
4. X-Ray
5. NB: Doping 2019
6. 15-MONTH 2016
![]()
Radiograph:
![]()
Radiograph:
Nathan
Nathan
![]()
Clinical photo: An intraoral view of the anterior dentition showing significant malocclusion, including crowding and irregular alignment of the upper and lower incisors.
![]()
Clinical photo showing a frontal intraoral view of the anterior dentition in a child, demonstrating significant crowding and misalignment.
![]()
Clinical photo of the maxillary and mandibular anterior teeth showing significant crowding, malalignment, and a midline diastema.
![]()
Clinical photo of the maxillary dental arch showing a 'shark tooth' presentation where a permanent canine is erupting lingually behind an unerupted primary canine.
![]()
Clinical photo of the lower dental arch showing severe malocclusion, including crowding, overlapping teeth, and an open bite.
**Nathan**
- Rapid maxillary expansion
- Upper fixed appliances
- Full-fixed appliances
- Force modules to protract the mandible
- Restoration or the dentition as required
- No sedation required
- Considerable parental involvement in home care needs
- Rapid maxillary expansion
- Upper fixed appliances
- Full-fixed appliances
- Force modules to protract the mandible
- Restoration or the dentition as required
- No sedation required
- Considerable parental involvement in home care needs
**Nathan**
**Nathan**
![]()
Clinical photo of the lower anterior dentition demonstrating fixed orthodontic appliances. The image shows metal brackets bonded to the teeth, secured by an archwire with blue and yellow elastic ligatures.
![]()
Clinical photo of a patient's anterior dentition showing orthodontic treatment in progress. The image displays the upper and lower arches with metal brackets bonded to the teeth, connected by an archwire featuring alternating blue and yellow elastic ligatures.
![]()
Clinical photo showing a close-up view of the upper and lower dental arches fitted with fixed orthodontic braces, featuring metal brackets on the teeth and elastic ligatures.
![]()
Clinical photo showing a close-up intraoral view of the maxillary and mandibular anterior teeth fitted with fixed orthodontic appliances. The image highlights metal brackets bonded to the teeth, connected by archwires, illustrating active orthodontic treatment.
Nathan
**bold**
Nathan
![]()
Clinical photo of a patient's dental arch showing multiple missing teeth in both the upper and lower jaws, with visible gaps between the remaining dentition.
![]()
Clinical photo: An intraoral view of the maxillary arch showing the upper teeth and gingiva.
![]()
Clinical photo: This image shows an intraoral view of the mandibular arch, highlighting a fixed dental prosthesis (likely a bridge) spanning multiple anterior teeth with visible metal framework.
**The Special Needs Patient in Orthodontics**
Rationale for treating disabled patients
Who is prepared to treat them?
Preparing the child for treatment
Drawing up a general treatment direction
Choosing the suitable management modality
Adapting traditional orthodontics to the Special Needs Patient
The ethical dilemma revisited
Becker, A. and Chaushu, S. (2004)
Australian Society of Orthodontics Meeting
- Rationale for treating disabled patients
- Who is prepared to treat them?
- Preparing the child for treatment
- Drawing up a general treatment direction
- Choosing the suitable management modality
- Adapting traditional orthodontics to the Special Needs Patient
- The ethical dilemma revisited
Becker, A. and Chaushu, S. (2004)
Australian Society of Orthodontics Meeting
#Warning# **At the end of this course you **\_DO\_** **\_NOT\_** have the didactic knowledge or clinical skills to treat comprehensive orthodontic cases.**
**At the end of this course you _DO_ _NOT_ have the didactic knowledge or clinical skills to treat comprehensive orthodontic cases.**
## Case: Orthodontic management of a patient with developmental learning disorders and skeletal malocclusion
### Question
**Scenario:** Phoebe, a patient with developmental learning disorders and moderate to severe skeletal malocclusion, is presented for orthodontic evaluation.
**What's shown:** Profile and intraoral photographs showing a concave profile, flat mid face, bilateral posterior crossbite, posterior open bite, lack of space for canine eruption, and late retention of lower primary teeth. A radiograph is also provided showing the developing premolars.
**Consider:** How to manage the eruption and transverse discrepancy given her special needs and cooperation limitations.
### Answer
**Observations:**
- Concave profile with a very flat mid face.
