Who Should Be Treated

Dental irregularity alone is not an indication for treatment. Most orthodontic treatment is carried out for aesthetic reasons and the benefit an indi vidual will receive from this will depend on the severity of the presenting malocclusion as well as the patients own perception of the problem. Some individuals can have a marked degree of dento-facial deformity and be unconcerned with their appearance. Although a practitioner may suggest treatment for such an individual, patients should not be talked into treatment and must be left to make the final decision themselves. Mild malocclusions should be treated with caution. Not only will the net improvement in the appearance of the teeth be small, but also as nearly all teeth move to some degree after orthodontic treatment the risk of relapse in these cases is high. Whilst minor movements after the correction of severe malocclusions will still produce a substantial net overall improvement for the patients, the same is not true of minor problems. Many practitioners will have encountered the parent who can spot a 5-degree rotation of an upper lateral incisor from fifty metres and is convinced this will be the social death of their child. Regardless of how insistent the parent or child is, the practitioner should approach such problems

Table 3 Index of Treatment Need

Dental health component

Treatment need

1 No need

2

Little need

3

Moderate need

4

Great need

5

Very great need

Aesthetic component

Treatment need

1

2

Little need

3

4

5

6

Moderate need

7

8

9

Great need

10

Fig. 8a This malocclusion has an extremely deep bite which can be associated with potential periodontal problems

L-iS

Fig. 8b The same patient as in Fig. 8a, but not in occlusion. The deep bite has resulted in labial stripping of the periodontium on the lower right central incisor with care and only carry out the treatment if it is in the best interests of the patient. It is essential that the patient and parent are fully aware of the limitations of treatment and that long term, ie permanent retention is currently the only way to ensure long-term alignment of the teeth.

In order to assess the need for orthodontic treatment, various indices have been developed. The one used most commonly in the United Kingdom is the Index of Orthodontic Treatment Need (IOTN).4 This index attempts to rank malocclusion, in order, from worst to best. It comprises two parts, an aesthetic component and a dental health component (Table 3). The aesthetic component consists of a series of ten photographs ranging from most to least attractive. The idea is to match the patient's malocclusion as closely as possible with one of the photographs. It is unlikely that a perfect match will be found but the practitioner should use his or her best guess to match to the nearest equivalent photograph. The dental health component consists of a series of occlusal traits that could affect the long-term dental health of the teeth. Various features are graded from 1-5 (least severe — worst). The worst feature of the presenting malocclusion is matched to the list and given the appropriate score.

Many hospital orthodontic services will not accept patients in categories 1-3 of the dental health component or grade 6 or less of the aesthetic component of the IOTN unless they are suitable for undergraduate teaching purposes.

Whilst the IOTN is a useful guide in prioritising treatment and determining treatment need it

Fig. 9 The Index of Treatment Need for this patient is 2. Although this is low, the level of expertise required to treat it is high

Fig. 9 The Index of Treatment Need for this patient is 2. Although this is low, the level of expertise required to treat it is high

takes no account of the degree of treatment difficulty. For example, class II division 2 malocclusions are notoriously difficult to treat yet they might have a low IOTN. Figure 9 illustrates such a case. The IOTN of this patient is only 2 but it is a difficult case to manage and treatment requires a high level of expertise.

1. Shaw W C, Meek S C, Jones D S. Nicknames, teasing, harassment and the salience of dental features among school children. BrJOrthod 1980; 7: 75-80.

2. Office of Population Censuses and Surveys (1994). Children's dental health in the United Kingdom 1993. London: HMSO 0116916079.

3. Office of Population Censuses and Surveys (1985). Children's dental health in the United Kingdom 1983. London: HMSO 0116911360.

4. Brook P, Shaw W C. The development of an index of orthodontic treatment priority. Eur J Orthod 1989; 11: 309-320.

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