Adult orthodontics--who's doing what?

Adult orthodontic patients: What is important to them?

OBJECTIVE

To understand patients' motivations for pursuing treatment, to appreciate what information patients seek and to explore potential factors affecting decision making in adults considering, undergoing or who have had orthodontic treatment in the private sector.

DESIGN

Cross-sectional questionnaire study.

SETTING

Online questionnaire.

PARTICIPANTS

A total of 209 (83% women, 16% men, 1% preferred not to say) completed responses were received.

METHODS

Once piloted, the final survey was made available online to adults in the United Kingdom (UK) and Republic of Ireland (RoI) who were either considering having orthodontic treatment, currently undergoing treatment or had recently completed treatment in the private sector.

RESULTS

The most commonly selected motivating factor was to 'improve the appearance of my teeth' (82%). The information sought related predominantly to treatment duration (64%), potential end results (56%), types of appliances that were available (55%) and cost (52%). The two most commonly reported social factors that had influenced participants to consider treatment were 'seeing myself on social media' (31%) and 'it is more socially acceptable to have braces' (31%).

CONCLUSION

While this area remains relatively underexplored in the literature, it is crucial to develop a comprehensive understanding due to the increasing number of adults seeking orthodontic treatment. This study not only reinforces the existing knowledge regarding adults seeking orthodontic treatment, such as the predominant role of aesthetics as a motivating factor, but also introduces some novel insights. Specifically, we highlight the influence of social factors on decision-making processes and the importance of effectively communicating the duration of treatment to patients.

A review of oral pathology in orthodontics. Part 2: Pathology of the jaw bones

For many patients, their first full jaw imagining will be requested and reported by an orthodontist. This may lead to the discovery of unexpected pathology in the jaws. In this review article, we discuss the clinical and radiological appearance as well as the pathologic features and treatment of the more common entities of the jaws. In addition, we will discuss the less common lesions which carry important consequences for the patient. Through the identification of these lesions, appropriate referral and management can be pursued.

A review of oral pathology in orthodontics. Part 1: Soft-tissue pathology

Orthodontists are well placed to detect soft-tissue disease of the oral cavity and associated structures because of the frequent repeat examinations of their patients. This review describes the clinical manifestations, pathologic features, and treatment of the soft-tissue pathology most likely to be encountered by the orthodontist and uncommon soft-tissue disease with significant implications for the patient. The recognition of soft-tissue disease will allow reassurance, referral, and early intervention when required.

Effect of personality traits on the association between clinically assessed malocclusion and the psychosocial impact of dental aesthetics

OBJECTIVE

We aimed to assess whether personality traits affect the relationship between malocclusion and the psychosocial impact of dental aesthetics and whether they act as its mediators or moderators.

SETTINGS AND SAMPLE POPULATION

The cross-sectional study included 252 participants with permanent dentition (62% female) aged 12-39 years.

MATERIALS AND METHODS

The Big Five Inventory, the Psychosocial Impact of Dental Aesthetics Questionnaire and the Index of Complexity, Outcome and Need were used. Moderation and mediation were tested by hierarchical stepwise multiple linear regression.

RESULTS

Malocclusion was the most significant predictor of dental self-confidence (DSC), aesthetic concern (AC), social impact (SI) and psychological impact (PI), accounting for 12%-28% of respective variability (P < .05). Adult age, male sex and higher neuroticism and agreeableness were additional predictors of higher DSC (P < .05). Adolescent age was a predictor of higher AC, SI and PI, and female sex of higher AC and PI (P < .05). Mediation by personality traits was not proven, however, openness, agreeableness and neuroticism were moderators. A tendency of decrease in AC was associated with an increase in malocclusion complexity in adolescents lower in openness and decrease in SI in adolescents with lower agreeableness. There was also a tendency of higher increase of AC associated with an increase of malocclusion degree in adults higher in neuroticism.