- Bilateral posterior crossbite and posterior open bite.
- Lack of space for canine eruption and late retention of lower primary teeth.
- Radiograph confirms premolars have approximately two-thirds of their root formation.
**Reasoning:**
- Due to her special needs, treatment objectives must be realistic and simplified.
- Initial management involved sedation to address caries, take impressions, and place a rapid maxillary expander (RME).
- The RME was kept in place longer than average (six months) with parental assistance for hygiene.
- Following expansion, she adapted to the treatment without further sedation.
- Deciduous teeth were extracted to allow eruption of the permanent premolars, focusing on resolving the crossbite and managing the dentition transition rather than achieving perfect intercuspidation.
**Takeaway:**
- In special needs patients, treatment should focus on resolving functional blockages (like crossbites) and managing dentition transition, often requiring initial sedation and strong parental collaboration to maintain realistic expectations.
## Case: Managing hypodontia and dentition transition in a patient with Down syndrome
### Question
**Scenario:** Nicholas, a patient with Down syndrome, presents with multiple missing teeth and requires management of his dentition transition.
**What's shown:** The clinical scenario of a patient with Down syndrome lacking lower incisors and upper lateral incisors, with late retention of primary teeth.
**Consider:** How to establish a functional occlusion and manage the transition from primary to permanent dentition with significant hypodontia.
### Answer
**Observations:**
- Multiple missing teeth, specifically lower incisors and upper laterals.
- Late retention of primary teeth.
**Reasoning:**
- Initial treatment required sedation for deciduous tooth extractions and restorations.
- Orthodontic treatment was limited to following the transition from primary to permanent dentition and monitoring the transverse relationship.
- With missing lower incisors and upper laterals, the canines are allowed to erupt and are reshaped or built up restoratively to function as lateral incisors.
- The goal is to achieve a functional relationship between the upper and lower first molars, accepting a modified occlusion rather than forcing ideal intercuspidation.
**Takeaway:**
- For patients with Down syndrome and hypodontia, treatment focuses on guiding eruption, extracting retained primary teeth, and using restorative techniques to reshape canines into missing lateral incisors to achieve a functional occlusion.
## Case: Full fixed appliance therapy in a Down syndrome patient with soft tissue imbalances
### Question
**Scenario:** Patrick, a patient with Down syndrome, presents with maxillary constriction, crowding, microdontia, and a skeletal Class II relationship. He undergoes maxillary expansion and full fixed appliance therapy.
**What's shown:** Post-expansion profile and intraoral views showing a very flat profile, deficient chin, and tongue interposition.
**Consider:** What are the limitations and expected outcomes of full fixed appliance therapy in this patient given his soft tissue and functional characteristics?
## Case: Orthodontic management of a patient with developmental learning disorders and skeletal malocclusion
### Question
**Scenario:** Phoebe, a patient with developmental learning disorders and moderate to severe skeletal malocclusion, is presented for orthodontic evaluation.
**What's shown:** Profile and intraoral photographs showing a concave profile, flat mid face, bilateral posterior crossbite, posterior open bite, lack of space for canine eruption, and late retention of lower primary teeth. A radiograph is also provided showing the developing premolars.
**Consider:** How to manage the eruption and transverse discrepancy given her special needs and cooperation limitations.
### Answer
**Observations:**
- Concave profile with a very flat mid face.
- Bilateral posterior crossbite and posterior open bite.
- Lack of space for canine eruption and late retention of lower primary teeth.
- Radiograph confirms premolars have approximately two-thirds of their root formation.
**Reasoning:**
- Due to her special needs, treatment objectives must be realistic and simplified.
- Initial management involved sedation to address caries, take impressions, and place a rapid maxillary expander (RME).
- The RME was kept in place longer than average (six months) with parental assistance for hygiene.
- Following expansion, she adapted to the treatment without further sedation.
- Deciduous teeth were extracted to allow eruption of the permanent premolars, focusing on resolving the crossbite and managing the dentition transition rather than achieving perfect intercuspidation.
**Takeaway:**
- In special needs patients, treatment should focus on resolving functional blockages (like crossbites) and managing dentition transition, often requiring initial sedation and strong parental collaboration to maintain realistic expectations.
