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Orthodontic treatment

Article  in  Vital · March 2011

DOI: 10.1038/vital1329 · Source: OAI

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 ADVANCED DENTAL NURSING
EXCLUSIVE TO VITAL!
This article is adapted from a
chapter of the second edition
of Advanced dental nursing
ADVANCED DENTAL
edited by Robert Ireland and NURSING SERIES
published by Wiley Blackwell in
May 2010 (£29.99).
COMMUNICATION

CLINICAL GOVERNANCE

ORAL HEALTH EDUCATION

SPECIAL CARE DENTISTRY

DENTAL ANXIETY

IMPLANT NURSING

ORTHODONTIC TREATMENT

Orthodontic treatment
It is important that all Introduction Assessment of a patient for
Orthodontics is the branch of dentistry orthodontic treatment
members of the dental concerned with facial growth, development Before any orthodontic treatment plan is drawn
of the dentition and occlusion together up it is very important to reach a diagnosis
team understand the with the prevention and correction of and establish a problem list. In order to do
reasons for undertaking occlusal anomalies. The main indications for this the orthodontist must take a history from
orthodontic treatment are to improve oral the patient and parent (if appropriate) and
orthodontic treatment function, aesthetics and general dental health. undertake a thorough examination of the hard
The main aims of orthodontic treatment are, and soft tissues of the face and mouth. Special
and the principal therefore, to eliminate functional problems investigations such as radiographs, study
treatment options that that may predispose a patient to TMD; models and photographs are also required
encourage the eruption and alignment of before arriving at the final treatment plan.
are available to the displaced or impacted teeth; remove any
trauma from occlusion and/or displaced History
patient, says Jayne teeth and/or improve facial and dental In the history, it is important to find out the
Harrison, Consultant aesthetics by aligning and levelling the teeth, patient’s main concerns, the reasons why
correcting the overjet and overbite to establish they are seeking treatment and their attitude
Orthodontist at a mutually protective occlusion, within a towards treatment together with an assessment
stable soft tissue environment. The benefits of the potential level of co-operation with any
Liverpool University of orthodontic treatment can be considered proposed treatment. At this point, children
Dental Hospital. in terms of reducing the negative impact that should be encouraged to voice their opinions
a malocclusion has on the dental health and about their teeth and how they feel about the
psycho-social well-being of an individual. prospect of orthodontic treatment.
However, orthodontic treatment does carry
risks which include decalcification, root Examination
resorption, gingival and periodontal problems The examination of the patient will include
and the failure to achieve the aims of treatment. extra- and intra-oral assessments of the skeletal
It is important, therefore, that treatment should pattern; soft tissues; temporomandibular
not be started unless there is a reasonable joints (TMJs) and dental relationships. The
chance that the patient will benefit from it. skeletal pattern is assessed by examining
This article aims to outline the process of the patient - sitting in an upright position,
orthodontic assessment, treatment planning looking straight ahead - in the anteroposterior,
and the treatment modalities available to vertical and transverse dimensions. The lips
correct patients’ problems. need to be examined at rest and in function