CONCLUSION

In adolescents, openness and agreeableness moderate the relationship between malocclusion and AC and SI, respectively. Neuroticism is a moderator of the association between malocclusion and AC in adults.

Applications of regenerative techniques in adult orthodontics

Management of the growing adult orthodontic patient population must contend with challenges particular to orthodontic treatment in adults. These include a limited rate of tooth movement, increased incidence of periodontal complications, higher risk of iatrogenic root resorption and pulp devitalisation, resorbed edentulous ridges, and lack of growth potential. The field of regenerative dentistry has evolved numerous methods of manipulating cellular and molecular processes to rebuild functional oral and dental tissues, and research continues to advance our understanding of stem cells, signalling factors that stimulate repair and extracellular scaffold interactions for the purposes of tissue engineering. We discuss recent findings in the literature to synthesise our understanding of current and prospective approaches based on biological repair that have the potential to improve orthodontic treatment outcomes in adult patients. Methods such as mesenchymal stem cell transplantation, biomimetic scaffold manipulation, and growth factor control may be employed to overcome the challenges described above, thereby reducing adverse sequelae and improving orthodontic treatment outcomes in adult patients. The overarching goal of such research is to eventually translate these regenerative techniques into clinical practice, and establish a new gold standard of safe, effective, autologous therapies.

Efficacy of Anterior Tooth Simulations with Clear Aligner Therapy - A Retrospective Cohort study of Invisalign and Flash Aligner Systems

Purpose:

The purpose of this study was to compare the efficacy of tooth movement between two clear aligner systems by comparing the predicted treatment outcomes versus actual outcomes achieved using a 3D best-fit algorithm.

Materials & Methods:

Clear aligner therapy (CAT) was used to treat 62 patients; n=38 Invisalign® and n=24 Flash®. The Invisalign group had a male to female distribution of 13:25 and a mean age of 35.5, while the Flash group had a male to female distribution of 6:18, with a mean age of 29.2. Differences in predicted versus achieved actual outcomes were compared using eModel Compare 8.1 software.

Results:

1) Intra-group differences between predicted and achieved tooth movements for angular movements were statistically (P<0.05) and clinically (>2°) significant with both treatment methods, except for tipping of maxillary and mandibular incisors for Flash® (<2◦). 2) Inter-group results demonstrated statistically significant differences in favor of Flash® for maxillary central incisor Tip (1.3°), BL movements for maxillary canines (0.1mm), and mandibular central incisor Rotations (1°). These did not exceed the threshold for the clinical relevance of 2° or 0.5mm.

Conclusions:

There were no differences in clinical accuracy and efficacy between Invisalign or Flash aligner systems in achieving predicted tooth movement.

The value of adult orthodontics: Do the public's willingness-to-pay values reflect the profession's?

OBJECTIVE

To explore how the public and dental professionals would value an orthodontic service for adults by eliciting their willingness-to-pay (WTP), a standardised health economics technique which quantifies 'strength of preference' in monetary terms. Despite increasing demand, adults in the UK are only eligible for NHS orthodontic treatment if there is severe dental health or complex multidisciplinary need. Orthodontic services are provided to children aged under 18 years who are eligible by their Index of Orthodontic Treatment Need (IOTN) score. Consequently, many adults who may have a need for treatment as determined by IOTN are unable to access this service.

DESIGN

Cross-sectional survey.

SETTING

General dental practices in North East England and national specialists approached through the British Orthodontic Society (BOS).

PARTICIPANTS

Public participants were recruited from general dental practices. Dentists were recruited from local dental lists and members of the BOS.

METHODS

Participants were asked if they would be willing to pay to see an orthodontic service extended to all adults in England with a qualifying IOTN. Clinical photographs of three malocclusions were presented and maximum WTP in additional tax per household per year was elicited using shuffled payment cards.