## Case: Managing hypodontia and dentition transition in a patient with Down syndrome
### Question
**Scenario:** Nicholas, a patient with Down syndrome, presents with multiple missing teeth and requires management of his dentition transition.
**What's shown:** The clinical scenario of a patient with Down syndrome lacking lower incisors and upper lateral incisors, with late retention of primary teeth.
**Consider:** How to establish a functional occlusion and manage the transition from primary to permanent dentition with significant hypodontia.
### Answer
**Observations:**
- Multiple missing teeth, specifically lower incisors and upper laterals.
- Late retention of primary teeth.
**Reasoning:**
- Initial treatment required sedation for deciduous tooth extractions and restorations.
- Orthodontic treatment was limited to following the transition from primary to permanent dentition and monitoring the transverse relationship.
- With missing lower incisors and upper laterals, the canines are allowed to erupt and are reshaped or built up restoratively to function as lateral incisors.
- The goal is to achieve a functional relationship between the upper and lower first molars, accepting a modified occlusion rather than forcing ideal intercuspidation.
**Takeaway:**
- For patients with Down syndrome and hypodontia, treatment focuses on guiding eruption, extracting retained primary teeth, and using restorative techniques to reshape canines into missing lateral incisors to achieve a functional occlusion.
## Case: Full fixed appliance therapy in a Down syndrome patient with soft tissue imbalances
### Question
**Scenario:** Patrick, a patient with Down syndrome, presents with maxillary constriction, crowding, microdontia, and a skeletal Class II relationship. He undergoes maxillary expansion and full fixed appliance therapy.
**What's shown:** Post-expansion profile and intraoral views showing a very flat profile, deficient chin, and tongue interposition.
**Consider:** What are the limitations and expected outcomes of full fixed appliance therapy in this patient given his soft tissue and functional characteristics?
Case: Orthodontic management of a patient with developmental learning disorders and skeletal malocclusion
![]()
Clinical photo showing the right lateral profile of a female patient, illustrating moderate to severe skeletal malocclusion.
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Radiograph: A lateral cephalometric view of a patient's skull displaying the skeletal profile, nasal cavity, and maxillary/mandibular dental arches.
![]()
A handwritten signature of Dr Peter Readman, which serves as the formal closing for the medical correspondence regarding patient Phoebe's treatment.
![]()
<img title="Information about a multiple missing teeth dental patient">Nicholas is a patient with **Downs Syndrome**. He has **moderate to severe dental malocclusion** and **multiple missing teeth**.
![]()
Clinical photo: This intraoral image displays the patient's dentition in occlusion, illustrating the corrected midline discrepancy and anterior crossbite mentioned in the case study.
![]()
Clinical photo showing an intraoral view of the patient's maxillary arch. The image displays the upper teeth and alveolar ridge, illustrating the specific area where the clinician noted thin and labially resorbed bone in the left second premolar and first molar region.
![]()
Clinical photo: An intraoral view of the patient's mandibular arch displaying a fixed lingual holding arch appliance. The image illustrates the conservative non-technique approach mentioned in the context, showing the wire positioned behind the lower anterior teeth.
### Answer
**Observations:**
- Maxillary constriction, crowding, and microdontia.
- Skeletal Class II relationship with a flat profile and deficient chin.
- Persistent tongue interposition.
**Reasoning:**
- Patrick was able to tolerate a full fixed appliance, which is a significant achievement.
- Maxillary expansion was performed to correct the posterior crossbite.
- However, finishing and intercuspidation were highly compromised due to the tongue interposition and inability to cooperate with elastics.
- Significant relapse in the anterior open bite was expected and occurred because the muscular and functional imbalances could not be fully corrected.
- The patient could not tolerate the upper bar, limiting the final alignment.
**Takeaway:**
- Even when a special needs patient can tolerate full fixed appliances, achieving stable intercuspidation is often impossible due to soft tissue and muscular imbalances, leading to expected relapse and compromised finishing.
## Case: Step-by-step orthodontic intervention for a patient with severe misalignment and visual impairment
### Question
**Scenario:** Nadel, a patient with a developmental disorder, visual impairment, moderate skeletal Class II malocclusion, maxillary constriction, and irregular tooth form, is presented for treatment.
