Indications and Contraindications for Treatment
Practitioners of the healing arts, who observe an abnormal situation, have a tendency to react by treating it. Many diseases are associated with pain or discomfort, or endanger life and health, and in such circumstances direct intervention is indicated.
Orthodontic patients rarely have such interference with chewing or speaking so immediate assistance is not essential. Consequently, there is ample opportunity to give the fullest consideration to the pro’s and con’s orthodontic treatment for any particular patient. The patient and his parents play an important part in the decision, so a good discussion is therefore imperative. Because orthodontic treatment is demanding, it is essential that the patient and his immediate circle know just what is involved. Only then an informed decision can be made as to whether or not to proceed with treatment. If a decision is taken from such a basis, patient cooperation will be considerably enhanced. Without such full cooperation, it is unlikely that the best result will be obtained in orthodontic therapy. In this context the family dentist has to play an important part, despite the fact that he may be unable to deal with the treatment him, and so has to refer the patient to the orthodontist for advice and eventual treatment.
The many factors that influences. the decision to treat, or not to treat, orthodontically can be divided into indications and contraindications, both of which are affected by psychosocial, dental and functional influences. The decision should be based on a careful weighing of the indications and contraindications involved.
In this chapter, the average orthodontic patient is discussed, rather than the patient with an extreme abnormality such as a cleft, where there is no question that orthodontic treatment would be needed. Even such cases, however, do not usually require immediate intervention.
Regular teeth and a harmonious facial appearance contribute, to a large degree, to the appeal and beauty of a face. An attractive exterior makes life easier and offers greater possibilities for a balanced psychological development. It fosters contact with other people and promotes a feeling of being accepted.3 233
For instance, in a study of schoolchildren, it was found that teachers adopt a more positive attitude towards attractive schoolchildren than to their less attractive peers.75 They also expect better results from the former. Children judge their peers who deviate from the norm (also orthodontically) less favorably; they are also often called names;342 adults do not behave much differently.
The self-respect that builds up over the years is determined by many things, but appearance is basic. However, this does not imply that persons with more attractive faces are proportionately more emotionally stable and intellectually balanced.344
In general it can be said that an improvement in appearance can contribute to an increase in self-confidence and a feeling of well-being.140 In fact, patients receiving orthodontic treatment often mention this.
In the appreciation of beauty, great differences exist between the diverse parts of the world. In a number of western countries, in particular North America, external appearance is extremely important. Physical attractiveness determines not only the initial impression, but to a great extent the contacts that are established, and the chances of being accepted in a group, of obtaining a job, of finding friends, etc. In the Western World, orthodontic treatment may in fact improve one’s chances in life.30
The classic saying “Beauty is in the eyes of the beholder” indicates that ideas of beauty are relative; an anomaly that does not disturb one person can be an impossible burden to another. Moreover, changing norms (fashions) have their part to play.
Principally, in America, the film and television industry has influenced concepts of what is desirable; racial differences (double proposition/eversion in negroes) play a part here. Film stars287 and beauty queens309 provide models for the norms what is desirable; racial differences (double proposition/eversion in negroes) value on a straight profile, in which the teeth and lips lose their prominence in the face. Assessing unselected groups of young men and women resulted in values exhibiting a wider range of “good profiles”.76
In our culture, regular maxillary incisors with, less importantly, regular mandibular incisors are found attractive. Diastemata, particularly between maxillary central incisors, are found undesirable. Minor aberrations in alignment of the incisors can influence the total impression of beauty in a face.342
Parents appear to accept the disposition of their children’s teeth as normal, more readily than do dentists and orthodontists.300 Also, where the profile is concerned, a difference in appraisal probably exists between the patient and his social circle on the one hand, and dentists and orthodontists on the other. Lay people are less ready to declare a profile abnormal.298 During the consultation the dentist should always guard against overemphasizing his own views as to whether or not treatment is required. Instead, it is wisest to explore carefully the patient’s and parent’s own views.
The society in which one circulates determines to a large extent the call for orthodontic treatment. The level of prosperity, the value placed on appearances and the availability of professional services influence the situation. Most enquiries regarding orthodontic treatment are made because the arrangement of the front teeth is considered ugly.
