Traditionally, orthodontic treatment relied on frequent in-person visits for evaluations, adjustments and consultations. However, with the advent of tele-orthodontics, orthodontists and patients can now connect remotely, revolutionising accessibility and convenience in orthodontic care.

Tele-orthodontics uses information technology and telecommunications to enable remote orthodontic consultations, allowing for effective communication among practitioners, patients and clients. This approach offers numerous benefits to clinical orthodontics, including initial patient screenings, reducing in-office visits and optimising schedules for clinicians and patients.

A major advancement in this field is the utilisation of medical applications on tablets and smartphones, which have been positively received for enhancing patient education and healthcare services. In recent decades, the exchange of health-related information through digital technology has increased significantly. The COVID-19 pandemic has further accelerated the adoption of teledentistry by facilitating healthcare consultations while maintaining social distancing. Towards the end of the pandemic, many practitioners realised that remote monitoring and consultations could be used to enhance office efficiency and offer greater convenience to patients by reducing office visits without compromising care or outcomes.

Tele-orthodontics provides valuable guidance on care, educates practitioners and patients, and raises public awareness about orthodontics. Research on the perspectives of orthodontists and general dentists has shown broad support for teledentistry, recognising its potential to make orthodontic consultations readily accessible. ^,

Teledentistry facilitates the sharing of patient information with healthcare providers and relevant organisations through digital platforms, using resources such as radiographic and photographic records for consultations and healthcare management.

Additionally, teledentistry improves collaboration among specialists, which is essential in multidisciplinary cases, and provides patients with convenient access to specialists for initial consultations, follow-ups and treatment monitoring.

Through tele-orthodontics, clinicians can prioritise cases, reducing the need for in-office visits—a benefit that lowers costs for patients, particularly those in remote or rural areas, and enhances efficiency for orthodontic providers by optimising office accessibility. ^,

Furthermore, tele-orthodontics eliminates geographical barriers, allowing patients in remote or underserved areas to access orthodontic care. Patients who may have difficulty travelling to a traditional orthodontic office can now receive the care they need from the comfort of their own homes.

Advances in telecommunication and digital technology are set to transform orthodontics by optimising treatment management, enabling remote patient assessments and reducing the need for in-office visits without compromising treatment effectiveness, thus enhancing the cost-benefit ratio. ^, This shift towards fewer chairside appointments benefits both patients, particularly adults and clinicians.

Scepticism persists among orthodontists, who raise questions such as, ‘How could I treat patients without seeing them in person?’ or ‘Will remote systems compromise the patient–orthodontist interactions?’ Additionally, there are concerns that the popularity of tele-orthodontics might lead patients to undervalue the clinician’s role, potentially fostering a ‘do-it-yourself’ (DIY) or direct-to-consumer (DTC) approach to orthodontics.

It is pertinent to highlight that tele-orthodontics is not a substitute but an additional tool for effective communication and the reduction of in-office visits. This chapter delves into the strengths, applications and limitations of this emerging communication system and its transformative potential for the future of orthodontic practice ( Fig. 97.1 ).

Scope of tele-orthodontics.

In orthodontics, the diagnostic process traditionally involves clinical evaluation supplemented with thorough analysis of the diagnostic records. An orthodontist can carefully examine diagnostic records from a remote location for a definitive diagnosis and develop an effective treatment plan for malocclusions while addressing the patient’s concerns. Accessing remote records has gained new importance as a fundamental aspect of tele-orthodontics with the rise of online consultations in recent years.

• While remote analysis offers convenience, in-person clinical inspections are irreplaceable. They allow for the assessment of specific characteristics that cannot be fully captured on a screen, such as a patient’s behaviour, level of cooperation, willingness to undergo treatment and psychological profile. Therefore, caution is advised when giving definitive consultations or treatment plans without conducting an in-person examination. From this perspective, clinical examination and remote patient evaluation work together as complementary steps in the diagnostic process. Additionally, information from digital communication systems can effectively aid in preliminary patient screening and help identify candidates for future orthodontic treatment.

• To enhance patient service, clinicians and healthcare managers could improve their brand’s online presence by implementing a screening panel for patient assessments. Recent advances in three-dimensional (3D) imaging have streamlined communication within orthodontic teams. Clinicians can now utilise patients’ digital diagnostic records—such as digital models, scans, photographs and radiographs, to facilitate collaborative analysis with colleagues and lab technicians. This is especially beneficial for multidisciplinary cases ( Fig. 97.2 ).

