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Justification%20for%20orthodontic%20treatment
Justification%20for%20orthodontic%20treatment
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The Justification for<br />
Orthodontic Treatment<br />
Advice for PCTs, LHBs and SHAs<br />
This document has been produced by the British Orthodontic Society
The Justification for<br />
Orthodontic Treatment<br />
This document has been produced by the Clinical<br />
Standards Committee of the British Orthodontic<br />
Society. It seeks to provide information for<br />
purchasers and other interested parties about the<br />
specialty of orthodontics. It is divided into eight<br />
sections covering modern orthodontic practice.<br />
1. What is Orthodontics? page 4<br />
2. Prevalence of orthodontic<br />
problems<br />
page 4<br />
3. Why do people need braces? page 5<br />
4. Health gains from orthodontic page 7<br />
treatment<br />
5. Risks of orthodontic treatment page 10<br />
6. Demand for orthodontic<br />
treatment<br />
page 11<br />
7. What is the best time to carry page 11<br />
out orthodontic treatment?<br />
8. Providers of orthodontic care page 12<br />
3
1. What is Orthodontics?<br />
Orthodontics comes from the Greek words “orthos”,<br />
meaning correct or straight and “odontes”, meaning<br />
teeth. It is a specialised branch of dentistry concerned<br />
with the development and management of deviations<br />
from the normal position of the teeth, jaws and face<br />
(malocclusions). A malocclusion is not a disease but<br />
simply a marked variation from what is considered to be<br />
the normal position of teeth. Orthodontic treatment can<br />
improve both the function and appearance of the mouth<br />
and face. Appliances (braces) can be fixed or removable<br />
and are used to straighten the teeth and encourage<br />
growth and development. The main aims of orthodontic<br />
care are to produce a healthy, functional bite, creating<br />
greater resistance to disease and improving personal<br />
appearance. This contributes to the mental, as well as the<br />
physical, well being of the individual.<br />
The photographs show how the treatment of dental<br />
malocclusions, often using fixed appliances, can greatly<br />
improve the aesthetics and function of an individual’s<br />
dentition. These dramatic improvements are known to<br />
have significant psycho-social benefits to the patient.<br />
People with obviously unsightly teeth are very keen to<br />
have them changed. Crowded teeth can be potentially<br />
unhealthy and often provoke teasing or ridicule. Once<br />
straightened, teeth are often less prone to being damaged<br />
and the improvement to facial appearance can be<br />
dramatic.<br />
2. Prevalence of orthodontic problems<br />
The 2003 Children’s Dental Health survey 1 found that<br />
approximately one third of children would benefit greatly<br />
from orthodontic treatment. Indicators of treatment need<br />
and outcome have been developed and validated by the<br />
whole orthodontic profession to assess the efficacy and<br />
appropriateness of care. The most widely used are the<br />
Index of Orthodontic Treatment Need (IOTN) 2 and the<br />
Peer Assessment Rating (PAR) 3 .<br />
The IOTN is divided into two parts called the dental<br />
health component (DHC) and the aesthetic index (AI).<br />
4
The DHC is used to quantify the impact of a particular<br />
malocclusion upon the long-term dental health of an<br />
individual whereas the AI provides an assessment of the<br />
socio-psychological impact through appearance. They<br />
are used to categorise malocclusion into five groupings<br />
measured from 1 to 5 with the most severe being 5. It<br />
is generally accepted that IOTN groups 4 & 5 would<br />
“greatly benefit” from orthodontic treatment as well as<br />
some individuals from IOTN 3 when the AI is high at 6 or<br />
more. The main flaw of this index system is that it fails to<br />
evaluate the child’s perception of need. This may lead to<br />
the denial of treatment of children with a genuine sociodental<br />
need 4 .<br />
Holmes 5 found that 38.5% of 12 year olds would greatly<br />
benefit from orthodontic treatment. The most common<br />
severe problems in a normal population are detailed:<br />
3. Why do people need braces?<br />
Evidence suggests that correcting the following tooth/<br />
jaw anomalies with orthodontic appliances will benefit the<br />
patient’s long-term dental health:-<br />
Crowding: Teeth may be poorly aligned because<br />
the teeth are too large for the mouth. Poor biting<br />
relationships and unsightly appearance may all result from<br />
crowding of the teeth. The upper canine teeth are one of<br />
the most frequent culprits.<br />
Deep (traumatic) overbite: Extreme (vertical) overlap<br />
of the top and bottom front teeth can lead to them<br />
contacting the roof of the mouth causing significant tissue<br />
damage and gum stripping. In some patients, this can<br />
contribute to excessive tooth wear and early tooth loss in<br />
adulthood.<br />
Increased overjet: Upper front teeth that protrude<br />
beyond normal contact with the lower teeth often<br />
indicate a poor bite of back teeth and can indicate<br />
unevenness in jaw growth. Thumb and finger sucking<br />
habits can also cause prominence of the upper incisor<br />
