risks and benefits of ortho tx Flashcards
benefits
improve:
appearance - QOL - dental and facial
function - mastication
dental health - trauma/resorption
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
IOTN DHC score and assoc need
1 and 2 - no/low need (min benefit)
3 - borderline need (some benefit)
4 and 5 - need/high need (significant benefit)
MOCDO
Missing Teeth OJ Crossbites Displacement of contact points Overbites
how are impacted/ectopic teeth a dental health risk?
- can cause resorption and be associated with cyst formation
- supernumerary teeth can prevent normal eruption
dental health risk of OJ >6mm
4a
risk of trauma to upper incisors increases with size of OJ
worse with incompetent lips
anterior cross bite dental health risk
- loss of perio support, gingival recession
- toothwear
- if associated with mandibular displacement may lead to TMJ issues
posterior cross bite issue
a significant displacement may lead to asymmetry
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
deep traumatic overbite dental health risk
can cause gingival stripping - L labial, U palatal
loss of perio support
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
ortho tx could aggravate existing TMD e.g. using inter maxillary elastics
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
what can decalcification lead to
- weakens enamel to caries
- unsightly staining - opacity
- frank cavitation
preventing decalcification
case selection
oral hygiene
diet advice
fluoride
preventing decalcification - good case selection
motivated pt
good OH pre-tx
low caries risk
if low or borderline need - no tx
how is caries risk indicated?
number and location of restorations - esp if anterior
indications of high risk of decalcification
pre-existing decalcification
erosion
caries history
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
preventing decalcification - diet advice
- encourage non-cariogenic diet
- drink with straw
- keep snacks in meal time
- sugar amount and freq - critical pH 5.5
- sugar free gum - with care - stimulate salivary buffers
preventing decalcification - fluoride
toothpaste
MW
Duraphat varnish
others - F releasing GIC
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
warn re overdose if tendency to swallow
preventing decalcification - fluoride - MW
daily 0.05%/225ppm
use in between brushing not after
beneficial but often low compliance
£ may be prohibitive - cheaper options
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
L incisor crowding rotations instanding 2s spaces and diastemas class 2 div 2 AOB reduced perio support/short roots
managing relapse
retainers - maintenance cost of retention
case selection/informed consent - tx severe malocclusions, leave mild
pressure-formed retainer thickness
usually 1-1.5mm - robust
removable retainers types
COR - clear occlusal retainer
PFR/VFR - pressure/ vacuum
Essix
Hawley type - robust, can eat, good for holding prosthetic lateral in hypodontia cases
pros of removable retainers
- remove for OH
- can wear part-time
- pt control
- easy to spot problem
after discharge - GDP to supply replacement
fixed retainers cons
- 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 management
- 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 more at risk
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 risk
gingivitis - common
active perio disease
recession
loss of perio support
headgear trauma risk
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
Nickel - 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
