risks and benefits of ortho tx Flashcards by Becky Wall

benefits

improve:
appearance - QOL - dental and facial
function - mastication
dental health - trauma/resorption

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improvement in function

mastication - when associated with severe malocclusion - large AOB, large OJ or reduced OJ
rarely improves speech defects - lisp can be associated with AOB but speech is established early in life

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IOTN DHC

1 and 2 - no/low need (min benefit)
3 - borderline need (some benefit)
4 and 5 - need/high need (significant benefit)

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MOCDO

Missing Teeth
OJ
Crossbites
Displacement of contact points
Overbites

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how are impacted/missing/ectopic teeth a dental health risk?

can cause resorption and be associated with cyst formation

supernumerary teeth can prevent normal eruption

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dental health risk of OJ >6mm

risk of trauma to upper incisors increases with size of OJ

worse with incompetent lips

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anterior cross bite dental health risk

loss of perio support, gingival recession
toothwear
if associated with mandibular displacement may lead to TMJ issues

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posterior cross bite issue

a significant displacement may lead to asymmetry

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crowding and caries

crowding per se not directly linked to increased risk of caries - more to do with diet and fluoride
crowded teeth are more difficult to clean and take longer

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crowding and periodontal disease

weak association between irregular teeth and PDD
crowding can make surfaces less accessible and harder to clean
individual motivation rather than tooth alignment has greater effect on effective brushing
better OH/awareness in pts with prev ortho

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deep traumatic overbite dental health risk

can cause gingival stripping - L labial, U palatal

loss of perio support

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TMJ dysfunction and ortho

TMD multifactorial
ortho/TMD - evidence is v weak
small association between TMD and some malocclusions
- CB with displacement (fct shifts)
- class 2 with retrusive mandible
- class 3
- AOB
but no guarantee correction will improve TMD
never offer ortho to improve TMD in isolation
if malocclusion does not warrant tx, ortho will not be offered to pts with TMD
conservative tx must be offered before any ortho
ortho tx could aggravate existing TMD e.g. using inter maxillary elastics

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risks

decalcification
root resorption
relapse
ST trauma
others
 - recession
 - loss of perio support
 - headgear injuries
 - enamel fracture and toothwear
 - loss of vitality
 - allergy
 - poor/failed tx

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decalcification

picture frame opacities
weakens enamel to caries
- ranges from staining to frank cavitation/gross caries

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preventing decalcification

case selection
oral hygiene
diet advice
fluoride

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preventing decalcification - good case selection

motivated pt
good OH pre-tx
low caries risk
if low or borderline need - no tx

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how is caries risk indicated?

number and location of restorations - esp if anterior

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indications of high risk of decalcification

pre-existing decalcification
erosion
caries history

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preventing decalcification - maintaining good OH

before start and during
 - toothbrushing - target areas
 - interdental brush
OHI
 - min x2 per day VERY thoroughly
 - after every meal
 - disclosing tablets
 - target gingival margins and around each bracket
GDP help

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preventing decalcification - diet advice

encourage non-cariogenic diet
sugar amount and freq - critical pH 5.5
- avoid snacks between meals
- avoid fizzy drinks etc
- sports drinks
- lollipop type sweets, haribos - stick to brackets and prolongs time sugar in mouth
sugar free gum - with care - stimulate salivary buffers

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preventing decalcification - fluoride

toothpaste
MW
Duraphat varnish
others - F releasing GIC

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preventing decalcification - fluoride - toothpaste

check which they use - switch to adults
F exposure at least x2 daily
spit don’t rinse
for high risk pts Duraphat 2800 or 5000 ppm x2 daily, ordinary at other times, warn re overdose if tendency to swallow

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preventing decalcification - fluoride - MW

daily 0.05%/225ppm
use in between brushing not after
beneficial but often low compliance
£ may be prohibitive - cheaper options - supermarket antiseptic MW now with F

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preventing decalcification - fluoride - Duraphat varnish

22600 ppm

4 monthly

root resorption

inevitable consequence of tooth movement | can also see RR even with no prev ortho

prevalence of RR

nearly everyone 25% radiographically 90% histologically mostly unnoticed

average amount of RR

1mm over two years fixed appliances

site of RR

``` any teeth but U incisors (esp 2s) > L incisors > 6s ```

prevalence of severe RR

1-5%

risk factors for RR

multifactorial - type of tooth movement - root form - prev trauma - nail biting? - length of tx

risk factors for RR - type of tooth movement

prolonged, high force intrusion large movements torque (root movement)

risk factors for RR - root form

``` short blunt apical bend PIPETTE shape resorbed already ```

prevention of RR

light forces | 3m treatment pause

relapse

the return of the features of the original malocclusion following correction

difficulty with relapse

common but unpredictable | tx all cases as if potential to relapse

features more prone to relapse

``` bridgework post-ortho (quickly fit retainer) L incisor crowding rotations instanding 2s spaces and diastemas class 2 div 2 AOB reduced perio support/short roots ```

IOTN AC and relapse

1-5 if relapse hard to distinguish before and after | 6-10 even if some relapse would see improvement

managing relapse

retainers - maintenance cost of retention | case selection/informed consent - tx severe malocclusions, leave mild

PFR thickness

usually 1-1.5mm - robust

removable retainers

``` COR/PFR/VFR Essix Hawley type - robust, can eat, good for holding prosthetic lateral in hypodontia cases remove for OH can wear part-time pt control easy to spot problem after discharge - GDP to supply ```

fixed retainers

``` prone to plaque and calculus build up can break and not notice need excellent OH tend to leave in situ for life require more care/long term maintenance VFRs often on top in case bonded breaks ```

where do you place a fixed retainer?

at contact points to avoid ST damage and allow cleaning

soft tissue trauma

pain/discomfort - analgesics | ulceration - ortho wax or babybel cheese wax

recession

increasing problem expansion, more adult tx may not manifest until years later

management of recession

correct tx planning - teeth within bone, avoid over expansion (out of cortical bone) thin biotype warn pt gingival graft

periodontal health - active perio disease

must be txed, stabilised and maintained before ortho tx starts - min 6m - 2 visits 2m apart with no active pockets during ortho tx - accelerates alveolar bone loss and perio destruction txed as priority over continuing tx

periodontal health

gingivitis - common recession loss of perio support

headgear trauma

ocular injuries - blindness/loss of eye

prevention of headgear trauma

safety mechanism - 2minimum - Nitom facebow - snap away traction spring

toothwear or enamel fracture

tooth vs bracket greater risk with ceramic brackets - ceramic harder than E E fracture during debond

loss of vitality

``` rare more risk if prev trauma or compromised tooth warn pt discolouration or darkened? lat incisors Xs force? idiopathic cause ```

allergies

latex - may be in elastics Ni - on rise due to wearing cheap jewellery/piercings etc adhesive - colophony

poor/failed tx

``` poor diagnosis/tx planning operator technique error poor cooperation - appliance wear - repeated breakages - non-attendance unfavourable growth ```

chance of tx success increases with:

severity of malocclusion motivation of pt operator expertise

social 6 smiles plus

cosmetic quick fixes - 6 month smiles etc mild problems unrealistic pt expectations informed choice relapse litigation prone in hands of inexperienced operator

what is ortho tx mostly?

elective

describe risks/benefits throughout tx timescale

risks throughout course of tx benefits more apparent at end of tx risks must not outweigh benefits

which pts have the most and least to gain?

most - those with severe malocclusions treated by experts | least - mild malocclusions

risk reduction

``` excellent OH highly motivated pt tx more severe malocclusions properly inform pts of risks retention for life or accept some relapse ```