One should also realize that some people, mostly young adults, project onto their teeth other nondental problems. A comparatively minor abnormality can be a source of many difficulties, while in reality there are other much more serious problems quite unrelated to the teeth. Should orthodontic treatment have been undertaken, the result will not be satisfactory even if the dentist finds it so, because the original problem has not been solved.
Adults occasionally seek treatment because periodontal deterioration leads to changes in tooth positions, particularly diastemata and labial tipping with elongation of the maxillary incisors. This is usually seen by the patient to be of social and psychological importance, rather than dental. This is particularly so when the changes are seen as an indication of old age and degeneration.
Older people often exhibit so little of their teeth, that irregularities are not obvious. However, this is not quite true of the mandibular incisors, which show more in speaking and laughing than in younger people, who tend rather to show their maxillary incisors. The reason most adults do not ask more often for correction of irregular mandibular incisors is partly because of a change in values that comes with maturity. It is therefore apparent that psychosocial indications must be considered in relation to the age of the patient. Young children are likely to be unaware of their teeth, which is when more credence is given to the opinions of the parents. With adolescents and adults, the position is usually different; they usually have a clear, personal view of their teeth.
The above remarks offer guidance, but in every case it should be borne in mind that one is dealing with the problems of an individual and every effort should be made to see those problems from his point of view. No-one must conform to a set of norms; it is often irrational to comply with conventions either as an orthodontist, or as a human being, or prospective patient.
Orthodontic treatment is seldom undertaken in order to avoid problems with caries or periodontal disease. Impacted teeth and prevention of trauma, or loss of incisors, can be indications for treatment. In association with restorative dentistry, the uprighting or translation of teeth may be indicated. Orthodontic treatment before and after surgery is a separate subject.
It would be incorrect to state that more caries will be present if teeth are not ideally aligned in the dental arch.193 It is true that there will be a higher accumulation of plaque.149 It is undisputed that irregular teeth are more difficult to clean than well aligned ones, but they can be well cleaned with extra effort. Studies of dental students have documented this.185 A favorable circumstance is also the fact that the most irregular teeth are usually the mandibular incisors, and these are also usually the teeth least susceptible to caries. While it can be said that poor cleansing of irregular teeth leads to heavy plaque and consequent risk of caries, this is not an indication for orthodontic treatment but rather for improving the poor hygiene.
A good caries experience (minimal caries predisposition) is a favorable factor in orthodontic treatment. The use of appliances increases the chance of decalcification and caries principally because of the increased difficulty in cleaning the teeth added to the inherent tendency for the appliances to cause an increase in retention of plaque on the teeth. A “strong” dentition suffers less from these conditions than one already heavily restored and/or decalcified. It goes without saying that a major factor in good caries experience is a favorable oral environment, i.e., good eating habits, ample nonviscous saliva, fluoride-protected enamel and alert dental-awareness. A person with a well-cared-for mouth is usually mentally superior and this also is a favorable indication for undertaking treatment.
Studies instituted to detect a relationship between orthodontic anomalies and periodontal disease have delivered little in the way of definite results. This is probably due to most such studies being conducted on dental students with normally good oral hygiene. It is concluded that irregular teeth are not related to periodontal problems if oral hygiene is either very good or very bad.4 However, if ordinary students at school and adults are investigated, a relationship between tooth alignment and gingivitis does appear to exist in the lay population.6 335
With average oral hygiene, abnormal alignment of the teeth can probably be a factor to encourage periodontal breakdown.4 27 297 This applies mainly to very large overjets, deep bites with gingival trauma, and reversed overjets.134 340
It may also be said that to align irregular teeth is not a means in itself of averting periodontal disease, but avoiding periodontal disease is best realized by achieving a high level of oral hygiene, with professional support if possible.
Third molars are the most commonly impacted teeth. The treatment is not orthodontic, but surgical.
Mandibular second premolars can be impacted after premature loss of the predecessor. Orthodontic treatment may then be required.