**What's shown:** Intraoral and radiographic views showing extremely proclined upper incisors, severe anterior misalignment with two lines of lower incisors, incomplete molar crown formation, and trauma with gingival inflammation.
**Consider:** How to approach the treatment step-by-step for a patient with severe misalignment, trauma, and special needs without using sedation.
### Answer
**Observations:**
- Extremely proclined upper incisors due to lower lip interposition.
- Severe anterior misalignment with two lines of lower incisors.
- Incomplete crown formation of molars and significant trauma/biofilm due to poor oral hygiene.
**Reasoning:**
- Treatment was broken down into manageable, step-by-step phases without the need for sedation.
- First, oral hygiene was controlled and caries treated.
- Rapid maxillary expansion (RME) was used to correct the posterior crossbite and create space.
- Partial fixed appliances with NiTi wires were used for minimal alignment and torque correction.
- Primary teeth were extracted to provide space for permanent teeth, acknowledging that tongue/muscle imbalance would prevent spontaneous alignment.
- The lower arch received minimal alignment, focusing on maintaining the corrected crossbite and resolving trauma, accepting that spaces could not be fully closed.
**Takeaway:**
- Complex cases in special needs patients can be managed successfully without sedation by breaking treatment into small, tolerable steps (e.g., RME, partial braces, selective extractions) focusing on hygiene, space creation, and minimal alignment rather than ideal occlusion.
### Answer
**Observations:**
- Maxillary constriction, crowding, and microdontia.
- Skeletal Class II relationship with a flat profile and deficient chin.
- Persistent tongue interposition.
**Reasoning:**
- Patrick was able to tolerate a full fixed appliance, which is a significant achievement.
- Maxillary expansion was performed to correct the posterior crossbite.
- However, finishing and intercuspidation were highly compromised due to the tongue interposition and inability to cooperate with elastics.
- Significant relapse in the anterior open bite was expected and occurred because the muscular and functional imbalances could not be fully corrected.
- The patient could not tolerate the upper bar, limiting the final alignment.
**Takeaway:**
- Even when a special needs patient can tolerate full fixed appliances, achieving stable intercuspidation is often impossible due to soft tissue and muscular imbalances, leading to expected relapse and compromised finishing.
## Case: Step-by-step orthodontic intervention for a patient with severe misalignment and visual impairment
### Question
**Scenario:** Nadel, a patient with a developmental disorder, visual impairment, moderate skeletal Class II malocclusion, maxillary constriction, and irregular tooth form, is presented for treatment.
**What's shown:** Intraoral and radiographic views showing extremely proclined upper incisors, severe anterior misalignment with two lines of lower incisors, incomplete molar crown formation, and trauma with gingival inflammation.
**Consider:** How to approach the treatment step-by-step for a patient with severe misalignment, trauma, and special needs without using sedation.
### Answer
**Observations:**
- Extremely proclined upper incisors due to lower lip interposition.
- Severe anterior misalignment with two lines of lower incisors.
- Incomplete crown formation of molars and significant trauma/biofilm due to poor oral hygiene.
**Reasoning:**
- Treatment was broken down into manageable, step-by-step phases without the need for sedation.
- First, oral hygiene was controlled and caries treated.
- Rapid maxillary expansion (RME) was used to correct the posterior crossbite and create space.
- Partial fixed appliances with NiTi wires were used for minimal alignment and torque correction.
- Primary teeth were extracted to provide space for permanent teeth, acknowledging that tongue/muscle imbalance would prevent spontaneous alignment.
- The lower arch received minimal alignment, focusing on maintaining the corrected crossbite and resolving trauma, accepting that spaces could not be fully closed.
**Takeaway:**
- Complex cases in special needs patients can be managed successfully without sedation by breaking treatment into small, tolerable steps (e.g., RME, partial braces, selective extractions) focusing on hygiene, space creation, and minimal alignment rather than ideal occlusion.
Case: Full fixed appliance therapy in a Down syndrome patient with soft tissue imbalances > Answer
![]()
Clinical photo: An intraoral view of the anterior dentition showing significant malocclusion, including crowding and irregular alignment of the upper and lower incisors.
