Top Ten Tips for Orthodontic Assessment: Best practices for general dentists

Prior to orthodontic treatment, we must perform a thorough clinical examination and assess the patient’s records, including X-rays, orthodontic study models or scans, and clinical photos. Last but not least, we must consider the expectations of the person sitting in front of us. The exam starts the moment the patient walks into the treatment room.

What is an orthodontic assessment?

During an orthodontic assessment, we observe the facial structures. We look for marked facial asymmetries like chin deviation, for example. The position of the upper and lower incisors, the upper lip and the lower lip, the soft tissue profile, and the nasolabial angle are crucial. That’s why we would like to improve them if that is feasible and requested by the patient.

There should be a soft tissue balance at the end of treatment. This is important if we want to achieve a stable result and pleasing dental and facial aesthetics.

To perform an extraoral assessment, we examine the patient’s facial proportions at the natural head position and look for deviations from the norm in all three space planes.

Based on the soft tissue profile, we could determine if we are dealing with Skeletal Class I or if there might be a skeletal discrepancy – for example, Class II or Class III malocclusion. The convexity of the profile gives us valuable information. For example, a convex profile is associated with Class II malocclusion, whereas a concave profile is associated with Class III.

Why is the orthodontic assessment crucial for your patients?

Accurate diagnosis is essential before we, as dentists, consider initiating any treatment. A thorough extraoral examination gives us valuable information regarding the underlying skeletal discrepancy. Observing the facial profile, the soft tissues and their relation to the upper central incisors is the first and probably the most crucial step before the treatment planning process is initiated.

The intraoral assessment will consider the dental arches’ symmetry, tooth decay, and gum problems. Addressing active periodontal disease before tooth movement is initiated is extremely important.

The forces determine the normal position of both upper and lower incisors in permanent dentition exerted on them by the lips, cheeks, tongue and the periodontal ligament.

A loss of periodontal attachment can lead to spaces between the teeth, their proclination, etc., which is usually the patient’s concern. It is a good idea to delay treatment of the main concern until we know the periodontal structures are stabilised. Before orthodontic treatment, a referral to a periodontist is a necessity for those cases.

What does an orthodontic assessment include?

I briefly mentioned some essential aspects of the extraoral assessment. Before orthodontic treatment, we perform a detailed intraoral assessment. We look at the general development of dentition, missing teeth, supernumerary teeth and general oral pathology.

Good oral hygiene is mandatory before and during brace treatment, and some patients would benefit from detailed oral hygiene instructions. Periodontal health is essential, and sometimes, a referral to a specialist is required. We do not start treatment in the presence of active oral disease or pathology.

Clinical examination

During the initial check-up, our goal is to determine the severity of the malocclusion in all three dimensions and discuss possible treatment modalities. The combination of intraoral and extraoral examination usually gives the clinician most of the required information.

A critical aspect of the intraoral assessment is determining the presence of a premature contact that leads to a functional shift of the lower jaw. The shift could be lateral or forward, as in pseudo-Class III cases. That is extremely important before starting treatment.

The mandibular shift can lead to midline deviation and worsening of the interarch relations. That is why we are so concerned not to miss them. Usually, a posterior crossbite due to a narrow maxilla is the main reason for a mandibular shift. However, premature contact with the front teeth could also cause a shift.

The skeletal pattern determining the malocclusion could form part of the clinical assessment. We should remember that dentoalveolar compensations could be present in all three dimensions and could easily mask the severity of the malocclusion.

Medical History 

Regarding the patient’s medical history, we consider the overall health condition, allergies and medication being taken. For example, if I have to treat a patient taking bisphosphonates, I will aim for a mild treatment without permanent teeth extractions. Sometimes, having a realistic, rather than overcomplicated, treatment plan is better.

Due to legislation in some countries, a referral to a cardiologist and premedication is a must before specific orthodontic procedures are undertaken due to a higher risk of bacteremia. It is wise to be in touch with the treating physician for patients with medical conditions.

Dental history

Previous trauma to the upper incisors, for example, can significantly change the orthodontic problem list. Cases that present with trapped lower lip and increased overjet are more vulnerable to trauma.

Sometimes, it is a mild enamel fracture. The periodontal ligament could be severely damaged in other cases, and the touch can become ankylotic.

In those cases, a referral to an endodontist and explaining the possible complications that could arise during the ortho treatment is essential.