RESULTS

A total of 205 dentists and 206 public participants were recruited. Pairwise tests showed a statistically significant difference in WTP between the public and professionals for all malocclusions, with the public giving higher valuations. In both groups, the Class III scenario elicited a higher WTP than the class I or II malocclusion. However, when all other factors were controlled for using a regression analysis, the group (public or profession) and the other variables did not significantly influence WTP.

CONCLUSION

The public and professionals were willing to pay for an adult orthodontic service. Due to this variability and unpredictability the allocation of healthcare resources will remain contentious.

Accelerated orthodontic tooth movement: surgical techniques and the regional acceleratory phenomenon

BACKGROUND

Techniques to accelerate tooth movement have been a topic of interest in orthodontics over the past decade. As orthodontic treatment time is linked to potential detrimental effects, such as increased decalcification, dental caries, root resorption, and gingival inflammation, the possibility of reducing treatment time in orthodontics may provide multiple benefits to the patient. Another reason for the surge in interest in accelerated tooth movement has been the increased interest in adult orthodontics.

REVIEW

This review summarizes the different methods for surgical acceleration of orthodontic tooth movement. It also describes the advantages and limitations of these techniques, including guidance for future investigations.

CONCLUSIONS

Optimization of the described techniques is still required, but some of the techniques appear to offer the potential for accelerating orthodontic tooth movement and improving outcomes in well-selected cases.

Eliciting Preferences for Adult Orthodontic Treatment: A Discrete Choice Experiment

INTRODUCTION

There has been little research to explore how adults financially value private orthodontic treatment and whether they have preferences for different attributes of treatment. This study used a discrete choice experiment and aimed to determine whether the recognized skill level of the dental professional and the type of orthodontic appliance influence the values that the public places on private adult orthodontic treatment.

METHODS

In total, 206 adult patients or the parents/guardians of children attending general dental practices in the northeast of England were recruited to complete a discrete choice experiment. Three attributes were included: the type of dental professional providing treatment, the type of orthodontic appliance, and cost. Also collected were demographic and orthodontic history characteristics. Results were analyzed with conditional logistic regression and elicited marginal willingness to pay (MWTP).

RESULTS

Participants value the training and expertise of the dental professional providing private orthodontic treatment greater than the type of orthodontic appliance. MWTP for orthodontic treatment increased in conjunction with the recognized skill level of the dental professional. Participants were willing to pay more for aesthetic appliances over a fixed metal appliance.

CONCLUSIONS

Participants value the training and expertise of the dental professional providing private adult orthodontic treatment greater than the type of orthodontic appliance. These preferences concur with other discrete choice experiments undertaken in medical specialties that included attributes focusing on the qualification, skill, or expertise of the health care professional. MWTP for orthodontic treatment increased in conjunction with the recognized skill level of the dental professional. Participants were willing to pay more for aesthetic appliances than metal fixed appliances. The cost of orthodontics is significant, and adults appreciate the importance of having options and making choices.Knowledge Transfer Statement: The results of this study suggest that patients are willing to pay more for orthodontic services provided by clinicians with higher levels of formal training. In a competitive market where the public appears to prefer the provider over treatment modality, there is an incentive for clinicians to optimize their knowledge and skills to deliver the high-quality orthodontic treatment that patients are demanding. Orthodontic clinicians should be mindful of the demand for the different adult orthodontic appliances and tailor their skill sets accordingly.

Predictors of treatment decisions made by adult orthodontic patients presenting with unerupted permanent teeth

OBJECTIVE

Unerupted permanent teeth are amongst the most commonly occurring dental anomalies in adults and present unique treatment challenges. The aim of this retrospective study was to (1) identify the prevalence of adult patients with unerupted teeth attending a multidisciplinary clinic and (2) to identify predictors (age, gender, incisor and skeletal classification) which influence the patients treatment decision.