  

  Virtual patient screening prior to first consultation workflow.

  Source: Katyal V, Vaid N. Virtual-First: a virtual workflow for new patient consultation, engagement and education in orthodontics. Semin Orthod. 2023;29(1):109–15. https://doi.org/10.1053/j.sodo.2023.02.001 .

Remote monitoring and compliance assessment ( Fig. 97.3 )

Approximately 15% of scheduled appointments during treatment with fixed appliances are emergency visits. Early detection of oral health and orthodontic issues through tele-orthodontics includes monitoring oral hygiene, misaligned aligners, broken appliances, or low compliance. Additionally, remote monitoring fosters greater patient engagement by enabling frequent communication between orthodontists and patients. Patients feel more involved in their treatment process, leading to increased satisfaction and possibly better overall treatment outcomes. However, remote monitoring has limitations for treatments involving fixed appliances, as regular in-office visits are necessary for appliance adjustments.

Aligner unseat detected using the Dental Monitoring App.

Source: Hansa I, Katyal V, Semaan SJ, Coyne R, Vaid NR. Artificial intelligence driven remote monitoring of orthodontic patients: clinical applicability and rationale. Semin Orthod. 2021;27(2):138–156.

Conversely, treatments using pre-programmed orthodontic appliances, where clinicians mainly monitor progress, could greatly benefit from tele-orthodontics. Tele-orthodontics can reduce unnecessary visits while preserving essential appointments for critical treatment actions like interproximal reduction, attachment placement or extractions. ^{, ,} This model appeals to adults seeking discreet and efficient treatment options and simplifies the orthodontic workflow for clinicians.

Many patients today, particularly adults, are looking for orthodontic treatments requiring fewer in-office visits while enabling their orthodontists to monitor their progress. Routine check-ups, previously considered essential, are often viewed as inconvenient by patients who prefer limiting their visits to key treatment milestones. Considering these changes, an efficient clinical workflow incorporating tele-orthodontics, remote communication and monitoring technologies is essential. This system can support clinical progress evaluations and manage emergencies while reducing in-person visits. Recommending clear aligners over fixed appliances, when appropriate, aligns with this new approach. Aligners typically require fewer adjustments and can reduce issues such as mucosal injuries and the need for debonding visits.

• Implementing early screening during growth stages, along with interceptive and functional treatments for skeletal discrepancies or malocclusions, would simplify later orthodontic treatment in permanent dentition and reduce the number of long-term appointments required. ^, Overall, this ergonomic approach requires a shift in mindset, encouraging clinicians to adopt digital workflow solutions and utilise clear removable appliances. Moving beyond traditional methods entails adapting to new digital technologies and modifying established practices.

Technological advancements are transforming traditional braces and aligners into sensor-based treatments that enhance precision, comfort and efficiency. These innovative devices use sensors and AI algorithms to monitor tooth movement and adjust the applied force in real-time. This results in shorter treatment times and fewer in-office visits, optimising the overall results.

Sensors are practical tools for monitoring patient compliance, especially with removable functional appliances. In orthodontics, force-monitoring sensors (FMS) are crucial in tracking tooth movement during treatment.

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  Strain sensors are affixed to the tooth surface to detect changes in strain as the teeth shift position. These data allow for precise adjustments to the treatment plan, enhancing outcomes. ^,

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  Piezoelectric sensors measure the forces that teeth exert on brackets and other appliances. Renowned for their sensitivity, these sensors provide precise information on the magnitude and direction of the applied force, although they can be expensive and difficult to install. ^,

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  Strain gauges offer another option, measuring deformation in brackets or appliances under force. While more affordable than piezoelectric sensors, they, too, can be complex to place correctly. ^,

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  Optical sensors utilise light to accurately track the position of teeth or brackets. However, these sensors tend to be more expensive. ^,

Each type of sensor plays a unique role in enhancing treatment precision, but factors such as installation complexity and cost are important considerations. ^,

Patients frequently need emergency orthodontic visits for various issues, including dislodged brackets and tubes, loose or broken bands, weld failures, trauma from extraoral appliances and soft tissue injuries caused by arch wires or bracket hooks. Other common emergencies may involve retainer repairs, adjustments and problems with elastomeric chains.

