As both restorative dentists and specialists have their respective realms of expertise, it is important to develop a team of qualified providers to improve treatment outcomes for patients. In many cases, this involves collaboration between a restorative dentist and orthodontist. Effective communication is critical, with the dentist’s understanding of basic orthodontic terminology and case planning considerations. Recognizing the context in which to apply normative occlusal and cephalometric values often necessitates comprehensive specialty-level experience. All providers should recognize when to involve the indicated team members when complex multidisciplinary treatment needs are present. The team approach offers an opportunity to optimize excellent patient care.
Key points
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Excellent communication between provider and patient, as well as between providers, is critical for case success.
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The restorative dentist’s understanding of basic orthodontic terminology and general orthodontic case considerations is useful in optimizing communication.
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Although esthetics are an important component, the functional and biologic limitations of the hard and soft tissues need to be carefully respected.
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Though orthodontists use cephalometrics and normative data, these are just some of the considerations when developing their treatment plans and goals.
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Early and consistent involvement of both restorative dentists and specialists can help provide patients with more complete and informed decision-making abilities, and can improve outcomes.
Introduction: nature of the problem
Multidisciplinary cases can be some of our most challenging yet rewarding experiences as providers. Restorative and orthodontic collaborations are frequently encountered when discussing multidisciplinary care. It is not uncommon for restorative cases to benefit from some degree of orthodontic care to support an esthetic and functional result. Likewise, orthodontic cases often are esthetically improved by involving the restorative dentist in optimizing tooth morphology.
Communication is of paramount importance to a successful treatment outcome. Understanding the goals of our patients assists in managing and meeting their expectations. In multidisciplinary cases, excellent communication not only between provider and patient is expected, but seamless collaboration between the involved practitioners is a requirement in achieving an outcome of the highest standard. Similarly, patients should not only be fully participatory in treatment discussions, but they should be provided consultation with indicated specialists when appropriate. Communication at all levels is at the core of these concepts.
Logistical challenges are not uncommon, but at the heart of interprovider communication is using standard terminology. In this article, an introduction to basic orthodontic terminology often used to describe certain components of occlusion, function, and esthetics is presented. In addition, global insight into some comprehensive orthodontic case planning considerations will be discussed to indicate that it is more than just simple tooth positioning; rather, specialty knowledge is imperative in recognizing limitations of jaw relationships, as well as anticipated effects on the hard and soft tissues. The scope of this article is limited in nature to give the restorative dentist an introduction to several factors included in case assessment from an orthodontic perspective. It is intended to augment their awareness of orthodontic considerations, promote discussion among different specialties, and to encourage inclusion of multidisciplinary practitioners in case planning.
Assess the patient’s goals, and build your team
In the dental profession, we are gifted in that we have the ability to collaborate with both our patients and other colleagues in a concerted effort to achieve excellent results.
As illustrated in Box 1 , first and foremost, it is important to ascertain the specific goals of the patient to determine what is and what is not in the realm of possibility with restorative and/or orthodontic treatment alone. Second, as the professional, it is our duty to determine if these esthetic goals are still supportive of overall function and health. Third, both specialists and restorative dentists must recognize when certain aspects of care are outside their realm of expertise, and must refer and consult accordingly. These concepts are in support of the American Dental Association’s Code of Ethics and Professional Conduct, which highlights the importance of enabling patients to make fully informed treatment decisions, as well as providers recognizing the potential limitations in their own expertise.
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What are the patient’s expectations and goals?
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Is this goal achievable with restorative and/or orthodontic treatment alone?
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Can this esthetic goal be met while still providing an outcome that is functionally and periodontally sound?
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Do I have the knowledge base to make these multidisciplinary decisions? With which specialists do I need to confer?