MATERIAL AND METHODS

Consecutive adult patients with unerupted permanent teeth attending the Joint Orthodontic-Restorative clinic were identified. Study variables were collected using a prespecified data collection form. Descriptive statistics were employed; Fisher's exact test was used to detect associations between variables and treatment decision outcome. Ordinal logistic regression derived multinomial regression relative risk ratios (RRR) and 95% confidence intervals (CI) were calculated for the effect of age, gender, incisor and skeletal classification on treatment decision/outcome.

RESULTS

Sixty-six patients with impacted teeth were identified from a sample of 483. The prevalence of adults with unerupted teeth was 13.7%. The mean age was 30.7 years (SD 11.2). The majority of the sample had a Class I incisor relationship (54.6%) or Class I skeletal base relationship (54.6%), and the most common distribution of impacted teeth was a single unerupted upper right canine (34.9%). Orthodontic treatment (non-extraction or extraction basis incorporating the alignment or removal of impacted teeth) and restorative treatment only were equally favoured. Factors including age, gender, incisor and skeletal classification did not appear to influence or predict the final treatment decision.

CONCLUSIONS

In this sample, adults presenting with impacted teeth favoured certain treatment modalities: orthodontic treatment only and restorative treatment only. Factors such as age, gender, incisor and skeletal classification did not influence the outcome.

Adult orthodontic retreatment: A survey of patient profiles and original treatment failings

INTRODUCTION

A growing number of adult patients are seeking orthodontic treatment. This research aimed to analyze the particulars of patients seeking retreatment and identify the causes of their original treatment failure.

METHODS

An online questionnaire survey of adults seeking first-time orthodontic treatment (control) and retreatment (study) was conducted. Index of complexity, outcome, and need (ICON) scores were determined. Appraisal of treatment records was carried out to identify the causes of original treatment failure.

RESULTS

No significant differences were found between retreatment adult patients and first-timers regarding reasons for seeking orthodontic treatment, malocclusion type, self-perception of malocclusion, level of self-motivation, willingness for surgery, expectations of treatment improvement and duration. The predominant reason for seeking treatment in both groups was for aesthetic concerns. Retreatment patients presented with lower ICON scores (39.4; standard error, 0.26) than the first-time patients (54.3; standard error, 0.23), P ≤0.001. The predominant reasons for original treatment failings were poor treatment, maturational changes, inadequate retention, shortcomings in diagnosis and treatment planning, and unfavorable growth. Other causes were related to transverse deficiency, secondary malocclusion (after periodontal breakdown), poor retention compliance, and temporomandibular joint degeneration.

CONCLUSIONS

Adult orthodontic retreatment and first-time seekers' profiles are remarkably similar. Aesthetic concerns were the leading reasons patients sought treatment. ICON was not a useful proxy of patient profiles. Poor treatment was the chief reason for the failure of the original treatment. In terms of clinical significance, clinicians should be mindful of the patient profiles of retreatment seekers and vigilant about the possible causes of failings of orthodontic treatment to avoid suboptimal outcomes.

Factors Affecting Satisfaction with the Process of Orthodontic Treatment in Young Adults: A Questionnaire Study

Introduction: Recently, there has been an increase in adults undergoing orthodontic treatment in both the public and the private sector. Satisfaction during and after the orthodontic treatment process has not been widely discussed so far, however, and few research studies have emphasized patient satisfaction with treatment outcome and the factors affecting patient satisfaction.

Aim: To investigate factors affecting patient satisfaction with the process of orthodontic treatment in young adults.

Material and methods: Fifty-eight patients (33 girls and 25 boys with a mean age of 25.05 years, SD 2.83) were included in the survey. All patients were young adults who had completed their orthodontic treatment with fixed appliances and were taken from two centers (a teaching hospital and a private practice). Data was collected using online survey forms and was analyzed using content thematic analysis. Five main factors were identified related to patient satisfaction with the process of orthodontic treatment: communication, faculty (orthodontist), physical surroundings, consultation/appointments, and impact of appliance treatment.