![]()
Clinical photo of a patient's anterior dentition showing orthodontic treatment in progress. The image displays the upper and lower arches with metal brackets bonded to the teeth, connected by an archwire featuring alternating blue and yellow elastic ligatures.
![]()
Clinical photo showing a close-up intraoral view of the maxillary and mandibular anterior teeth fitted with fixed orthodontic appliances. The image highlights metal brackets bonded to the teeth, connected by archwires, illustrating active orthodontic treatment.
[^1]: Original PDF page 1: [[12 - The Special Needs Patient in Orthodontics.pdf#page=1|12 - The Special Needs Patient in Orthodontics, p.1]]
[^2]: Original PDF page 2: [[12 - The Special Needs Patient in Orthodontics.pdf#page=2|12 - The Special Needs Patient in Orthodontics, p.2]]
[^3]: Original PDF page 3: [[12 - The Special Needs Patient in Orthodontics.pdf#page=3|12 - The Special Needs Patient in Orthodontics, p.3]]
[^4]: Original PDF page 4: [[12 - The Special Needs Patient in Orthodontics.pdf#page=4|12 - The Special Needs Patient in Orthodontics, p.4]]
[^5]: Original PDF page 5: [[12 - The Special Needs Patient in Orthodontics.pdf#page=5|12 - The Special Needs Patient in Orthodontics, p.5]]
[^6]: Original PDF page 6: [[12 - The Special Needs Patient in Orthodontics.pdf#page=6|12 - The Special Needs Patient in Orthodontics, p.6]]
[^7]: Original PDF page 7: [[12 - The Special Needs Patient in Orthodontics.pdf#page=7|12 - The Special Needs Patient in Orthodontics, p.7]]
[^8]: Original PDF page 8: [[12 - The Special Needs Patient in Orthodontics.pdf#page=8|12 - The Special Needs Patient in Orthodontics, p.8]]
[^9]: Original PDF page 9: [[12 - The Special Needs Patient in Orthodontics.pdf#page=9|12 - The Special Needs Patient in Orthodontics, p.9]]
[^10]: Original PDF page 10: [[12 - The Special Needs Patient in Orthodontics.pdf#page=10|12 - The Special Needs Patient in Orthodontics, p.10]]
[^11]: Original PDF page 11: [[12 - The Special Needs Patient in Orthodontics.pdf#page=11|12 - The Special Needs Patient in Orthodontics, p.11]]
[^12]: Original PDF page 12: [[12 - The Special Needs Patient in Orthodontics.pdf#page=12|12 - The Special Needs Patient in Orthodontics, p.12]]
[^13]: Original PDF page 13: [[12 - The Special Needs Patient in Orthodontics.pdf#page=13|12 - The Special Needs Patient in Orthodontics, p.13]]
[^14]: Original PDF page 14: [[12 - The Special Needs Patient in Orthodontics.pdf#page=14|12 - The Special Needs Patient in Orthodontics, p.14]]
[^15]: Original PDF page 15: [[12 - The Special Needs Patient in Orthodontics.pdf#page=15|12 - The Special Needs Patient in Orthodontics, p.15]]
[^16]: Original PDF page 16: [[12 - The Special Needs Patient in Orthodontics.pdf#page=16|12 - The Special Needs Patient in Orthodontics, p.16]]
[^17]: Original PDF page 17: [[12 - The Special Needs Patient in Orthodontics.pdf#page=17|12 - The Special Needs Patient in Orthodontics, p.17]]
[^18]: Original PDF page 18: [[12 - The Special Needs Patient in Orthodontics.pdf#page=18|12 - The Special Needs Patient in Orthodontics, p.18]]
[^19]: Original PDF page 19: [[12 - The Special Needs Patient in Orthodontics.pdf#page=19|12 - The Special Needs Patient in Orthodontics, p.19]]
[^20]: Original PDF page 20: [[12 - The Special Needs Patient in Orthodontics.pdf#page=20|12 - The Special Needs Patient in Orthodontics, p.20]]
[^21]: Original PDF page 21: [[12 - The Special Needs Patient in Orthodontics.pdf#page=21|12 - The Special Needs Patient in Orthodontics, p.21]]