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ADVANCED DENTAL NURSING

treatment is related to the stage of

dental development.
Deciduous dentition Treatment of
crowding or spacing is not indicated in the
primary dentition, but crossbites that cause a
displacement on closing, whether anterior
or posterior, can be treated successfully at
this stage.
Mixed dentition Treatment in the mixed
dentition can involve the extraction of
deciduous teeth, the correction of an anterior or
Quad helix appliance Transpalatal arch posterior crossbite and/or growth modification.
Early permanent dentition The majority of
fixed orthodontic treatment is carried out at the
to determine their competency, position and problem list of all the patient’s dental problems, early permanent dentition stage.
length. The TMJs need to be checked for signs not just the orthodontic ones. This means that Adult dentition Most types of orthodontic
of temporomandibular disease including joint any pathology eg caries, or gingivitis, needs treatment, with the exception of growth
noises, extent of opening and deviation when to be brought under control and treated as a modification, can be undertaken in adulthood.
opening/closing. The intra-oral examination of priority before orthodontic treatment is started. Orthognathic surgery is best delayed until this
a patient for orthodontic reasons is similar to When thinking about the orthodontic stage to ensure that growth has stopped.
that performed for routine dental patients but problems, again the treatment of any pathology
puts more emphasis on the inter- and intra-arch eg impacted teeth, ankylosed teeth, and Types of orthodontic treatment
relationships. The incisor, canine and molar root resorption, takes precedence. Skeletal In the absence of a skeletal discrepancy,
relationships are assessed together with the discrepancies, in all three planes of space, malaligned teeth can be aligned, once sufficient
overjet, overbite, centrelines – in relationship also need to be recognised, quantified and space has been created, using fixed orthodontic
to each other and the facial centre line – prioritised. Dental problems including any appliances. Space can be created in a variety
transverse relationships, including crossbites, excessive protrusion or retrusion together of ways including extraction of appropriate
scissors bites and any associated displacement with problems involving dental development teeth, arch expansion and/or interproximal
on closing. The general dental health must also eg abnormal sequence of development, enamel reduction.
be considered so any active or restored caries missing teeth and supernumerary teeth, are If the patient has a skeletal discrepancy,
should be noted together with an assessment of then considered. Finally, problems involving there are three main approaches to
the patient’s level of oral hygiene. crowding and malalignment of teeth orthodontic treatment:
are considered. 1. Growth modification - growth is used
Special investigations to correct the skeletal discrepancy. To
Impressions of the upper and lower jaws are The timing of orthodontic treatment correct a skeletal discrepancy using growth
taken and reproduced as study models. The In most cases the timing of orthodontic modification, the patient needs to be growing
study models are then used to record the so this type of treatment is best carried out in
treatment from start to finish and are used to the late mixed or early permanent dentition.
observe the changes that take place throughout Growth modification treatment can involve
the orthodontic procedure. Radiographs are a
valuable addition to the information gathered
‘Orthodontics is the use of a functional appliance and/
or headgear
during the examination of a patient. They
are used to assess facial and dento-skeletal
concerned with 2. Camouflage treatment. If the patient is near
or at the end of growth, mild or moderate
relationships and to identify any missing, skeletal discrepancies may be treated with
unerupted or impacted teeth. The most facial growth, camouflage treatment that involves the
commonly used radiographs in orthodontics use of fixed orthodontic appliances, often
are the orthopantomograph (OPG, OPT), development in combination with extractions, to
lateral cephalogram and intra-oral views of the move the teeth so as to disguise the
teeth in the upper labial segment. Photographs
are also taken before treatment commences,
of the dentition skeletal discrepancy
3. A combination of orthodontic treatment
during treatment and post-treatment. They
record the severity of malocclusion, changes
and occlusion and orthognathic surgery to correct the
malocclusion and underlying skeletal
occurring during treatment as well as a discrepancy. If the skeletal discrepancy is
useful record of any pre-existing pathology, together with severe and the patient is at the end of growth,
decalcification or trauma to the teeth. then the malocclusion and underlying
the prevention skeletal discrepancy can be treated using
Problem list a combination of orthodontics and
Having gathered information from the patient,
the clinical examination and appropriate special
and correction orthognathic surgery.

investigations, a list of the patient’s problems

can be put together. This should be an overall
of occlusal Functional appliances
Functional appliances are a group of

32 vital
anomalies.’ www.nature.com/vital
 ADVANCED DENTAL NURSING

Fixed orthodontic appliances

Fixed appliances can move the teeth in all
directions. These appliances are fixed to the
teeth and forces are applied by archwires or
auxiliaries through these attachments. Fixed
appliances can:
• Tip – change the mesio-distal angle of teeth
• Torque – change the bucco-lingual
inclination of teeth
• Rotate teeth
• Bodily move teeth.

A fixed appliance has attachments (brackets,

tubes, bands), which are attached to the teeth
by composite resins (brackets, tubes) or cement
(bands).

