APO Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics
Orthodontics and Dentofacial Orthopedics is a specialty area of dentistry concerned with the supervision, guidance and correction of the growing or mature dentofacial structures, including those conditions that require movement of teeth or correction of malrelationships and malformations of their related structures and the adjustment of relationships between and among teeth and facial bones by the application of forces and/or the stimulation and redirection of functional forces within the craniofacial complex.
Major responsibilities of orthodontic practice include the diagnosis, prevention, interception, and treatment of all forms of malocclusion of the teeth and associated alterations of their surrounding structures; the design, application, and control of functional and corrective appliances; and the guidance of the dentition and its supporting structures to attain and maintain optimal occlusal relations and physiologic and esthetic harmony among facial and cranial structures. Practice guidelines, as defined by the Institute of Medicine, are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”
The Orthodontic Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics presented in this document are condition based and are related to the International Classification of Diseases, Clinical Modification, 9th Edition (ICD-9Codes) and is the basis for the CPG adhered to by the American Association of Orthodontists. This approach recognizes the need for integrated treatment of oral and dentofacial conditions rather than isolated treatment procedures. These guidelines are also directed toward the process of patient care and outline considerations related to diagnosis, treatment, and quality of care. These guidelines were derived from a professional consensus, based on a review of relevant clinical and scientific literature, the expert opinion of educators, and the clinical experience of practicing orthodontists. Similar documents written by other specialty organizations locally in the Philippines, and publications related to guideline development were also reviewed.
There is a wide and disparate gamut of professionally accepted philosophies regarding orthodontic diagnosis, treatment, and retention. Because of the nature of the doctorpatient relationship, the trained and experienced orthodontic practitioner who is actively engaged in treating the patient, is in the best position to evaluate and interpret the complexities, timing, and potential efficacy from among different philosophies and systems available. Deviations from these guidelines may be appropriate based on professional judgment and individual patient needs. Where a practitioner chooses to deviate from these guidelines (based on the circumstances of a particular patient or for any other reason) the practitioner is advised to note in the patient's record the reason for the procedure followed.
Finally, it should be understood that adherence to these guidelines does not guarantee a successful treatment outcome.
AGE TO SEEK ORTHODONTIC TREATMENT:
The ideal age for the first orthodontic check-up is 7 years, after the eruption of the permanent first molars which are the key to occlusion (“bite”). However, in some cases where there are obvious signs of skeletal deficiency or excess, a child may be seen as early as 5 years old.
There is no age limit for treatment. Any adult may be treated as long as the bone and other supporting tissues are healthy.
A complete set of orthodontic records is required prior to diagnosis and treatment of a patient. This consists of the following:
- Lateral Cephalometric Radiograph
- Panoramic Radiograph
- Study Models (properly trimmed and polished)
a. Intraoral: center, right and left buccal (cuspid to 1st molar) shots, maxillary
and mandibular occlusal shots
b. Extraoral: Frontal (lips at rest), Frontal (full smile), and profile (Right and
left) facial photos against a white background
Additional radiographs such as the following may be required as necessary:
- Occlusal Radiograph
- Postero-Anterior Cephalometric Radiograph
- Peri-apical x-rays
- TMJ radiographs, etc.
Progress records may be taken at any time during treatment and final records are taken at the end of treatment for purposes of case documentation.
WHO NEEDS ORTHODONTIC TREATMENT?
There is no age limit. Anyone, regardless of age, can undergo orthodontic treatment. As long as there are no existing infections (periodontal, endodontic etc...) or pathology that may be aggravated by tooth movement, one may proceed with orthodontic treatment. In cases where there are existing problems, the appropriate specialist must be sought out for clearance to commence tooth movement.