Results: Effective communication was the most prominent factor among all five factors considered, especially detailed explanation given during treatment and making patients feel comfortable under their care. Median values were generally high for satisfaction with treatment results. There was a clear correlation ( p < 0.001) between patient satisfaction and treatment outcome. Age, sex and treatment time did not have any correlation with treatment satisfaction.

Conclusion: In general, young adults were observed to be satisfied with the treatment process, and good communication played a dominant role in this. Though there were many differences in working models between public and private sectors, many similarities were observed when comparing the factors between the two centers.

Age effect on orthodontic tooth movement rate and the composition of gingival crevicular fluid : A literature review

PURPOSE

To evaluate and form a comprehensive understanding of the effect of patient age on bone remodeling and consequently on the rate of orthodontic tooth movement (OTM).

METHODS

A systematic search in PubMed and Embase from 1990 to December 2017 was performed and completed by a hand search. Prospective clinical trials which investigated the rate of OTM and/or studies assessing age-related changes in the composition of gingival crevicular fluid (GCF) in older compared to younger study groups were included. Study selection, data extraction and risk of bias were assessed by two authors.

RESULTS

Eight studies fulfilled the inclusion criteria. Among them, four evaluated the rate of OTM and six investigated mediators in the GCF (prostaglandin E₂, interleukin [IL]-1β, IL‑6, IL‑1 receptor antagonist, receptor activator of nuclear factor kappa‑Β ligand, osteoprotegerin, granulocyte-macrophage colony-stimulating factor, pentraxin 3). Patient age ranged between 16 and 43 years for older and <16 years for younger groups. In most of the studies, the younger patients showed faster OTM in the first phase of treatment and more pronounced cytokine levels. Older patients had a delayed reaction to orthodontic forces.

CONCLUSION

The small number of included studies and large heterogeneity in study design give limited clinical evidence that the older patients are less responsive to orthodontic force in comparison to younger patients. The initial cellular response to orthodontic force is expected to be delayed in older patients. Control intervals during orthodontic treatment should be adjusted to the individual's treatment response.

Orthodontic treatment in National Dental Centre of Singapore: Trends toward higher proportion of adult patients

Background

Adult patients used to be daunted with the prospect of having fixed appliances to correct malocclusions. However, this has gradually changed and recent literature reported an increasing trend in adults receiving orthodontic treatment. To date, there has been no information regarding the trend of adult orthodontic patients in Singapore.

Objective

The objective of this study was to determine the changes in the proportion of adult patients seeking orthodontic treatment at the National Dental Centre Singapore (NDCS) from 2011 to 2017.

Materials and Methods

The study sample consists of all patients who commenced active orthodontic treatment from 2011 to 2017 at the NDCS. The data collected were analyzed for the number, gender, and proportion of adult orthodontic patients treated annually from 2011 to 2017. Linear-by-linear association test was used to test for any significant linear trend in proportion of adult orthodontic patients over the 7 years. Pearson’s Chi-squared test was used to test for any significant gender differences.

Results

There was a significant increasing linear trend (p = 0.001) in the proportion of adult orthodontic patients from 2011 to 2017. No significant difference (p = 0.770) between the proportions of male and female adults undergoing orthodontic treatment was found. The ages of adults undergoing orthodontic treatment ranged from 21 to 73 years old and majority (48.61%) of them was in the 21–25 years old age range.

Conclusion

There is a rising trend in adults seeking orthodontic treatment at the NDCS from 2011 to 2017. No statistically significant gender difference was observed in this rising trend.