Phases of treatment
The progress of most orthodontic treatment,
using fixed appliances, falls into quite well-
defined phases. There are subtle variations on
this basic format and patients may be treated
with other types of appliances before or as part
of their fixed appliance therapy.
Twin Block appliance Pre-adjusted fixed appliances
Bonding and banding This is normally
completed over two or three visits. A typical
pattern is to place the brackets on the anterior
orthodontic appliances that aim to modify the These include the following. teeth and separators between the molars at the
growth of the jaws by using the forces generated Dentoalveolar changes Evidence on the first visit. At the second visit the bands can then
within the masticatory and facial muscles. effects of functional appliances suggests that be selected and fitted and the archwires placed.
Most functional appliances are removable most of the changes (70-80%) that they bring Levelling and aligning Levelling and aligning
but some, eg the Herbst appliance, are fixed to about are due to changes in the dentoalveolar involves levelling the curve of Spee (the curve in
the teeth for the duration of active treatment. complex. In Class II cases the maxillary incisors the occlusal plane in the antero-posterior plane)
The majority of functional appliances have been retrocline and the eruption of teeth in the and aligning the teeth. Alignment is usually
designed to correct Class II malocclusions eg maxillary buccal segments is directed distally carried out over several visits using flexible
the Twin Block, Andresen, Harvold, bionator during treatment. In the mandibular arch the nickel titanium (eg 0.014” and then 0.018” x
and Frankel appliances. However, some have lower incisors tend to procline and the teeth 0.025”) archwires to align the teeth.
been modified to correct Class III malocclusion, in the buccal segments erupt in a more mesial Overbite reduction Overbite reduction is
eg the Frankel FR3 appliance. Functional direction. The reverse occurs in Class III cases. a key stage in most courses of orthodontic
appliances to correct a Class II discrepancy are Skeletal changes Evidence on the effects of treatment because it is impossible to obtain a
designed to hold the mandible forwards often functional appliances suggests that only 20-30% Class I incisor relationship unless the overbite
to an edge-to-edge position. For a Class III of the changes that they bring about are due is fully reduced. Effective overbite reduction
discrepancy only minimal posterior positioning to alterations in the growth of the maxilla or needs stiff archwires and only starts to occur
of the mandible is possible so the mandible is mandible. In Class II cases there is minimal when stainless steel archwires, of at least 0.016”
held open and rotated backwards. restriction of maxillary growth and about 1-3 diameter, are in place with 0.019” x 0.025”
Functional appliances are usually worn mm increase in mandibular growth. In Class III stainless steel archwires being the most effective
full time and work in a similar way. For Class cases studies show that there is 1-2 mm increase and bring about most of the overbite reduction.
II cases, the appliances hold the mandible in maxillary growth and 1-2 mm restriction Overbite reduction can also be initiated by an
forwards so that the teeth are not in occlusion, of mandibular growth. Functional appliances upper removable appliance (URA), with a flat
the condyles of the mandible are displaced from also have the effect of redirecting mandibular anterior bite plane, used in conjunction with a
the glenoid fossa and the muscles of mastication growth downwards and backwards. This may lower fixed appliance at the start of treatment.
are stretched. For Class III cases, the appliances not be beneficial in Class II cases but appears to Overjet reduction Overjet reduction is
hold the mandible in a posterior position and improve a Class III relationship. usually achieved by retracting the upper labial
open in an attempt to redirect mandibular Changes in the glenoid fossa Animal studies segment once the overbite has been reduced.
growth in a downward and backwards have shown that when the condyle of the This can be assisted by forward mandibular
direction. In each case the repositioning of the mandible is displaced from the glenoid fossa, it growth, maxillary restraint, distalisation of
mandible generates forces that are directed remodels causing the temporomandibular joint maxillary molars and/or advancement of the
primarily to the teeth but can also have an effect and mandible to move forwards. However, the lower labial segment. Overjet reduction can be
on the growth of the maxilla and/or mandible. evidence that this also happens in humans is brought about using a combination of space-
There are several theories on how functional weak and if it does occur, the changes it causes closing mechanics and is usually carried out on
appliances bring about the changes they do. are minimal. a 0.019” x 0.025” stainless steel archwire

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ADVANCED DENTAL NURSING

– the working archwire. A variety of auxiliaries Assessment of a patient for orthodontic treatment
can be used alone or in combination to reduce
the overjet. These include active tie-backs, History
elastomeric chain or springs between the
maxillary molars and canine hooks, Class II Patient’s main concerns
elastics and/or headgear. Reasons why they are seeking treatment
Space closure Once the overjet has been
Attitude towards treatment together
reduced, any residual space needs to be closed.
Several auxiliary attachments may be used Potential level of cooperation
to bring this about, eg active tie-backs, nickel Medical history
titanium closed coil springs, elastomeric chain
Social history
and Class II or III elastics.
Finishing and detailing Once the desired Examination
incisor, canine and molar relationships have
been achieved it is usually necessary to Extra-oral examination
finish and detail the occlusion to achieve the Skeletal pattern
best possible occlusion. At this stage careful
Antero-posterior
attention is paid to the position of the brackets
and bands because if they are incorrectly Vertical
positioned, the teeth will not be in their ideal Transverse
position. It is therefore quite common for Soft tissues – lips
brackets or bands to be repositioned at this
stage. Inter-maxillary elastics, placed in a Competency
variety of patterns, can be used to achieve a well Smile line
interdigitated occlusion at the end of treatment. Fullness
Debond Once the best possible occlusion
Temporomandibular joints (TMJs)
has been achieved arrangements are made to
remove the fixed appliance, clean the teeth and Sounds
provide the patient with retainers. Opening
Retention Following active orthodontic
Deviation
treatment, it is important that the teeth are
held in their new position so that relapse does Intra-oral examination
not occur. This stage of treatment is called Inter-arch relationships
retention. Retainers maintain the teeth in
Incisor, canine and molar
the position achieved by active orthodontic
relationships
treatment whilst the gingival tissues and
bone around the teeth heal. Retainers can be Overjet
removable or fixed to the teeth. Overbite
Centrelines
Orthognathic surgery
Cross/scissors bite ±
If a patient has a significant skeletal discrepancy
displacement on closing
then orthodontic treatment alone may not
be sufficient to correct all aspects of the Intra-arch relationships
malocclusion and facial disproportion. In Alignment
such cases it may be necessary to consider
General dental health
orthodontic treatment combined with
orthognathic surgery. Orthognathic surgery Active or restored caries
is that branch of surgery concerned with Patient’s level of oral hygiene
the correction of dentofacial deformity and
particularly with disproportions of the tooth- Special investigations
bearing segments of the jaws, and associated
Extra-oral examination
facial skeleton.
Radiographs
Stages of treatment Orthopantomograph (OPG, OPT)
There are several stages of treatment for Lateral cephalogram
patients undergoing a combined orthodontic/
orthognathic treatment plan. These include: Intra-oral views of upper labial segment
History and examination When initially Photographs
seeing the patient it is important to establish Intra-oral
their motivations for treatment. These may
Extra-oral
include aesthetic concerns regarding their teeth

