Orthodontics: Role and Rationale

Learning Objectives

• Dental hygienists should understand their role, challenges, and opportunities in orthodontic therapy due to the high number of patients undergoing such treatment.
• The American Association of Orthodontists (AAO) recommends orthodontic assessment by age seven.
• Assess posterior occlusion when the first molars erupt to evaluate anteroposterior and transverse relationships, functional shifts, or crossbites.
• Incisor eruption allows for detection of crowding, habits, deep bites, open bites, and jaw discrepancies.
• The AAO does not advocate comprehensive orthodontic treatment at age seven, but interceptive treatment may be appropriate.

Rationale for Orthodontic Treatment

• The AAO lists the following reasons for adult orthodontic treatments:
• Prevent/improve periodontal problems
• Reduce bone loss around teeth.
• Improve dentist's ability to restore missing teeth.
• Improves aesthetics for a better smile and facial appearance.
• Improves teeth function.
• Boost self-confidence and self-esteem.
• Improves oral health.

Periodontal and Orthodontic Connection

• Periodontal status is crucial for successful tooth movement, irrespective of age, especially in conjunction with controlled orthodontic forces.
• Bone regeneration in the direction of movement is achieved via light, consistent, controlled forces.
• Appropriate force maintenance negates necrosis and undermining resorption.
• The process produces osteoclasts, which impact the lamina dura.
• Lighter forces are less uncomfortable.
• The goal is tissue remodeling without destruction, hence the need for an orthodontist's supervision.

Identifying the Orthodontic Patient

• Orthodontic assessment entails dental hygiene diagnosis and occlusion evaluation.
• The "Orthodontic Six-Point Quick Check System" recommends checking the following:
• Arch width; an average measurement is 36 mm between molars.
• Spacing or crowding
• Missing or ankylosed teeth
• Upper and lower teeth relationships in occlusion
• Angle’s classification
• Overbite/overjet amount
• Openbite/crossbite appearance
• The frontal evaluation includes symmetry, size proportions of midline/lateral structures and vertical proportionality.
• The profile evaluation includes the jaw position, lip protrusion, vertical facial proportions and mandibular angle.
• A standard dental hygiene assessment of hard and periodontal tissues should complement orthodontic evaluations.
• Adults need a full periodontal assessment, and active infection is a contraindication for any orthodontic treatment form.
• For pre-orthodontics, radiographs plus full-mouth 6-point probing and clinical attachment assessments are critical.
• It is essential to evaluate plaque biofilm, bleeding, and inflammation.
• Any periodontal infection, like gingivitis, needs treatment before orthodontic therapy.

Orthodontic Therapy Options

• Fixed orthodontic appliances generally need 24–36 months of active therapy, moving teeth systematically, sometimes involving extraction.
• One-phase fixed orthodontic treatment generally starts after eruption of permanent teeth and may not address facial or profile concerns and often involves extraction therapy.
• It consists of brackets, elastics, bands, archwires, and ligation.
• Indirect bonding is gaining popularity.
• Primer and light-cure orthodontic adhesive is applied to the teeth and bracket bases.
• A tray is seated to give even pressure.
• Each bracket is cured from the most posterior tooth forward and the tray is carefully removed.
• Excess bonded adhesive (flash) is removed.
• The indirect bonding method is gaining popularity over direct bonding.
• A custom, clear tray is made from patient models, and a small amount of orthodontic adhesive is used to position braces.
• Clinically, it involves polishing teeth with pumice and water slurry.
• Molar bands come after the indirect method so there is no impingement on the seating of the tray.
• Ceramic brackets have esthetic advantages but varying strength compared to stainless steel.
• A risk of severe enamel wear to opposing dentition has been reported when ceramic brackets are placed in the mandibular arch because they are are second in hardness only to diamond.
• Enamel damage during debonding is more likely compared to metal.
• Avoid ceramic brackets on compromised teeth to reduce debonding damage.
• Lingual orthodontic brackets and archwires are customized and aid in reducing speech problems and tongue irritation because they are of the reduced thickness of brackets.
• Two-phase treatment provides early intervention for severe malocclusion, initiated during the mixed dentition phase with traditional fixed appliances.
• Rapid maxillary expansion, headgear, lip bumpers, and orthopedic appliances may all be used during the first phase to correct skeletal imbalances, neuromuscular problems, crowding or habits.
• The first phase lasts 6-14 months and growth is taken advantage of during this phase.
• It can also include traditional fixed appliances.
• Invisalign is an 'invisible' therapy option for those who would not use fixed appliances.
• Good candidates can include adults and teens with mild malocclusion, crowding, spacing issues or non-skeletal constricted arches, and those who have experienced relapse.
• Active periodontal infection is a contraindication for Invisalign.
• Restorative work and second molar eruption must be completed beforehand.
• This is not recommended for a complicated malocclusion, like severe deep bite.
• Contraindicated are 2mm+ anteroposterior corrections, up-righting severely tipped teeth and premolar extractions without implant or bridge.
• Aligners must be worn for 24 hours, removed during eating, drinking, and oral hygiene, and distributed in four to six-week intervals, at 2-3 sets for each appointment.
• Aligners must be switched every 2 weeks, being evaluated attachments, spacing, oral hygiene, periodontal status, and seating by the dentist.
• Invisalign patients reported less pain and fewer life-quality effects than those with fixed appliances in the first orthodontics weeks.

