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Retention procedures for stabilising tooth position after treatment with orthodontic braces.

BACKGROUND: Retention is the phase of orthodontic treatment that attempts to keep teeth in the corrected positions after orthodontic (dental) braces. Without a phase of retention there is a tendency for the teeth to return to their initial position (relapse). To prevent relapse almost every patient who has orthodontic treatment will require some type of retention. OBJECTIVES: To evaluate the effectiveness of different retention strategies used to stabilise tooth position after orthodontic braces. SEARCH STRATEGY: The Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE and EMBASE were searched. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) were identified and contacted to identify unpublished trials. Most recent search: December 2002. SELECTION CRITERIA: RCTs on children and adults, who have had retainers fitted or adjunctive procedures undertaken, following orthodontic treatment with braces to prevent relapse. The outcomes are: how well the teeth are stabilised, survival of retainers, adverse effects on oral health and quality of life. DATA COLLECTION AND ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two reviewers. As no two studies compared the same retention strategies (interventions) it was not possible to combine the results of any studies. MAIN RESULTS: Four trials satisfied the inclusion criteria. These trials all compared different interventions: circumferential supracrestal fiberotomy (CSF) combined with full-time removable retainer versus a full-time removable retainer alone; circumferential supracrestal fiberotomy (CSF) combined with a nights-only removable retainer versus a nights-only removable retainer alone; removable Hawley retainer versus a clear overlay retainer; and three types of fixed retainers versus a removable retainer. There was weak unreliable evidence, based on data from one trial, that there was a statistically significant increase in stability in both the mandibular (p < 0.001) and maxillary anterior segments (p < 0.001) when the CSF was used, compared with when it was not used. There was also weak, unreliable evidence that teeth settle quicker with a Hawley retainer than with a clear overlay retainer after 3 months. The quality of the trial reports was generally poor. REVIEWER'S CONCLUSIONS: There are insufficient research data on which to base our clinical practice on retention at present. There is an urgent need for high quality randomised controlled trials in this crucial area of orthodontic practice.

Humans↗

Long-term effects of orthodontic treatment on periodontal health.

The periodontal health of a group of ninety-six patients who had received comprehensive fixed-appliance orthodontic treatment during adolescence between 12 and 35 years previously was evaluated. Comparisons were made with a group of 103 adults who were similar with regard to race, sex, age, socioeconomic status, dental awareness, and oral hygiene status but had malocclusions that had not been orthodontically treated. There were no statistically significant differences in the general prevalence of periodontal disease between the two groups. However, more detailed analysis revealed that the orthodontic group had a greater prevalence of mild to moderate periodontal disease in the maxillary posterior and mandibular anterior regions of the mouth, as compared to the control group. The results suggested that orthodontic treatment in adolescence is not a major factor in determining the long-term periodontal health status. No significant amount of either damage or benefit to the periodontal structures could be directly attributed to orthodontic therapy. Conversely, the lack of orthodontic therapy in adolescence does not appear to influence subsequent development or nondevelopment of periodontal disease in adults.

Adult↗

Long-term benefits of orthodontic treatment on oral hygiene.

The purpose of this project was to determine whether orthodontic patients have better oral hygiene than dental patients who have not received orthodontic treatment. A random sample of 158 boys and girls ranging from 11 to 15 years of age were selected for this project. Seventy-four had been treated orthodontically and seventy-four had not had orthodontic treatment. Gingivitis and plaque indices were used to measure the patients' oral hygiene. The patients who had received orthodontic treatment displayed superior oral hygiene to those dental patients who had not received orthodontic treatment.

Adolescent↗

Enamel demineralization following orthodontic treatment.

A cross-sectional study was carried out to determine the prevalence and severity of enamel opacities in patients before and after orthodontic treatment. The sample consisted of 527 patients examined prior to and 269 patients examined after completion of multibanded orthodontic treatment. The results showed that there was a significant increase in both the prevalence (before, 72.3 per cent; after, 84.0 per cent) and severity (Opacity Index: before, 0.125; after, 0.200) following completion of orthodontic treatment. Male patients experienced a significantly higher increase in the severity of enamel opacities following orthodontic treatment. There was no significant sex differential in the prevalence of enamel opacities either before or after orthodontic treatment. This study showed that orthodontic treatment with multibanded appliances contributed to the development of new areas of enamel demineralization and to an increase in the severity of enamel opacities as measured by the Opacity Index.