Those with the following may benefit from orthodontic treatment:
1. Skeletal malocclusions:
- Class I: Maxillary and Mandibular Excess/ Bimaxillary protrusion
- Class II: Maxillary excess and/or Mandibular deficiency
- Class III: Maxillary deficiency and/or mandibular excess
- Maxillary/ Mandibular Anterior and/or Posterior Vertical Excess/ Deficiency
- Transverse skeletal discrepancies (maxillary and/or mandibular arch constriction: posterior crossbite)
2. Dental Malocclusions:
- Class I molar and canine relationship with crowding/ spacing/ alignment problems
- Class II molar and/or cuspid relationships
- Class III molar and/or cuspid relationships
- Crowding and rotations
- Increased Overjet/Overbite
- Open Bite
- Crossbites (Posterior/ Anterior/Single Tooth)
- Narrow Upper/Lower arches
- Flaring of Upper and/or lower teeth
- Habits: Tongue thrust, thumb sucking, clenching, bruxing etc…)
- Supernumerary or Missing Teeth
- Impacted teeth
3. Soft Tissue Problems:
The following may or may not be affected by orthodontic treatment:
- Lip protrusion
- Mentalis strain
- Retrusive lips
PHASES OF ORTHODONTIC TREATMENT:
This is otherwise known as INTERCEPTIVE ORTHODONTICS. This phase addresses problems diagnosed in patients who are in the primary and mixed dentition stages. It may involve growth modification, space regaining/maintenance, expansion etc…
Goals for this phase are as follows:
- to develop the upper and lower jaws sufficiently to accommodate all teeth
- to improve the relationship of both jaws to each other
Phase 1 aims to simplify phase 2. It may prevent future extractions or orthognathic
surgery and in some cases, it may eliminate the need for Phase 2.
The following are possible treatment options for Phase 1:
- High pull or Cervical headgear
- Reverse Pull Head Gear or Face Mask
- Palatal or Lingual Expanders
- Active/Spring Retainers
- Space Maintainers (i.e. Lower Lingual Arch, TPA, Band & Loop)
- Bite Plate
- Myofunctional appliances
- Habit Control Appliances (i.e. Tongue Crib)
- Lip Bumper
- Functional Appliances (i.e. Bionator, Twin block…)
- Limited fixed appliances (brackets placed on permanent incisors and first molars/ 2 x 4 Upper and/or Lower)
- Hawley Retainers
- Chin Cup
In some cases, early extraction or planned removal of certain teeth (both primary and/or permanent) may be necessary to allow certain permanent teeth to come in. This is called SERIAL EXTRACTION OR GUIDED ERUPTION.
This is the CORRECTIVE PHASE. When all permanent teeth have erupted into the oral cavity, Phase 2 may begin. It involves the placement of brackets in most, if not all of the erupted teeth. Bonding materials may be chemically or light cured, directly or indirectly bonded. Bands may be placed on molars or bicuspids using various types of band cement.
During treatment, the use of elastics/rubber bands or springs to aid in correction may be necessary. Various types of materials may also be utilized depending on the type of movement desired. Wires and springs made of stainless steel, copper Niti (nickel titanium), TMA etc. in various sizes and thickness may be employed.
LENGTH OF TREATMENT
Comprehensive Phase 2 treatment may last anywhere from several months to 3 years depending on the difficulty of the case, cooperation of the patient, and other factors.
INTERVAL OF VISITS
Depending on the nature of adjustments and type of treatment, orthodontic visits may be spaced weekly, every two weeks, monthly, or every 6-8 weeks. Nevertheless, a patient should be seen on a regular basis. In most cases, patients are seen monthly for regular adjustments. This allows the bone and surrounding
tissues to remodel as the teeth are orthodontically moved into the proper position.
After orthodontic treatment, teeth need to be retained in their corrected position in order to prevent relapse. Depending on the case, retention may last for several months, a year, a few years or lifetime. It may either be made of wires and acrylic such as the Hawley and circumferential retainers, Clear invisible retainers, or fixed bonded/banded lingual retainers.
TYPES OF APPLIANCES
Intraoral (may be fixed or removable-The advantage of fixed appliance is it eliminates the need for patient compliance.)
: functional appliances
: bite plates
: active retainers
: space maintainers
: myofunctional appliances
: Invisalign or similar clear plastic appliances
: fixed appliances: brackets and bands
- Clear (Ceramic or Plastic)
* Brackets come in .022 or .018 slots depending on the orthodontist’s preference.
: Mini screws or temporary anchorage devices may be utilized in cases where additional anchorage is necessary.
Extraoral auxillary appliances:
: Protraction Facemask
: Chin Cup
Orthodontic patients must visit their dentist at least every three months. Oral prophylaxis and caries control are the responsibility of the patient’s general dentist. Restorative dental treatments and prophylaxis are not the responsibility of the orthodontic specialist.