• Among these, the most frequent reason for unexpected visits in fixed orthodontic treatment is to repair debonded brackets, which tend to detach more frequently from certain teeth. Beyond poorly fitting prostheses, orthodontic appliances are also significant contributors to iatrogenic injuries affecting both intraoral and extraoral tissues, often leading patients to seek immediate care. Bracket breakage and wire loosening are among the most common orthodontic emergencies. Managing these issues through tele-orthodontics involves guiding patients on simple temporary solutions. Although a complete repair may need an in-office visit, here are some general instructions that can be offered over the phone:

  Bracket Breakage:

  • Assessment: Instruct the patient to carefully examine the affected area. If the bracket is still attached but loose, advise avoiding excessive manipulation.

  • Avoid certain foods: Recommend refraining from hard and sticky foods to prevent further stress on the bracket.

  Wire Loosening:

  • Repositioning with tweezers: If the wire has shifted and caused discomfort, patients can gently use clean tweezers to guide it back into place.

  • Orthodontic wax: Suggest using orthodontic wax to cover any protruding or sharp edges of the wire to prevent irritation.

  • Soft foods: Advise consuming soft foods to minimise the risk of further wire displacement.

  Immediate Consultation:

  • Virtual consultation: If the issues persist or cause significant discomfort, recommend a virtual consultation with the orthodontic team. This can include sending clear photos of the affected area for evaluation.

  • Schedule an in-person visit: For more complex problems, emphasise the importance of scheduling an in-person visit to address the issue thoroughly.

It is essential to explain that these are temporary solutions and that professional care is required for a permanent fix. Additionally, the guidance provided may vary based on the specific circumstances and the patient’s treatment plan.

Tele-orthodontics has been used effectively to help screen patients for orthodontics in private and public health settings. ^{, ,} This benefit is apparent in the public health sector, as it reduces the burden on clinicians by reducing unsuitable referrals who are not eligible for treatment and reducing societal costs. However, there is always a risk that a patient suitable for treatment with a clinical examination could not been accepted via virtual consultation.

Like within the public health setting, an online assessment or screening can help understand new patients’ suitability for treatment, recommend treatment plans and aid the patients in meeting their expectations before a private in-office visit. DM Engage allows patients to submit pictures of their teeth wherever they are. The software uses AI to analyse the patient’s oral health and occlusion and gauge their interest and readiness for treatment before their appointment. A report is generated, which the clinician can review and edit before sharing with the patient. This allows the patient to access detailed information about their malocclusion and the available treatment options with minimal inconvenience.

Remote monitoring is most suitable for customised appliances with pre-programmed movements, where deviation from the planned course can be detected. Monitoring includes a few fixed appliance systems but is primarily used in clear aligner treatment (CAT). The proactive and frequent remote monitoring optimises in-office appointments based on the patient’s needs, avoiding arbitrary intervals. Increased monitoring and reminders encourage patients to maintain good oral hygiene, allowing clinicians to identify issues early and make adjustments sooner in CAT cases. Oral hygiene can be closely monitored using software that identifies issues such as dental caries, gingivitis, gum recession and tooth attrition. If any problems are detected, the patient can be scheduled for an in-office visit to provide motivation or referred to a general dentist for scaling, polishing, restorations and oral hygiene instructions. Wafaie et al. in a systematic review concluded that the integration of sensor-based monitoring systems within tele-orthodontics offers significant advantages for clinical practice and patient convenience.

• Monitoring CAT:

  • In terms of CAT, DM is able to detect aligner fractures, loss of attachments or buttons. The clinician can then decide on how to proceed, that is proceed with the aligners, or stay on the current one until an in-office visit is possible. Loss of tracking of the aligners can also be identified by DM, in which case the clinician again has the prerogative to decide whether the patient should continue as normal, or to perform a refinement set of aligners.

• Monitoring accelerated tooth movement with a corticotomy:

  • Hannequin et al. demonstrated another beneficial application of remote monitoring in a patient with a clear aligner therapy (CAT) undergoing accelerated tooth movement following a corticotomy. Traditionally, patients in this situation are reviewed every 2 weeks. However, the patient can be monitored remotely using customised appliances and planned tooth movements. As a result, in-office visits can be scheduled only when necessary.

• Monitoring fixed appliances:

  • DM can identify broken brackets or loss of ligatures timeously, thus preventing unwanted tooth movement. A passive arch wire can also be detected, thus allowing for customised appointment schedules based on when tooth movement is completed. It can also be used to monitor tooth eruption when awaiting sufficient eruption for bonding, thus preventing an assessment appointment. Similarly, monitoring of patients using rapid maxillary expanders has also been performed, giving a remote advice to patient when to cease expansion.