Adolescent↗

Use of osseointegrated implants in adult orthodontic treatment: a clinical report.

This article describes the complex dental treatment of an adult patient with multiple missing teeth, mild periodontitis, and a malocclusion. Titanium implants were placed in the posterior mandibular edentulous segments and became osseointegrated. The placement of the mandibular implants was originally designed for orthodontic anchorage. The mandibular implants would subsequently be used for implant-retained crowns on completion of orthodontic treatment. After a 4-month healing period, an impression was made of the implant hexes and a master cast was formed. Two-piece temporary healing abutments were placed on the implants and used to retain orthodontic brackets. The orthodontist retracted the mandibular anterior teeth using the posterior implants for anchorage. The abutment screws of the 2-piece temporary healing abutments were tightened to 20 N-cm at the insertion appointment and did not need to be tightened again during the course of orthodontic therapy. Standard orthodontic brackets were cemented to the 2-piece temporary healing abutments. Orthodontic treatment was accomplished uneventfully. Prosthodontic treatment was completed using the osseointegrated implants to replace the missing teeth. The methods described in this clinical report present clinicians with additional choices in the treatment of complex dental disease using osseointegrated dental implants.

Combined Modality Therapy↗

Orthodontic literature: an overview of the last 2 decades.

The aim of this study was to explore the orthodontic literature in the most important orthodontic and other dental and medical journals from 1981 to 2000. The most commonly used medical bibliographic database, MEDLINE, was used. In addition, some journals were hand searched to estimate the error of the method. Despite some indexing inconsistencies, MEDLINE was found to be a powerful and relatively accurate tool for use in bibliometric studies. About 16,000 articles with orthodontic interest were published during this period. The number of orthodontic articles written in English rose during this period, but almost half of them (45%) were published in nonorthodontic journals. Articles in the orthodontic journals are focusing more and more on diagnosis and treatment evaluation as the need for high-quality evidence becomes obvious, while other topics, such as new techniques and new materials, are losing ground. Many high-quality studies with orthodontic interest are published in nonorthodontic journals with a high Impact Factor, remaining more or less out of reach for most orthodontists.

Abstracting and Indexing↗

Distribution of orthodontic services and fees in an insured population in Washington.

Previous attempts to quantify the amount and type of orthodontic therapy provided by nonorthodontists in the United States have relied on survey data. Although there are advantages to surveys, such as control over survey recipients and inclusion of specific questions, they also have limitations, such as low response rates, response bias, and recall bias. This study used insurance claims data from a large dental benefits provider in Washington to assess the distribution of orthodontic services and fees among various dental providers. All orthodontic claims allowed by Washington Dental Service in 2001 were retrieved, along with treatment codes, fees, and demographic information for both patients and providers. A total of 102,984 orthodontic claims were included in the study. General dentists submitted 7.0% of these claims, orthodontists submitted 90.9%, and pedodontists submitted 1.9%. Orthodontists submitted higher average fees for space maintainers, first payments, and records. The percentage of orthodontic treatment preformed by general dentists and pedodontists in this claims-based study was substantially less than what has been previously reported in survey-based studies. Additionally, a smaller percentage of general dentists and pedodontists in this study performed comprehensive treatment, compared with previous studies. This study illustrates the value of insurance claims data to assess the provision of orthodontic care.

Analysis of Variance↗

Orthodontic treatment timing: a survey of orthodontists.

There has been much debate with respect to the ideal time to initiate orthodontic treatment. Recent clinical trials have tested the effects of early orthodontic treatment. The purpose of this study was to understand orthodontists' perspectives on the best time to initiate treatment, factors that preclude early treatment, and experiences with compliance or adherence problems among their younger patients. Questionnaires were distributed to 335 practicing orthodontists throughout the United States. Respondents were first asked to indicate the best stage to initiate orthodontic treatment for 41 different types of occlusal deviations. They were then asked what conditions might preclude early orthodontic treatment. After one reminder, 137 questionnaires (41%) were returned. The sample consisted of practitioners with 3 to 52 years of experience and represented 46 different orthodontic training programs; 19% were female. The majority (92%) were in private practice. Among the 41 conditions listed, orthodontists would most likely treat 21 in the early mixed dentition, especially anterior crossbites (> 76%); 13 in the late mixed dentition, especially deepbite (> 60%) and mandibular inadequacy (> 59%); and 4 in either stage. Only two conditions would be treated in later stages (maxillary midline diastema, 43%; and congenitally missing teeth,39%). One third would postpone treating mandibular prognathism until adulthood. Patient variables that precluded treatment were behavior (98%) and compliance (96%) problems. Finances (76%) and family disruptions (57%) were less important deterrents to treatment. Orthodontists' experience with Phase I treatment influenced their decisions (p < 0.01). Orthodontists who have been in practice longer were more likely to treat temporomandibular joint sounds (p < 0.003) and deviations in opening (p < 0.002) than less experienced orthodontists; the latter were more likely to refer such patients to temporomandibular disorder specialists. These findings suggest that early orthodontic intervention is the norm, but practice characteristics affect treatment timing.