Successful treatment outcomes depend on the assessment of the case, treatment planning, and the implication of reasonable treatment mechanics. We cannot make everyone happy, but a detailed discussion and explanation of all possible complications are required before initiating braces treatment.

Diagnostic records: radiographs, photos and study models

If a patient is concerned that the upper front central incisors are protrusive, we are discussing a Class II Div 1 case.

However, based only on extraoral assessment, we can not precisely determine the severity of the skeletal discrepancy. Are we dealing with protrusive upper incisors on a Class I skeletal base, or maybe the lower jaw is in a distal position, and the upper incisors have normal angulation concerning the maxillary base?

A cephalometric analysis could reveal the severity of the sagittal discrepancy. We can determine exactly how severe the malocclusion is and determine the skeletal pattern. Once the lateral cephalometric X-ray is analysed, both sagittal and vertical deviations from the norm will be exposed.

We also need to remember that the proclination of the incisors equals crowding. It is just a different visual presentation of the same problem. A clinical case that appears with mild crowding might easily turn into an extraction case if there is also a proclination.

That’s why detailed treatment planning and analysis of all clinical records is required to understand the presented malocclusion thoroughly. Before we assess the deviations from the norm, we have to know the norm.

That’s why, in our orthodontic courses, we use a systematic approach to understanding the basics and learning the valuable skills required to offer orthodontic treatment to your patients and meet their expectations.

Best tips for orthodontic assessment

The first assessment of the patient’s bite is performed around the age of seven or eight. I prefer to see the patient during early mixed dentition. By age eight, all permanent incisors should have erupted. If there is one, I can assess the molar and canine relations, the overjet, overbite and the presence of a functional shift.

After an initial assessment, I like to follow up with the patients during the subsequent years. I usually invite them once a year and would like to ensure they get a space maintainer if needed. In many cases, preserving the leeway space could prevent the necessity for permanent tooth extractions.

We can also use technology to communicate our message. For example, dental scans could be used to explain to the parent and the child the amount of crowding and the specific problems that we will have to deal with. Sometimes, even a simple intraoral photo can be enough, but the 3D image from the scan will give a more detailed explanation.

Tip number one: Pay attention to the vertical dimension 

The assessment of the lower anterior facial height (LAFH) during the initial check-up shows us whether we are dealing with a patient with a typical growth pattern or deviation from the norm- hypodivergent or hyperdivergent growth pattern.

For example, incompetent lips at rest are usually seen in cases with increased LAFH. That information is considered during the treatment planning because we have to be careful with intermaxillary elastics in open bite cases. Upper jaw expansion is ideally performed with an expander with occlusal coverage in those cases.

Tip number two: Look at the bigger picture

A systematic approach during extraoral and intraoral assessment is necessary to gather all relevant information, analyse it and prepare a reasonable treatment plan. The patient is usually concerned with the smile arc or the appearance of the front teeth.

However, we look at the case from a different perspective because orthodontic treatment usually involves rearranging the position of each tooth in the mouth.

Some clinicians assess the position of the upper incisors and plan the whole treatment based on their ideal position. That means that, in their opinion, many skeletal discrepancy cases will require jaw surgery.

Tip number three: Accept the fact that some people may need jaw surgery

A Class II Div 2 case with deficient LAFH could be converted into Class II Div 1, and an attempt to forward reposition the mandible could be made during the pubertal growth spurt. That is a feasible treatment option for some growing patients, and we could use functional appliances. Some adult patients may benefit from orthognathic surgery.

Tip number four: Do not underestimate the camouflage treatment approach.

Different treatment options and modalities are available, and I genuinely believe that many Class II and III cases could be treated successfully with a camouflage treatment approach.

Of course, the decision comes after thoroughly assessing the occlusion, x-rays, and the patient’s preference. We should not be surprised if two orthodontists come up with two different treatment approaches. That is usually based on their experience, training, and preference regarding work with specific bracket systems.

Tip number five: pay attention to the dental proclination

A moderate to severe Class II Div 1 case could have its increased overjet masked by severe proclination of the lower incisors. If there are also diastemas between the lower teeth and mild retroclination of the upper incisors, we could easily mislead ourselves as clinicians.

Tip number six: pay attention to the midlines

The upper and lower dental midlines should match the facial midline. An asymmetric crowding of the arches will explain a midline deviation. However, if there is a chin deviation, I would like to know if I am dealing with a functional shift of the lower jaw or an asymmetric growth of the condyles. That topic is discussed in detail in our online orthodontic course on assessing the orthodontic patient.

