Before determining a problem list or objectives, it is important for dental practitioners to recognize what ideal soft tissue, skeletal, and occlusal features are. Soft tissue profiles are ideally Class I with a 90° or slightly obtuse nasolabial angle. The upper and lower lip should have adequate support and lip curl. From the frontal perspective the face should be symmetric. When smiling, the upper and lower midlines should be on with the facial midline. Ideal tooth show is full maxillary incisor plus 1–2 mm of gingival show as previously discussed. Esthetically gingival margin heights should be at the proper heights in relationship to one another and symmetrical. The shape of the smile from canine to canine based on the incisal edges should follow the shape lower lip. In the vertical dimension, the facial thirds should be about equal. Skeletal ideals are based off of the lateral cephalometric radiograph. The ideal skeletal evaluation would reveal a Class I relationship of the maxilla and mandible in good anteroposterior relationship to the rest of the face. SNA, SNB, and ANB are used to determine this and are described above.

“Ideal” occlusion has been described by a number of authors. Angle was responsible for developing the first classification system for molar relationships as Class I, II, or III as described above. Andrews developed six occlusal features consistent in a series of “ideal” occlusions which has since been used to develop what is considered the norm for objectives (Andrews 1972). The first is molar relationship, similar to the Angle’s classification; Class I molar relationship is ideal. Other features of the ideal occlusion are proper mesiodistal and buccolingual tip of the crowns of the teeth, no rotations, no spacing, and a flat curve of Spee. The mesiodistal tip of teeth can be evaluated on a panoramic radiograph. The buccolingual tip, also known as torque, of the incisors is evaluated on a lateral cephalometric radiograph, while the torque of molars is evaluated on study models. Other ideal aspects of occlusion are 1–2 mm of overjet, 20 % overbite, lack of crossbites, no crowding, and Class I canine. Ideal functional aspects of occlusion are incisor guidance in protrusion and canine guidance in excursive movements. Some patients may require group function for guidance when the canines are worn down significantly. Contacts on all of the teeth should be even in maximum intercuspation, and no slide from CR to MI should exist.

Based on the known ideal features and the information collected during the exam, a problem list is developed. This list can then be used in determining objectives, assessing the difficulty of a case, or in communicating information in a referral to an orthodontic specialist. The most important problem that should be included in the list is the patient’s chief complaint. Inability to address this in orthodontic treatment would result in an overall failure of treatment.

Ackerman and Proffit developed a system of categorizing problems into five main groups (Ackerman et al. 2007). The first is the dentofacial appearance, which includes symmetry, facial proportions, incisor display, lip support, and soft tissue profile. The second category includes the teeth and arch form including alignment, symmetry of the jaws, and spacing or crowding. The next three categories include the skeletal and dental problems in the transverse, anteroposterior (sagittal), and vertical planes of space. In the transverse problems include posterior crossbites, torque of the posterior dentition, and asymmetries of the maxilla and/ or mandible. In the sagittal plane, classification of the molar, canine, and skeleton are noted, as well as anterior crossbites and overjet. A slide or shift forward from CR to MI would also constitute a problem in the sagittal plane. Lastly, the dental deviations in the vertical category would include overbite which would result in a deep or open bite. Skeletally, vertical problems would include vertical maxillary excess or a steep or flat mandibular plane. Some traits in malocclusions may not be easily categorized. For example, open bites can have both skeletal and dental etiologies. Cases such as this and other skeletal issues are more complex and should be referred to the orthodontist for comprehensive orthodontic treatment. Some problems do not meet the qualifications for any of these categories. Such examples are periodontal health and maxillary frenum attachments.

When treating orthodontic cases, the Ackerman-Proffit analysis can be used to develop soft tissue, skeletal, and dental objectives. Objectives are then used to determine optimal treatment options for the patient. Every patient presents with a unique set of problems and diagnoses and therefore a unique treatment plan should be developed for every patient to properly treat them.

The five categories of the Ackerman-Proffit analysis are also useful in referring a patient to orthodontics. A list of concerns that the general dentist has in regard to the patient can be listed simply as:

Use of this concise method helps streamline the referral process and alerts the orthodontist to the potential complexity of a case.

Malocclusions in younger patients can lead to functional issues, psychological problems, or dental disease, including increased susceptibility to caries, periodontal disease, and traumatic injury (Proffit et al. 2013). While many of these patients may benefit from orthodontic treatment, it is not an immediate need for all. Orthodontic treatment typically begins between the ages of 9 and 14, but some malocclusions can benefit from earlier treatment. The American Dental Association recommends that children visit the dentist by age one. In addition to maintaining regular dental care and oral hygiene, it is the responsibility of the general or pediatric dentist to monitor the child’s dental and craniofacial development during these critical years. If any abnormalities in the development of the dentition or craniofacial complex are noted, parents should be informed and a referral to an orthodontist should be made.

Distinguishing the complexity of orthodontic problems is a crucial skill for the dentist to attain (Proffit et al. 2013). Intervention at the appropriate time allows the practitioner the opportunity to guide jaw growth, lower the risk of trauma to protruded teeth, correct harmful oral habits, improve appearance and self-esteem, guide permanent teeth into a more favorable position, improve the way lips meet, and maintain or develop space for erupting teeth. The decision to treat a patient or refer to a specialist depends on the experience of the general dentist and the severity of the malocclusion. Unless earlier treatment is indicated, the American Association of Orthodontists recommends that a child has a complete orthodontic evaluation and/or referral no later than age 7 to determine treatment needs and timing (Suresh et al. 2015). Prior to this time, close monitoring of radiographs, eruption sequence, space analysis, and jaw relation should be integrated by the general or pediatric dentist from much earlier in life.

It is known that skeletal patterns and malocclusions are established in early childhood. Early treatment may consist of intraoral and extraoral appliances to exert the greatest control over dentoskeletal form and function. Proper orthodontic evaluations and treatment of children can prevent the development of more serious problems and may result in shorter or less complicated treatment at a later age. While the literature provides some conflicting evidence, there are some indications that some correctable dental discrepancies left untreated can turn into permanent skeletal discrepancies and even worsen. The rationale for early orthodontic treatment is to eliminate skeletal or dental disharmonies and enhance occlusal development to promote normal growth and development, improve function, and avoid psychosocial distress during the formative years (Bahreman 2013).

It is of utmost importance for primary care dentists to be able to distinguish problems that need to be treated soon and those that can wait for later comprehensive orthodontic care. Indications for early orthodontic referral and treatment can be broadly categorized into the following ten signs seen in a child’s or young adolescent’s dentition:

These characteristics should be kept in mind while evaluating children at each regular visit. If identified involving permanent teeth, appropriate measures to prevent, maintain, or correct should be attempted without delay.