Adult↗

Nonlinear large-deflection analysis of orthodontic wires.

The purposes of this study were (1) to measure the nonlinear force-deflection behavior of selected orthodontic wires using a conventional tensile test, (2) to extend a mathematical model for simulating the force system produced by orthodontic wires based on the small-deflection linear theory to the large-deflection nonlinear theory, and (3) to examine the effects of the cross-section and mechanical properties of orthodontic wires on nonlinear characteristics. A method for extending a mathematical model for simulating the force system produced by orthodontic wires based on the small-deflection linear theory to the large-deflection nonlinear theory was established, and this can provide a clear view of the true nature of orthodontic wires. Furthermore, our results demonstrated that the nonlinear properties of orthodontic wires were affected more by the cross-sectional shape than by mechanical properties.

Algorithms↗

Archwire ligation techniques, microbial colonization, and periodontal status in orthodontically treated patients.

Fixed or removable orthodontic appliances impede the maintenance of oral hygiene and result in plaque accumulation. Plaque retention surrounding orthodontic appliances leads to enamel demineralization caused by organic acids produced by bacteria in the dental plaque. Many studies have evaluated the effects of fixed orthodontic appliances on microbial flora and periodontal status, but only a few have evaluated the method of ligation as an additional factor. The aim of this study was to determine the changes in microbial flora and periodontal status after orthodontic bonding and to determine whether two different archwire ligation techniques affect these changes. A total of 21 orthodontic patients scheduled for fixed orthodontic treatment were selected for this split-mouth study. Two commonly used auxiliaries (elastomeric rings and ligature wires) for tying archwires were tested. Microbial and periodontal records were obtained before bonding (T0), one week later (T1), and five weeks after bonding (T2). Paired t-test and Wilcoxon signed rank test were used to compare the groups statistically. Although, teeth ligated with elastomeric rings exhibited slightly greater numbers of microorganisms than teeth ligated with steel ligature wires, the differences were not statistically significant and could be ignored. The two archwire ligation techniques showed no significant differences in the gingival index, bonded bracket plaque index, or pocket depths of the bonded teeth. However, teeth ligated with elastomeric rings were more prone to bleeding. Therefore, elastomeric ring use is not recommended in patients with poor oral hygiene.

Adolescent↗

A prospective long-term study of signs and symptoms of temporomandibular disorders in patients who received orthodontic treatment in childhood.

This investigation analyzed the influence of orthodontic treatment performed in childhood on the long-term development of signs and symptoms of temporomandibular disorders (TMDs). The original sample consisted of 50 consecutive patients (27 girls and 23 boys) with different morphological malocclusions, who were to receive orthodontic treatment. Their mean age at start of treatment was 12.9 years. Seventeen (range 15-18) years after completion of orthodontic treatment, 40 former patients (89% of the traced subjects) completed and returned a questionnaire, and 31 subjects (69% of the traced subjects) were also examined clinically. A great majority of the participants were pleased with the result of the orthodontic treatment. Relapses of morphological malocclusions were very uncommon. The prevalence of signs and symptoms of TMD was low both before and after the active phase of orthodontic treatment, as well as at the long-term follow-up after 15 to 18 years. The incidence per year of manifest TMD requiring treatment was approximately 1%. The result of the present investigation supports the opinion that orthodontic treatment in childhood does not entail an increased risk to develop either signs or symptoms of TMD later in life.

Case-Control Studies↗

Professional perceptions of the benefits of orthodontic treatment.