teeth and increase the risk of trauma and permanent<br />
Dental Feature Prevalence<br />
in<br />
Population<br />
(%)<br />
CLEFT LIP AND<br />
0.3%<br />
PALATE<br />
IMPACTED TEETH 8.5%<br />
HYPODONTIA<br />
(missing teeth)<br />
1.8%<br />
REVERSE OVERJET<br />
(lower teeth in front<br />
of upper teeth)<br />
LARGE OVERJETS (top<br />
teeth stick out)<br />
CROSSBITE AND<br />
DEVIATION OF JAWS<br />
ON CLOSING<br />
DEEP OVERBITE<br />
(lower teeth bite on<br />
palate)<br />
SEVERE CROWDING<br />
OF TEETH<br />
OPEN BITE (teeth do<br />
not meet)<br />
2.1%<br />
8.8%<br />
3.0%<br />
4.3%<br />
9.0%<br />
0.7%<br />
5
damage to the front teeth. A systematic review of the<br />
available evidence on this topic found that individuals<br />
with an increased overjet had more than double the risk<br />
of injury 6 .<br />
Open Bite: An open bite results when the upper and<br />
lower front teeth do not touch when biting together. This<br />
leads to all the chewing pressures being placed on the<br />
back teeth, which may cause these teeth to wear down<br />
quicker. It may also make the patient’s biting less efficient,<br />
which may cause social problems especially at meal times.<br />
Spacing: If teeth have either not developed or are<br />
missing, or smaller than average in size, unsightly spaces<br />
may occur between the teeth. This is a less common<br />
problem though when compared with patients who have<br />
significant crowding of their teeth. Some malocclusions<br />
have a greater adverse effect on quality of life than other<br />
types. Individuals with four or more missing teeth have<br />
been shown to have poorer “quality of life” scores 7 .<br />
Crossbite: This occurs when the upper front teeth bite<br />
inside the lower teeth i.e. towards the tongue. This can<br />
lead to one or more of the lower incisor teeth becoming<br />
mobile with early receding of the gums. It can also occur<br />
on the back teeth and is best corrected at an early age<br />
e.g. 8-10 years, due to biting and chewing difficulties as a<br />
result of the deviated bite and associated displacement of<br />
the lower jaw.<br />
“Reverse” overjet or lower jaw protrusion:<br />
Approximately 3 - 5% of the population have a lower<br />
jaw that is significantly longer than their upper jaw. This<br />
causes them to bite their lower front teeth ahead of the<br />
upper front teeth thus creating a total crossbite of the<br />
teeth. It can also lead to significant wearing down of the<br />
tips of the upper front teeth.<br />
6
4. Health gains from orthodontic treatment<br />
Improved dental health and resistance to<br />
dental disease: Clinical experience suggests that<br />
poorly aligned teeth reduces the potential for natural<br />
tooth cleansing and increases the risk of tooth decay.<br />
Malocclusion could thereby contribute to both<br />
dental decay and periodontal disease, which would<br />
damage the long-term health of the teeth and gums<br />
as it makes it harder for the patient to take care of<br />
their teeth properly 8 . However, the evidence linking<br />
periodontal (gum) disease and crowding of the teeth<br />
is conflicting. Some studies have found no associations<br />
between crowded teeth and periodontal destruction 9 .<br />
Others have shown that mal-aligned teeth may have<br />
more plaque retention than straight teeth but socioeconomic<br />
group, gender, tooth size and tooth surface<br />
have greater influences 10 . Studies seem to indicate that<br />
malocclusion has little impact on diseases of the teeth<br />
or supporting structures as the presence or absence of<br />
dental plaque is the major determinant of the health of<br />
the hard and soft tissues of the mouth. Straight teeth<br />
may be easier to clean than crooked ones but patient<br />
motivation and dental hygiene seems to be the overriding<br />
influencing factor in preventing gum disease 9 .<br />
Having straighter teeth may help moderate tooth<br />
brushers to be more efficient with their oral care.<br />
Improvements in the overall function of<br />
the dentition: Teeth which do not bite together<br />
properly, can make eating difficult. Individuals<br />
who have a poor occlusion can find it difficult and<br />
embarrassing to eat because of their poor control of<br />
either biting through food or poor chewing ability<br />
on their back teeth. Adults with severe malocclusion<br />
often report difficulties in chewing, swallowing or<br />
speech. Studies have found no causative association<br />
between orthodontic treatment and jaw joint (TMJ)<br />
problems 11, 12 . In the main, speech is little affected<br />
by malocclusion. However, if a patient cannot attain<br />
contact between their front teeth, this may contribute<br />
to the production of a speech lisp.<br />
Prevention of trauma to prominent teeth: The<br />
risk of trauma/injury to upper incisors has been shown<br />
to increase to 45% for children with significantly<br />
7
protruding upper front teeth 13 . These malocclusions<br />
score a Dental Health Component of 5, indicating<br />
a “great need” for treatment. Such trauma to the<br />
mouth of an untreated child can result in a fracture<br />
of the tooth and/or damage of the tooth’s nerve<br />
(pulp). Prominent upper front teeth are an important<br />