Of note, a patient’s concern may not be able to be addressed by orthodontics or restorative means alone. An example of this might be a patient’s discontent with a gummy smile, and the diagnosis may be vertical maxillary excess of a skeletal nature. Similarly, a patient may want to address a large overjet, but it is determined that the skeletal discrepancy between the jaws is beyond simple tooth repositioning or restorative care. In these examples and others, certain presentations may benefit from surgical assistance to avoid jeopardizing oral health and function. Therefore, a third provider should be consulted, which is in many cases an oral and maxillofacial surgeon, to fully diagnose and triage certain cases as well. Although the emphasis in this article is on orthodontic and restorative communications, it should be noted that certain cases often require involvement of additional specialist providers to support case success as well.
In summary, it is recommended to involve the indicated specialists in the discussion and decision-making as early in the assessment process as possible. When referring to a specialist or any outside provider, creating a supportive document to indicate your findings and goals for the referral would also prove helpful. This team perspective of involving multiple qualified providers can work to provide the best comprehensive plan for our patients, and allow them to make more fully informed decisions.
General orthodontic terminology: the basics of communication
Initial orthodontic assessment of facial morphology and proportion is performed in 3 dimensions (anterior-posterior, transverse, and vertical) at rest and various active states, such as when smiling and speaking. Supplemental angles and views of the face also can be helpful. This evaluation is executed with clinical observation of the patient, as well as review of records in the form of photographs, radiographs, and study models. In the facial assessment, the entirety of the face is considered when developing an orthodontic treatment plan, but for the limited nature of this article, the focus is on the lower third.
The main ingredient to proper communication is standardizing terminology. No matter what terminology a dental team uses, it is critical to ensure it is consistent and there is full understanding of the definitions. Although not intended to be a comprehensive list of factors or considerations in orthodontic functional and esthetic assessment, this summary of basic terms ( Table 1 ) may often be discussed when reviewing cases and should serve as an introduction to orthodontic terminology.
| Term | Definition | Related General Esthetic Considerations |
|---|---|---|
| Overjet ( Fig. 1 ) |
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The ideal is commonly +2 mm. Reverse overjet (in anterior crossbite) as well as significant excess overjet have been reported to be considered less esthetic. , |
| Overbite ( Fig. 2 ) |
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The ideal is generally +2 mm. A deeper bite is more esthetically pleasing than an open bite, however. , |
| Smile arc ( Fig. 3 ) |
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The maxillary incisal edges should follow the contour of the lower lip when smiling. Consonant smile arcs are generally more preferred. , |
| Dental midlines ( Fig. 4 ) | Midlines are generally taken between the maxillary and mandibular central incisors, and measured relative to one another as well as the facial midline. | Despite some variation in the literature, generally slight midline deviation (approximately 2–3 mm) may be considered acceptable, depending on the observer; however, angulated dental midlines (reportedly 10°, or 2 mm as measured from papilla to incisal embrasure ) tend to be more noticeable and less desirable, as discussed in a systematic review. |
| Buccal corridors ( Fig. 5 ) | Space observed between the buccal surfaces of the maxillary posterior teeth and the inside of the cheeks when smiling. This may impact the appearance or perception of a full or narrow smile. | Based on review of studies assessing natural smile images rather than digitally induced buccal corridors, the presence of buccal corridors does not necessarily detract from smile esthetics. The literature is inconsistent with regard to acceptable buccal corridor dimensions. |
| Occlusal canting | Asymmetric tilting of the occlusion, when viewed from the frontal perspective. | Generally, the line following the incisal edges of the anterior teeth should be parallel to the interpupillary line (assuming level orbits), and therefore no occlusal canting. , An occlusal cant has been reported to be observed when exceeding 2.8°, or when the incisal plane is rotated 1–3 mm. |
| Gingival display ( Fig. 6 , in green) | Vertical assessment of maxillary gingiva observed when smiling. | This varies depending on age and sex, with younger female individuals tending to have more gingival reveal than older male individuals. With regard to esthetic preference, the literature is variable on indicating the threshold for acceptability. |
| Incisal display (see Fig. 6 , in red) | Vertical assessment of maxillary incisor show while at rest and when smiling. | This varies depending on age and sex, with younger female individuals tending to have more incisal display than older male individuals. , Like gingival display, the esthetic parameters and etiology of incisal display are multifactorial. |
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