The aim of this study was to assess general dental practitioners' and orthodontists' perceptions of the benefits of orthodontic treatment. A specially designed questionnaire was sent to a random sample of 150 general dental practitioners (GDPs) and all orthodontists in Northern Ireland (excluding hospital practitioners) with a postgraduate qualification (n = 29). There was a 93 per cent response rate by the general dental practitioners and all but one specialist practitioner returned the questionnaire. The questionnaire comprised 14 visual analogue scales (VAS) whereby participants were asked to rate the importance of various possible dental health and psychosocial benefits of orthodontic treatment. In addition to the VAS, the influence of dentist variables such as number of years since qualification, orthodontic cases completed, referral rates and attendance at postgraduate lectures were examined. When ratings on the 14 dental health and psychosocial scales were examined overall, GDPs rated an improvement in self-esteem while orthodontists considered an improvement in physical attractiveness as the most important benefit of orthodontic treatment. Even though psychosocial variables received the highest ratings, examination of the mean ratings (and 95 per cent confidence intervals) revealed that some dental health factors were also rated highly by both groups. While the results do indicate an encouraging awareness of the psychosocial benefits of orthodontic treatment, they also suggest that both GDPs and orthodontists have an unrealistic expectation of the dental health gain likely to result from orthodontic treatment.

Dentists↗

A survey of undergraduate orthodontic education in 23 European countries.

This paper reports on a survey of teaching contents and time allocation within the undergraduate orthodontic curriculum in European countries in 1997, and on whether or not these countries set a formal undergraduate examination in orthodontics. A questionnaire and an explanatory letter were mailed to all members of the EURO-QUAL BIOMED II project. Answers were validated during a meeting of project participants and by fax when necessary. Completed questionnaires, which were subsequently validated, were returned by orthodontists from 23 countries. They indicated that orthodontics was taught in all undergraduate curriculums of the countries surveyed. The number of hours in the undergraduate curriculum devoted to orthodontics was reported as varying from 135 to 500 hours with a mean of 245 hours. The time reported as allocated to theory, clinical practice, laboratory work, diagnosis, and treatment planning varied widely. In general, clinical practice and theory were reported as being allocated most curriculum hours, whilst diagnosis, laboratory work, and treatment planing were reported as receiving relatively less time. Removable appliances were reported to be taught in 22 of the 23 countries, functional appliances in 21 countries and fixed appliances in 17 countries. An undergraduate examination in orthodontics was reported by 20 countries. It was concluded that orthodontics occupies a small proportion of the undergraduate curriculum in dentistry in most countries, the emphasis is on theory and clinical work, and that removable appliances, functional appliances, and certain aspects of fixed appliances are taught in the majority of countries that responded to the questionnaire

Curriculum↗

Unmet orthodontic treatment need in rural Nigerian adolescents.

A survey of orthodontic treatment need was carried out among randomly selected rural Nigerian adolescents using the index of orthodontic treatment need. Altogether, 704 subjects (381 boys and 323 girls) aged 12-18 years (mean 14.8, SD 1.79) were recruited in the study. The results indicated that 12.6% of the population were in objective need of orthodontic treatment. Whilst there was a discrepancy in the proportions of Nigerian adolescents needing orthodontic treatment on aesthetic and dental health grounds, girls were found to have a more attractive dental appearance and less orthodontic treatment need than boys. However, the differences were not statistically significant (P>0.05). The correlation between the orthodontist's and the subject's rating of dental appearance was found to be low (r=0.35). The study also provided reliable baseline data for planning orthodontic services in Nigeria especially in areas where there are no dental services.

Adolescent↗

Changes in lip contour following treatment of maxillary protrusion with esthetic orthodontic appliances.

