March 28, 2014

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.


  • 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!

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