Experiences of the challenges of undertaking an orthodontic needs assessment within the National Health Service in England

The purpose of undertaking Orthodontic (Oral Health) Needs Assessment is to identify unmet healthcare need in a systematic way. The NHS Five Year Forward View set out a clear direction for the NHS in 2014, showing why change is needed and what it will look like. It has been recognised that the health needs and personal preferences of individuals are continuously adapting; therefore, orthodontic services are required to meet this changing environment. Here, we describe some of the challenges for orthodontic needs assessment. Current methods used to assess normative, perceived and expressed need are reviewed, highlighting how these may fail to accurately identify current orthodontic need. Currently, there is no index assessing either psychological need or psychological benefit from orthodontic treatment, despite evidence to suggest that there is a moderate improvement in the emotional and social wellbeing dimensions of the oral health-related quality of life of adolescents following orthodontic treatment. Commissioning of NHS orthodontic services should be guided by the best available evidence of need. As such, a number of recommendations are made which include establishment of comprehensive and comparable datasets for both primary and secondary care providers; review of the instruments used for measuring normative need in view of a changing society influenced by social media developments; and electronic referral management systems should be established which accurately monitor treatment provision. Moreover, further research is required to understand the health inequalities associated with orthodontic care and determine how social deprivation impacts on orthodontic treatment needs and uptake in local populations.

Motivation, expectations and understanding of patients and their parents seeking orthodontic treatment in specialist practice

Objectives:

To determine patient and parent/guardian motivation, expectation and understanding of orthodontic treatment.

Design:

A self-completion questionnaire survey of new patients referred for orthodontic assessment.

Setting:

Specialist practices in Surrey and Berkshire (United Kingdom).

Participants:

A total of 500 questionnaires were issued (250 were issued to patients and 250 to parents).

Methods:

The survey was based on a self-completed questionnaire which was issued at the assessment appointment. Both questionnaires were adapted and extended from originally validated questionnaires previously used in a hospital setting. Patients and parents were asked to complete separate anonymous questionnaires. The patient questionnaire consisted of 24 closed-ended questions divided into three domains: motivation; understanding; and expectation of orthodontic treatment. The parent questionnaire consisted of 13 questions covering the same three domains

Results:

The response rate for the patient and parent questionnaires was 95% and 91%, respectively. Forty-seven percent of the patients were aged 11–13 years. In 77% of cases, the referral was initiated by their dentist. Only 3% of patients thought there was nothing wrong with their teeth. There was a poor understanding of what a retainer is and for how long patients are expected to use it.

Conclusions:

Referral for orthodontic treatment was initiated by the patients’ general dental practitioner in the majority of the cases. The anticipation of improved dental appearance was a prime motivating factor. Participants had realistic expectations and there was a good acceptance of appliances and dental extractions for orthodontic treatment. Nevertheless, both patients and parents/guardians were less well informed on the nature and duration of orthodontic retention.

Adults seeking orthodontic treatment: expectations, periodontal and TMD issues

The growth in adult orthodontics presents new challenges to both the general dental practitioner and the orthodontist. Although many of the main objectives of orthodontic treatment are similar for adults, young adults and children, adult patients frequently bring significant challenges in several areas not often seen in the younger patient group. In areas such as planning realistic treatment outcomes, it is paramount that the patient's expectations are identified, respected and managed where appropriate. The adult patient's dental health often dictates deviation from the ideal treatment plan and periodontal problems are a common example. Based on current evidence, this paper presents an overview of some of the difficulties in the management of these issues, as well as highlighting developments with regard to pain conditions and their relevance to orthodontic treatment and its effects on temporomandibular joint disorders (TMD) management.

Orthodontic referrals: why do GDPs get it wrong?

Aim &objectives A clinical audit was carried out to assess suitability of orthodontic referrals at Kings College Hospital Orthodontic Department with the objective to investigate the reasons and seek solutions to inappropriate orthodontic referrals.Design and setting Prospective audits of consecutive new patient referrals to the King's College Hospital Orthodontic department diagnostic teaching clinics.Methodology Two hundred and twenty-eight patients referred to the orthodontic diagnostic teaching clinics over a 5-month period were assessed. Data were collected using a questionnaire, completed by the undergraduate dental student and checked by the supervising clinical teacher. A second audit cycle was carried using the same methods after implementation of an action plan devised for referral guidelines and pathway to be sent back to the referring practitioner.Results At the initial audit cycle, 37.2% of patients met the standards, dropping to 33.3% at second audit cycle demonstrating high levels of inappropriate referrals. Our results showed: poor use of IOTN, patients presenting with IOTN scores too low for treatment, poor oral hygiene and caries; patients presenting too early for treatment, adult patients; and incorrect referral pathway implementation. Targeted education of referring practitioners via referral guidelines were found ineffective. We suggest that other methods to improve the quality of referrals are required, such as proformas and improving education among the profession.