For those with other concomitant problems, regular consultations with other dental specialists such as periodontists, endodontists, surgeons, and prosthodontists are necessary. Orthodontic practitioners who are treating patients with medical conditions must be in close communication with the patient’s attending physician.
Patients must always be informed of risks and certain unforeseen events which may occur during the course of orthodontic treatment.
Some risks and limitations of orthodontic treatment:
- Pain or discomfort
- Tooth sensitivity
- Chipping of teeth or dislodging of restorations
- Facial Change (soft tissue Adaptation to tooth movement)
- Root resorption due to tooth movement, hormone disorders, genetic predisposing factors, previous trauma, impaction or idiopathic reasons
- Bone loss due to tooth movement, genetic predisposition, poor oral hygiene, certain medical conditions or other idiopathic factors
- Tooth mobility
- Gingival recession or attachment loss
- Temporomandibular joint (TMJ) symptoms
- Loss of tooth vitality may or may not be related to tooth movement
- Excessive/Inadequate jaw growth which may lead to orthognathic surgery
- Caries or decalcification (whitish spots/areas on teeth) usually due to poor oral hygiene
- Injuries from brackets, headgears, elastics etc.
- Post retention tooth movement/ relapse/ space reopening
- Unexpected growth in any or both jaws
Any of these may complicate treatment or may necessitate an early termination of orthodontic treatment to prevent any unwarranted conditions. This may lead to a less than ideal result. When any of these risks are noted during treatment, the orthodontist should notify the patients and their guardians ASAP regarding the specific situation.
Patients must be instructed on how to handle simple emergencies such as cold sores, poking wires or loose brackets. Supplements such as wax must be provided when needed. Pain relievers such as paracetamol or NSAIDS (i.e. Mefenamic Acid, Ibuprofen or Naproxen Na) may also be prescribed as necessary. It is normal for the patient to experience some discomfort for 2-3 days after every adjustment.
WHO CAN PERFORM ORTHODONTIC TREATMENT?
Here in the Philippines any dentist can do orthodontics but ethically speaking they should not declare themselves an orthodontist unless they possess the credentials, clinical experience and certification. An orthodontist is a licensed dentist who underwent advanced training to specialize in diagnosing, preventing, and correcting malformations of the teeth and jaws. He is a specialist with a practice, limited to ORTHODONTICS (does not perform general dentistry). A specialist is preferred because he/she is better experienced clinically to handle various cases and treat problems related to the occlusion and alignment of teeth.
Ideally, orthodontic training is obtained at an accredited University involving a 3 year graduate residency program (after obtaining a 6 year dental degree). The postgraduate certificate and/or degree may be received from an American Association of Orthodontists’ or World Federation of Orthodontists’ accredited university in various parts of the world.
In the past, formal postgraduate orthodontic education was only available abroad thus in it’s absence, preceptorships sufficed in the “Philippine setting” but a paradigm shift has changed as the public and practitioner, sought conformity to “global standards” This impetus for change can be attributed to a convergence from both local and external forces. These include the legislative passage locally of the Philippine Dental Act of 2007, the 2008 PRC Dental Code of Ethics and PRC Resolutions 14,16, 17 Series 2008. Most significantly it is the availability locally of university-based graduate orthodontic programs
and internationally, the 2010 ASEAN Mutual Recognition Arrangement on Dental Practitioners and most importantly, the adoption of the 2009 World Federation of Orthodontist's (WFO) Guidelines on Postgraduate Orthodontic Training by the Philippine Board of Orthodontics.
As of this date, only the following local dental universities offering graduate programs in orthodontics have been recognized by the Commission on Higher Education (CHED):
- University of the Philippines
- University of the East
- Manila Central University
- Centro Escolar University
*The Philippine Board of Orthodontics (PBO) is a specialty board that accredits the qualifications of dentists who practice orthodontics. A person who passes the Philippine Board of Orthodontics Examinations is conferred a Diplomate status by the PBO. Undergoing this accreditation process is encouraged. Its main objective is to protect the public and the profession.
*Only graduates of certified university based orthodontic programs here and abroad and Diplomates of the PBO shall be allowed to use the title “Orthodontist”.