Tip number seven: be careful with the anterior open bite

Before we consider the treatment for this particular malocclusion, we need to differentiate between a dental problem due to a bad habit, for example, and a skeletal discrepancy due to increased LAFH and excessive vertical growth.

The extraoral and intraoral examinations and a cephalometric analysis are essential in the differential diagnosis.

Tip number eight: The deep bite is usually due to skeletal discrepancy

A lot of Class II cases can present with an increased deep bite and an increased overjet. If the tongue does not interfere with the eruption of the lower incisors, they can over-erupt and reach the palate. The normal incisor relationship will be affected, which will be a combination of an overjet and overbite problem that we need to address.

Tip number nine: Crossbite correction is tricky to be retained

An anterior crossbite is easier to retain than a posterior one. If we manage to achieve a positive overjet in the presence of favourable facial growth, the position of the upper incisors will remain stable. However, transverse relationships in the posterior segment are much more difficult to retain. A long-term retention with a removable Hawley retainer is usually recommended.

Tip number ten: the deciduous molars

Observe the position of the deciduous molars and especially their tendency for submergence in mixed dentition. Sometimes, they may become ankylotic, which can significantly affect not only the position of the adjacent teeth but also the permanent teeth underneath them.  

Early treatment

I implement early treatment protocols in mixed dentition in the following situations. If I notice a functional shift in the lower jaw, I recommend its correction ASAP. Sometimes, I use 2 by 4 if I have to correct midline deviation due to premature exfoliation of a deciduous canine.

However, I am very cautious because I do not want the roots of the lateral incisors to collide with the erupting canines. Careful biomechanics and light forces should be implemented in those clinical situations.

If I have to treat a Class II case with a functional appliance, I use two phases of treatment, and I try to deliver the functional appliance or the headgear during the growth spurt. If there is favourable growth combined with good cooperation, an excellent correction of a skeletal discrepancy could be achieved.

If there was a premature loss of lower E, sometimes the space has to be regained and retained later on. That is important to prevent the impaction of the second premolar.

Use a team-based approach

We are not supposed to deal with all the dental issues a patient might present with. I think that close collaboration with other colleagues and specialists is crucial. For example, close collaboration with endodontists and periodontists is mandatory when dealing with adult patients. The multidisciplinary approach is usually preferred for complex cases.

Utilise technology

The combination of intraoral scans, photos, and videos gives us a chance to better communicate with our prospective patients. We can offer different treatment options and present case studies of patients we have treated. The person will be better informed and have a chance to understand the pros and cons of the suggested treatment options.

The more informed the prospective patient is about the orthodontic treatment, the better. During the initial consultation, I try to understand what exactly bothers the person in front of me and assess whether they have realistic expectations about the treatment. If I realise I can’t meet the person’s specific requirements, I do not initiate treatment.

Stay up to date

We live in a digital era where the techniques and procedures we use daily are constantly improved. Attending valuable postgraduate continuous development seminars, networking with colleagues, and being a member of a study group are musts in our profession.

Orthodontics is a dental speciality that requires a constant desire for self–improvement, attention to detail, and professional curiosity.

Educate and explain the process to your patient

There is nothing worse than miscommunication between the people who are about to work together for the next year or two. To avoid misunderstanding, I show photos of previously treated cases and explain the advantages of the different treatment modalities.

I came to the conclusion that it is better to invest a bit more clinical time in discussion instead of dealing with a person who has failed to understand everything in detail. If complications arise, they have to be explained. For example, a traumatized incisor in the past could lose vitality, and that would necessitate the need for root canal treatment.

Good oral hygiene during braces treatment is highly challenging for some patients, especially teenagers. Visualising dental plaque around their braces is quite helpful for them. They must also understand the risks of white spot lesions, caries, and gum disease that are inevitable with bad oral hygiene.

The parent and child must understand that the treatment could be terminated before the optimal result is achieved if the oral hygiene does not meet acceptable standards.Another issue that needs to be clarified is the need for retention at the end of treatment. Different retention protocols could be implemented. Some cases need permanent retention. Some clinicians prefer fixed retainers, others removable ones. In some clinical cases, a combination of both is the best solution. I think it has to be discussed in detail, and the person should know about that phase after the teeth are straightened.