An impacted maxillary permanent canine occurs in about one in a hundred people.78 The canine can stay put a lifetime without trouble, but should however be kept under observation since follicular cysts can develop. These impacted canines can also cause root resorption of adjacent teeth if they continue to erupt along their anomalous path. In general, it is advisable to move impacted canines into the arch between the ages of 12 and 15 years, after exposing them and attaching traction if necessary.
Permanent maxillary central incisors can be displaced by trauma to their predecessors and become impacted. It is also possible and usually indicated to move these teeth to their correct position after exposing them, unless ankylosis has developed.
In accidents involving the head, maxillary incisors are often injured. The chance of this happening increases (by over 25%) depending on the degree to which the maxillary incisors are everted and are less covered by the lips.190 221 278 Consequently, it is often better to begin orthodontic treatment sooner than normally would be desirable, especially if there is a considerable risk of trauma to the maxillary incisors. This is more likely to be the case with boys than with girls; more with wild, restless children than with quiet ones. Generally, however, an early beginning leads to an extra long treatment time, which eventually makes great demands on continuing cooperation.
The loss of one or more front teeth at an early age—mostly the result of an injury—can later be an indication for orthodontic treatment. Often it is preferable to close the existing space orthodontically, rather than use a prosthesis.
If a tooth is lost when the development of the dentition is almost complete, a bonded bridge can be a good solution particularly when orthodontic treatment is not indicated for any other anomaly.
Prosthetic treatment can sometimes be more satisfactory if involved teeth are uprighted and/or translated. By this means it is possible to achieve a technically or aesthetically better solution to the prosthetic problem. Some examples of such indications for orthodontic treatment are given.
After extraction of a mandibular first permanent molar, the second molar will tilt mesially. If later a bridge has to be provided there, it can be desirable to first upright the second molar.
Agenesis of maxillary lateral incisors is often associated with a central diastema and mesial migration of the maxillary canines. Usually it is desirable in such a case to perform the necessary tooth movements (close the central diastema and move the canines distally) first and then provide a suitable prosthesis.
It can sometimes be advantageous to perform minor tooth movements prior to restoring defective teeth, so as to facilitate the preparation of crowns or other restorations and secure correct location and form of contact points.
An abnormality can be so great that no acceptable result could be achieved without surgery. This particularly applies to adults because with them facial orthopedics has no longer an effect. In such treatment it is essential to perform pre and/or postsurgical tooth movements in order to achieve a better operative result and to subsequently secure a good occlusion. Sometimes it will also be necessary to complement the treatment with prostheses.
With children having an extreme skeletal anomaly (Class III), it is wise not to attempt an orthodontic solution but rather to aim for surgical correction, although this will usually require postponement of treatment until facial growth has been completed. However, even in these cases, there may be indications for minor orthodontic intervention if it can be seen that by doing so local conditions can be improved during the waiting period.
The consideration of indications related to function is limited to respiration, speech, abnormal habits, occlusal disturbances and forced bites, and the mandibular dysfunction syndrome.
Mouth breathing causes alternate wetting and drying of the mucosa on the anterior aspect of the maxillary alveolar process, which leads to a mild gingivitis.106 Also, for general health reasons, nose breathing is to be preferred to mouth breathing.
An orthodontic anomaly associated with incomplete lip closure, and which predisposes to mouth breathing, should as a consequence be considered for possible treatment. This is not to say, however, that correction of the anomaly will always result in a changeover to nose breathing.
Despite the fact that it is often assumed that the position of the teeth influences the quality of speech, there is no proof of this.353 Moreover, diverse abnormalities of speech are of a transient nature. Many people with orthodontic anomalies have quite normal speech. Adaptation and compensation make it possible to overcome the handicap of the anomaly insofar as it affects speaking.141 Sometimes though this is not enough and in such an exceptional case orthodontic treatment can make an improvement in speech possible. There are also many people with a good occlusion, but whose speech leaves something to be desired.
Digit sucking over a long period should preferably be attempted to be stopped by means other than fitting orthodontic appliances. However, if for other reasons orthodontic treatment is indicated and an appliance is inserted, the sucking habit is nearly always halted. In exceptional cases, a simple plate or directly bonded sharp projections on the palatal side of />