With the advent of acid etching techniques and the elimination of unesthetic band materials, direct bonding of orthodontic attachments kindled a desire for cosmetic appliances such as labial ceramic brackets and lingual orthodontics. Owing to the esthetic nature of our combination upper-lingual lower-ceramic orthodontic approach, adults who would have normally avoided orthodontic treatment are now seeking treatment. This study evaluated the cephalometric changes in the soft tissue lip profile following treatment of Class II Division 1 malocclusion with upper first bicuspid extractions with our esthetic orthodontic appliance approach. Serial lateral cephalograms (pretreatment and posttreatment) of 16 adult patients with a mean age of 22.1 +/- 3.2 years were studied. The mean upper incisor retraction, upper lip retraction, upper lip lengthening, and lower lip retraction were 5.75 +/- 1.91 mm, 2.8 +/- 1.4 mm, 1.5 +/- 0.6 mm, and 1.4 +/- 0.6 mm, respectively. All these changes were statistically significant (p < 0.01). The nasolabial angle increase of 10.8 +/- 3.0 degrees was also statistically significant (p < 0.01). The upper lip retraction to upper incisor retraction was 1:2.1, while the upper lip lengthening to upper incisor retraction was 1:3.8. The correlation coefficients (r) were 0.91 (p < 0.01) and 0.57 (p < 0.01), respectively. This study shows that significant esthetic changes in lip profile are possible with this cosmetic orthodontic appliance approach. The treatment results in this study appear comparable to those published with labial metal brackets. With very few exceptions, patients were able to adapt within 2 weeks, with almost no trauma to the tongue.

Adult↗

Patients' motivations for treatment and their experiences of orthodontic preparation for orthognathic surgery.

OBJECTIVE: To determine patients' motivations for undergoing orthognathic surgery and their experiences of the orthodontic aspects of this treatment. DESIGN: Retrospective questionnaire survey using a patient-centred measure. SETTING: Thirteen National Health Service (NHS) hospital orthodontic departments. SUBJECTS: Three-hundred-and-twenty-six patients (58% response rate) who underwent orthognathic surgery during the period 1 January 1995 to 30 September 2001 completed a questionnaire. MAIN OUTCOME MEASURES: Motivations for treatment and perception of information about treatment and experiences of orthodontic treatment. RESULTS: Major motivations for treatment were to have straight teeth (80%), to prevent future dental problems (69%) and to improve self-confidence (68%). Females sought treatment to improve self-confidence and their smile. Males wanted treatment to improve their social life. Most of these issues had improved following surgery. Most (94%) respondents felt well-informed about their orthodontics. However, 36% wore braces for longer than they expected. Males and younger patients knew less about the duration of treatment than other groups. Fifty-eight per cent of subjects found their braces difficult to clean and 9% reported that they were very painful. Older patients experienced fewer problems wearing braces than younger patients. CONCLUSIONS: Improving dental appearance and preventing future dental problems are major motivators for orthognathic patients. Although patients felt well informed about what to expect from their orthodontic treatment, a significant proportion, particularly younger patients and males, were surprised at the length of treatment and the need to wear retainers. This suggests that orthognathic patients might benefit from better information regarding the orthodontic aspects of their care.

Adolescent↗

Factors influencing the uptake of orthodontic treatment.

The aim of this investigation was to evaluate the factors that influenced the uptake of orthodontic treatment for patients who were referred for orthodontic treatment to two types of orthodontic treatment provider; a fee per item and hospital service. The following data were collected: (i) basic demographic data; (ii) the need for orthodontic treatment as measured by IOTN; and (iii) the outcome of the consultation. The data analysis with logistic regression revealed that the following variables had a predictive effect on the uptake of treatment: (i) the need for orthodontic treatment; and (ii) the patient's gender. Most of the patients that were referred and accepted for treatment had a definite need for orthodontic treatment.

Adolescent↗

Early orthodontic treatment: what are the imperatives?

BACKGROUND: Then authors provide a critical review of the issues involved in determining the appropriate timing of orthodontic treatment. Both single- and two-phase treatments are discussed and guidelines are offered to assist in formulating treatment plans. OVERVIEW: In providing orthodontic care for pediatric patients, clinicians often question whether to begin treatment early--during the primary or early-transitional dentition--or wait until all or most of the permanent teeth are present. The authors review the most current literature (from 1991 to 1999), including several recently completed and ongoing randomized clinical trials, to critically evaluate the effectiveness of each approach. PRACTICAL IMPLICATIONS: The controversy surrounding early vs. late orthodontic treatment is often confusing to the dental community. This article reviews both sides of the issue for orthodontic treatment of Class II and III malocclusions, as well as for the management of Class I crowding and problems in the transverse dimension. Early orthodontic treatment is effective and desirable in specific situations. However, the evidence is equally compelling that such an approach is not indicated in many cases for which later, single-phase treatment is more effective. Therefore, clinicians must decide, on a case-by-case basis, when to provide orthodontic treatment. For many patients, delaying treatment until later in their dental and skeletal development may be advisable.

Adolescent↗