[^22]: Original PDF page 22: [[12 - The Special Needs Patient in Orthodontics.pdf#page=22|12 - The Special Needs Patient in Orthodontics, p.22]]
[^23]: Original PDF page 23: [[12 - The Special Needs Patient in Orthodontics.pdf#page=23|12 - The Special Needs Patient in Orthodontics, p.23]]
[^24]: Original PDF page 24: [[12 - The Special Needs Patient in Orthodontics.pdf#page=24|12 - The Special Needs Patient in Orthodontics, p.24]]
[^25]: Original PDF page 25: [[12 - The Special Needs Patient in Orthodontics.pdf#page=25|12 - The Special Needs Patient in Orthodontics, p.25]]
[^26]: Original PDF page 26: [[12 - The Special Needs Patient in Orthodontics.pdf#page=26|12 - The Special Needs Patient in Orthodontics, p.26]]
[^27]: Original PDF page 27: [[12 - The Special Needs Patient in Orthodontics.pdf#page=27|12 - The Special Needs Patient in Orthodontics, p.27]]
[^28]: Original PDF page 28: [[12 - The Special Needs Patient in Orthodontics.pdf#page=28|12 - The Special Needs Patient in Orthodontics, p.28]]
[^29]: Original PDF page 29: [[12 - The Special Needs Patient in Orthodontics.pdf#page=29|12 - The Special Needs Patient in Orthodontics, p.29]]
[^30]: Original PDF page 30: [[12 - The Special Needs Patient in Orthodontics.pdf#page=30|12 - The Special Needs Patient in Orthodontics, p.30]]
[^31]: Original PDF page 31: [[12 - The Special Needs Patient in Orthodontics.pdf#page=31|12 - The Special Needs Patient in Orthodontics, p.31]]
[^32]: Original PDF page 32: [[12 - The Special Needs Patient in Orthodontics.pdf#page=32|12 - The Special Needs Patient in Orthodontics, p.32]]
[^33]: Original PDF page 33: [[12 - The Special Needs Patient in Orthodontics.pdf#page=33|12 - The Special Needs Patient in Orthodontics, p.33]]
[^34]: Original PDF page 34: [[12 - The Special Needs Patient in Orthodontics.pdf#page=34|12 - The Special Needs Patient in Orthodontics, p.34]]
[^35]: Original PDF page 35: [[12 - The Special Needs Patient in Orthodontics.pdf#page=35|12 - The Special Needs Patient in Orthodontics, p.35]]
[^36]: Original PDF page 36: [[12 - The Special Needs Patient in Orthodontics.pdf#page=36|12 - The Special Needs Patient in Orthodontics, p.36]]
[^37]: Original PDF page 37: [[12 - The Special Needs Patient in Orthodontics.pdf#page=37|12 - The Special Needs Patient in Orthodontics, p.37]]
[^38]: Original PDF page 38: [[12 - The Special Needs Patient in Orthodontics.pdf#page=38|12 - The Special Needs Patient in Orthodontics, p.38]]
[^39]: Original PDF page 39: [[12 - The Special Needs Patient in Orthodontics.pdf#page=39|12 - The Special Needs Patient in Orthodontics, p.39]]
[^40]: Original PDF page 40: [[12 - The Special Needs Patient in Orthodontics.pdf#page=40|12 - The Special Needs Patient in Orthodontics, p.40]]
[^41]: Original PDF page 41: [[12 - The Special Needs Patient in Orthodontics.pdf#page=41|12 - The Special Needs Patient in Orthodontics, p.41]]
[^42]: Original PDF page 42: [[12 - The Special Needs Patient in Orthodontics.pdf#page=42|12 - The Special Needs Patient in Orthodontics, p.42]]
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[^44]: Original PDF page 44: [[12 - The Special Needs Patient in Orthodontics.pdf#page=44|12 - The Special Needs Patient in Orthodontics, p.44]]
[^45]: Original PDF page 45: [[12 - The Special Needs Patient in Orthodontics.pdf#page=45|12 - The Special Needs Patient in Orthodontics, p.45]]
[^46]: Original PDF page 46: [[12 - The Special Needs Patient in Orthodontics.pdf#page=46|12 - The Special Needs Patient in Orthodontics, p.46]]
[^47]: Original PDF page 47: [[12 - The Special Needs Patient in Orthodontics.pdf#page=47|12 - The Special Needs Patient in Orthodontics, p.47]]