Dental Hygienist's Role

• Clinical research showed that orthodontic patients have the challenge of maintaining optimal oral health in hard and soft tissues and the dental hygienist plays an important role in short-term and long-term patient success.

Dental Hygiene Care Plan

• Before orthodontic therapy, evaluate and treat periodontal and hard tissue status.
• Pre-therapy intervention includes full mouth instrumentation, daily care evaluation, plus care during/post therapy plans.
• Patients' health, risk factors, and hygiene practices dictate the plan.
• Clinicians should consider full-mouth disinfection (FMD) or accelerated instrumentation for periodontal cases.
• Accelerated treatment features FMD, full-mouth instrumentation within 24 hours, and chlorhexidine use.
• Accelerated treatment can fast-track orthodontic plans, healing, or referral.
• Instrumentation helps arrest periodontal infection before orthodontic treatment.
• Delay orthodontic treatment for 2-3 months post periodontal therapy.
• This patient type needs professional periodontal care every 3 months.
• During orthodontic therapy, instrumentation should deplaque areas around appliances and soft tissue using powered scalers.
• Coordinate archwire removals with the orthodontist and special tools for self-ligating systems are required.
• Replace the archwire soon as possible.
• Patients should visit the orthodontist to remove wires before visiting the dental hygienist.
• All orthodontic cases should receive in-office fluoride treatments, regardless of periodontal status, to prevent enamel demineralization around brackets.
• Post-orthodontic treatment involves caries and periodontal evaluation.
• Evaluate for residual bonding post-debanding and dry the tooth surface with air if needed.
• Remove excess material with ultrasonic instrumentation or a high-speed handpiece.
• Decalcification can be addressed and teeth can be whitened.
• Retention devices, fixed or removable, may be a life-long method involving cleaning removable appliances with powered toothbrushes, daily use of powered toothbrushes or cleaning and freshening products for fixed ones.
• Make same recommendations for aligner patients.
• Hygienists should motivate patients to uphold orthodontists’ retention therapy recommendations.

Dental Hygiene Care Plan - Oral Hygiene Instruction (OHI)

• Orthodontic upkeep poses challenges due to fixed appliances or in maintaining aligners/retainers.
• Pre-treatment education should include mechanical and chemotherapeutic ways to control oral plaque biofilm around appliances, tongue, gingival margin and interproximally.
• Mechanical methods include powered toothbrushes and replace manual toothbrushes, as they are safe and effective for removing bracket plaque and stain.
• Daily tongue cleaning is most effective for fresh breath and removing plaque with periodontal and caries-related flora and they should be instructed to use the tongue cleaner at least once a day.
• Chromogen staining can be prevented with daily tongue cleaning.
• Interdental hygiene options include floss threaders, oral irrigators, toothpicks, interdental brushes, and mechanical flossers.
• A Waterpik® Power Flosser is equally effective as floss and easy to use with fixed appliances.
• Daily care includes avoiding gum or foods that dislodge appliances while preventing/treating oral irritations (orthodontic wax, ulcers).

Nutritional Counseling

• Nutritional counseling includes information caries-related diets and nutrient-dense, soft options.
• Sugar or acidic beverages, sticky carbohydrates, and cariogenic foods should be avoided.

Fashion Braces

• Fashion braces involve improper dental braces installed for lower costs solely in the name of fashion.
• No x-rays or photos are taken.
• These are often placed by someone who is not an orthodontist and are accompanied by a low cost when it is installed by a professional.
• There may also be no diagnosis from an orthodontist.
• This may lead to head and neck pain, TMJ pain, limited jawbone mobility, and recessions.