34 vital www.nature.com/vital
 ADVANCED DENTAL NURSING

Phases of fixed orthodontic treatment benefit of the surgery. In order to do this it is

usually necessary to:
Bonding and banding • Relieve crowding. Just like in conventional
orthodontics, any crowded teeth are aligned
Levelling and aligning during the pre-surgical phase
• Correct centre-lines. The centre-lines need to
Overbite reduction be corrected relative to the facial centre-line
and those of the individual jaws
Overjet reduction • Decompensate. During the development of
a malocclusion the upper and lower incisors
Space closure
tend to compensate for the underlying
skeletal discrepancy. The implication of
Finishing and detailing
compensation on orthognathic surgery is that
the amount the jaws can be moved is limited
Debond
so, in order to maximise the movement of the
Retention jaws the surgeon can undertake, the incisors
usually have to be moved so that they are at
the correct angle to their respective jaw
and/or face or functional problems that may • Co-ordinate the arches. The width of the
give rise to difficulties eating certain foods, arches often needs to be adjusted so that they
signs and/or symptoms of temporomandibular fit in a normal bucco-lingual relationship
joint dysfunction or a speech impediment. when the jaws are in their new position
Preliminary planning At this stage an after surgery
assessment of where the skeletal discrepancy • Level or maintain the curve of Spee. This
lies, in all three planes of space, is made to depends on the presenting malocclusion.
establish what surgery will be required to
correct it. The surgery may involve the maxilla, Final planning At this stage full records
mandible or both jaws and occasionally other of the patient are taken so that a check can
procedures eg genioplasty. From an orthodontic be made that the planned orthodontic tooth
point of view, the expected tooth movements movements have been achieved. Special
needed to be undertaken pre-surgically and attention is paid to the centre-lines, incisor
extractions necessary are planned. angulation and fit of the arches. At this point,
Pre-surgical orthodontics The aims of pre- the amount of skeletal movement required
surgical orthodontics are to maximise the to correct the malocclusion, in all three
planes of space, can be determined. Working
Top: Pre-treatment, Middle: Mid-treatment,
study models are made and mounted on Bottom: Post-treatment
an articulator so that the anticipated jaw
‘The most movements can be simulated and the planned
occlusion achieved. From these models acrylic

frequently wafers are made that the surgeon uses to

guide the teeth and jaws into position during
the exit of the nerve from the respective jaw.
Post-surgical orthodontics Immediately after
the surgery. surgery it is common for patients to have a
carried out Surgery In theory it is possible to move the limited number of teeth in occlusion. The aims
jaws in three planes of space, however, some of post-surgical orthodontics are therefore to
surgical movements are harder to do or not as stable as maintain the surgical correction achieved; level
others. The most frequently carried out surgical the curve of Spee if necessary; close down the
movements in movements in the maxilla are advancement,
expansion, impaction and down fracture with
lateral open bites; finish and detail the occlusion
to achieve maximal intercuspation.

the maxilla are bone grafting. In the mandible advancement

and set back are the most common procedures.
Debond and retention – As for fixed
appliance treatment.
Most procedures these days are carried
advancement, out from within the mouth so that it is rare Summary
for patients to be left with any external scars Patients present for orthodontic treatment with
expansion, following surgery. The jaws are usually held a very wide range of problems and deciding
in their new position by small titanium plates which treatment to provide them with depends
impaction and or screws. The main complications of these
specific procedures are nerve damage, swelling
on the diagnosis, ie what’s wrong. Once the
orthodontist has reached a diagnosis and

down fracture and bruising. These usually resolve over

the following weeks or months but a small
formed a problem list, then the appropriate
treatment to correct the patient’s problems can
proportion of patients will be left with a small be selected from the range that is available to
with bone area of numbness or altered sensation overlying the specialist orthodontist.

grafting.’
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