[^48]: Original PDF page 48: [[12 - The Special Needs Patient in Orthodontics.pdf#page=48|12 - The Special Needs Patient in Orthodontics, p.48]]
[^49]: Original PDF page 49: [[12 - The Special Needs Patient in Orthodontics.pdf#page=49|12 - The Special Needs Patient in Orthodontics, p.49]]
[^50]: Original PDF page 50: [[12 - The Special Needs Patient in Orthodontics.pdf#page=50|12 - The Special Needs Patient in Orthodontics, p.50]]
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[^54]: Original PDF page 54: [[12 - The Special Needs Patient in Orthodontics.pdf#page=54|12 - The Special Needs Patient in Orthodontics, p.54]]
[^55]: Original PDF page 55: [[12 - The Special Needs Patient in Orthodontics.pdf#page=55|12 - The Special Needs Patient in Orthodontics, p.55]]
[^56]: Original PDF page 56: [[12 - The Special Needs Patient in Orthodontics.pdf#page=56|12 - The Special Needs Patient in Orthodontics, p.56]]
[^57]: Original PDF page 57: [[12 - The Special Needs Patient in Orthodontics.pdf#page=57|12 - The Special Needs Patient in Orthodontics, p.57]]
[^58]: Original PDF page 58: [[12 - The Special Needs Patient in Orthodontics.pdf#page=58|12 - The Special Needs Patient in Orthodontics, p.58]]
[^59]: Original PDF page 59: [[12 - The Special Needs Patient in Orthodontics.pdf#page=59|12 - The Special Needs Patient in Orthodontics, p.59]]
[^60]: Original PDF page 60: [[12 - The Special Needs Patient in Orthodontics.pdf#page=60|12 - The Special Needs Patient in Orthodontics, p.60]]
[^61]: Original PDF page 61: [[12 - The Special Needs Patient in Orthodontics.pdf#page=61|12 - The Special Needs Patient in Orthodontics, p.61]]
[^62]: Original PDF page 62: [[12 - The Special Needs Patient in Orthodontics.pdf#page=62|12 - The Special Needs Patient in Orthodontics, p.62]]
[^63]: Original PDF page 63: [[12 - The Special Needs Patient in Orthodontics.pdf#page=63|12 - The Special Needs Patient in Orthodontics, p.63]]
[^64]: Original PDF page 64: [[12 - The Special Needs Patient in Orthodontics.pdf#page=64|12 - The Special Needs Patient in Orthodontics, p.64]]
[^65]: Original PDF page 65: [[12 - The Special Needs Patient in Orthodontics.pdf#page=65|12 - The Special Needs Patient in Orthodontics, p.65]]
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[^70]: Original PDF page 70: [[12 - The Special Needs Patient in Orthodontics.pdf#page=70|12 - The Special Needs Patient in Orthodontics, p.70]]
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[^72]: Original PDF page 72: [[12 - The Special Needs Patient in Orthodontics.pdf#page=72|12 - The Special Needs Patient in Orthodontics, p.72]]
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[^78]: Original PDF page 78: [[12 - The Special Needs Patient in Orthodontics.pdf#page=78|12 - The Special Needs Patient in Orthodontics, p.78]]
[^79]: Original PDF page 79: [[12 - The Special Needs Patient in Orthodontics.pdf#page=79|12 - The Special Needs Patient in Orthodontics, p.79]]
[^80]: Original PDF page 80: [[12 - The Special Needs Patient in Orthodontics.pdf#page=80|12 - The Special Needs Patient in Orthodontics, p.80]]
[^81]: Original PDF page 81: [[12 - The Special Needs Patient in Orthodontics.pdf#page=81|12 - The Special Needs Patient in Orthodontics, p.81]]
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[^86]: Original PDF page 86: [[12 - The Special Needs Patient in Orthodontics.pdf#page=86|12 - The Special Needs Patient in Orthodontics, p.86]]
[^87]: Original PDF page 87: [[12 - The Special Needs Patient in Orthodontics.pdf#page=87|12 - The Special Needs Patient in Orthodontics, p.87]]