Adult orthodontics: a quality assessment of Internet information

OBJECTIVES

This study evaluated the quality, reliability and readability of information on the Internet on adult orthodontics.

DESIGN

A quality assessment of adult orthodontic websites.

SETTING

Postgraduate Orthodontic Unit, Cork University Dental School and Hospital, Cork, Ireland.

METHOD

An Internet search using three search engines (Google, Yahoo and Bing) was conducted using the terms ('adult orthodontics' and 'adult braces'). The first 50 websites from each engine and under each search term were screened and exclusion criteria applied. Included websites were then assessed for quality using four methods: the HON seal, JAMA benchmarks, the DISCERN instrument and the LIDA tool. Readability of included websites was assessed using the Flesch Reading Ease Score (FRES).

RESULTS

Only 13 websites met the inclusion criteria. Most were of US origin (n = 8; 61%). The authors of the websites were dentists (n = 5; 39%), professional organizations (n = 2; 15%), past patients (n = 2; 15%) and unspecified (n = 4; 31%). Only 1 website displayed the HON seal and three websites contained all JAMA benchmarks. The mean overall score for DISCERN was 3.9/5 and the mean total LIDA score was 115/144. The average FRES score was 63.1/100.

CONCLUSIONS

The number of informative websites on adult orthodontics is low and these are of moderate quality. More accurate, high-quality Internet resources are required on adult orthodontics. Recommendations are made as to how this may be achieved.

Dentoalveolar surgery techniques combined with orthodontic treatment: A literature review

Surgery on the dentoalveolar process combined with orthodontic treatment was emphasized as an alternative method for reducing the treatment time and improving the orthodontic treatment on post-adolescent and adult patients. This combined treatment facilitates and accelerates orthodontic tooth movement. This article reviews the clinical practice in surgery-assisted orthodontic treatment in relation to historical perspective, indications and biological principles, as well as limitations and risks of dento-osseous surgical techniques, including dento-osseous osteotomy and/or ostectomy, dento-osseous microfracture, dento-osseous corticotomy, and/or corticoectomy, and dental distraction.

Lingual orthodontic treatment: what is the current evidence base?

As the number of adults that seek orthodontic treatment continues to grow, so too is the popularity of lingual fixed appliances. Although the aesthetic advantages associated with these systems are obvious, for some orthodontists, there has been a reluctance to offer lingual-based treatment to their patients. This is often based upon the perceived problems associated with lingual braces, relating to discomfort and difficulties with speech for the patient, and problems in using these appliances for the orthodontist. Although some of these factors have been investigated, the current evidence base is weak, possibly due to the fact that these are evolving appliance systems. Among the studies that have been carried out to date, pain and discomfort for the patient appears to be similar following the placement of labial or lingual appliances, although the onset can be earlier with lingual brackets and the location different, with the tongue more frequently being involved. Customized lingual brackets may be associated with less pain than pre-fabricated. In addition, patients do seem to be more likely to experience difficulties with speech and mastication when fitted with a lingual appliance. However, there is some evidence that the lingual surfaces of the teeth are more resistant to early demineralization and caries. Little data exist regarding treatment outcome and ease of use for the orthodontist, either between lingual or labial appliances or between different lingual systems. Further research is required to investigate the efficiency of lingual appliance systems, both for the patient and orthodontist.