Stats – in the UK…

• 45% of adults are unhappy with the appearance of their teeth
• 20% would undergo orthodontic treatment
• 74% of all adults have had a tooth extracted
• 84% of all adults have at least one or more restoration
• Each adult has an average of 7 restorations

Patients clinical awareness and expectations on treatment outcomes has increased. There have also been advances in orthodontics – braces are more acceptable, they are smaller and inconspicuous, can be invisible and also usually customised. Short term orthodontics – “speedy braces” is becoming more popular.
Particular challenges in adult patients:

• Old failing restorations
• Edentulous spaces/missing teeth
• Misshaped and/or malformed teeth
• Worn dentition
• Fractured teeth
• Periodontal disease
• Gingival level discrepancies
• Bony defects
• Jaw discrepancies

Diagnosis and planning is key:

• Periodontal examination – pocket depths, plaque control, recession, furcations, mobility, gingival height discrepancies.
• Dental assessment
• Orthodontic assessment – incisor relationship, crowding/spacing, overjet/overbite, buccal segment relationship
• Radiographic assessment

Treatment objectives:

• Problem list
• Inter-disciplinary planning
• Realistic goals
• Determine final set up and occlusion with restorations first and then work backwards
• Define roles and stages of treatment – treat active disease and stabilise dentition, restorations to facilitate movement, adjunctive surgery/restorative treatment, final restorative treatment and retention.

Orthodontic planning:

• Anchorage is key for all treatment
• Simple (mild crowding, crowding with crown/veneer preparation, minimal space closure) – consider removable appliances (traditional or clear aligners) or fixed appliances (“short term orthodontics”, fixed braces, metal/ceramic/lingual).
• Complex (anchorage demanding, tooth wear, reorganised occlusion, periodontal disease, implants, moderate-severe crowding, extraction cases) – consider fixed appliances (fixed braces, metal/ceramic/lingual).

Informed consent is absolutely essential:

• Discuss the alternatives including no treatment
• Create the vision
• Define all stages and who is responsible for each one
• Discuss the risks of all stages
• Long term maintenance
• Realistic timeline
• Written plan and costs

Problem solving:

• Missing anterior teeth is a common problem and as well as spacing it can cause ridge atrophy, tipping of adjacent teeth and poor gingival contour. Options to open space, re-morphologise teeth, gingival surgery or open up space, root paralleling and restore teeth.
• If periodontal disease is stable and well maintained then orthodontic treatment can commence. Light forces and good anchorage is important. Interproximal reduction to reduce black triangles.
• Root resorption is inevitable. Look for risk factors. Undermining resorption, heavy forces, hyalinisation and avascular necrosis.

Summary:

• Take time planning and plan jointly where appropriate.
• Plan the final occlusion first and then work back.
• Plan for orthodontic/restorative failure at the outset.
• Breakdown treatment into stages
• Take good clinical records and consent.
• Long term maintenance is vital!

General Dental