and potentially harmful type of orthodontic problem.<br />
Providing early orthodontic treatment for young<br />
children (aged 7-9 years) with prominent upper front<br />
teeth is of questionable clinical significance. It may be<br />
prudent to delay treatment until early adolescence.<br />
However, important factors such as psychological<br />
impact and the reduction of associated accidents<br />
(trauma) to the protruding front teeth need to be<br />
evaluated on an individual basis 14 .<br />
Treatment of impacted (buried, partially<br />
erupted) teeth: Unerupted teeth may cause<br />
resorption (dissolving) of the roots of adjacent teeth.<br />
Cyst formation can also occur around unerupted<br />
wisdom or canine teeth. Extra (supernumerary) teeth<br />
may also give rise to problems and prevent the normal<br />
eruption of a permanent tooth. Unerupted or partially<br />
erupted wisdom teeth can often be left alone in the<br />
mouth if they are not giving the patient any problems.<br />
Improvement in dental/facial aesthetics: Often<br />
resulting in improved self-esteem and other psychosocial<br />
aspects of the individual. Until recently, this<br />
aspect has been harder to measure and quantify. A<br />
number of studies over the years have confirmed that<br />
a severe malocclusion can be a social handicap. Social<br />
responses, conditioned by appearance of the teeth,<br />
can severely affect an individual’s whole adaptation<br />
to life. This can lead to the concept of a patient’s<br />
malocclusion being “handicapping”.<br />
One of the most significant effects of a malocclusion<br />
is its psycho-social impact on the individual patient.<br />
There is little doubt that a poor dental appearance<br />
can have a profound psycho-social effect on children.<br />
Shaw et al. (1980) found that children were teased<br />
more about their teeth than anything else e.g. clothes,<br />
weight, ears. A person’s dental appearance can have a<br />
significant effect on how they feel about themselves 15 .<br />
Children and adolescents with poor teeth can often<br />
8
ecome targets for teasing and harassment from other<br />
children. This results in these patients being unsure<br />
of themselves in social interaction and having lower<br />
self-esteem.<br />
Adolescents who complete orthodontic treatment<br />
report fewer oral health impacts on their daily life<br />
activities than those who had never had treatment.<br />
Groups of children who need orthodontic treatment<br />
exhibit significantly higher impacts on their emotional<br />
and social well-being 16 . Malocclusion has a negative<br />
impact on the oral health related quality of life of<br />
adolescents. Children aged between 11 and 14 years<br />
old with malocclusion demonstrate significantly more<br />
“impacts” i.e. worse quality of life, compared with a<br />
minimal malocclusion group based on the IOTN 17 .<br />
Johal et al. (2006) investigated the impact that<br />
a malocclusion has on a child’s quality of life by<br />
assessing the effect of an increased overjet (>6mm)<br />
or spaced front teeth. These groups of children also<br />
had more significant social and emotional issues than<br />
children with well-aligned teeth 18 . Their research also<br />
found that both these occlusal traits had a significant<br />
negative impact on the quality of life of their parents<br />
and other family members.<br />
Shaw et al. (2007) carried out a major multidisciplinary<br />
longitudinal study in Cardiff back in 1981<br />
of an initial sample of 1,018 11-12 year olds. A 20-year<br />
follow-up study looked at the dental and psycho-social<br />
status of individuals who received, or did not receive,<br />
orthodontics as teenagers 19 . Unfortunately, only a third<br />
(n=337) of the original sample could be re-examined<br />
in 2001 due to a 67% dropout rate. Those patients<br />
with a prior need for orthodontic treatment, who had<br />
treatment completed as a child, demonstrated better<br />
tooth alignment, better self-esteem and “satisfaction<br />
with life” scores. However, orthodontics seemed to<br />
have little positive effect on psychological health<br />
and quality of life in adulthood. Unfortunately, this<br />
long-term study suffered with problems of an archaic<br />
treatment regime (mainly removable appliances being<br />
used), antique methodology and short retention<br />
regime. Its relevance to 21st century orthodontics is<br />
therefore debatable.<br />
9
In summary, it appears that both psycho-social and<br />
functional handicaps can produce a significant need for<br />
orthodontic treatment in addition to the dental health<br />
benefits described.<br />
The benefits of orthodontic treatment include an<br />
improvement in dental health, function, appearance and<br />
self-esteem. These perceived benefits are described in<br />
more detail below. Prospective patients (and their parents)<br />
seem to be confident of the gains that they expect to<br />
achieve by undergoing a course of orthodontic treatment.<br />
The benefits of orthodontic treatment often go beyond<br />
improving a person’s dental health. People may feel they<br />
look better, which can contribute to self-esteem and one’s<br />
overall quality of life 20 .<br />
5. Risks of orthodontic treatment<br />
In the vast majority of well-planned cases, the benefits<br />
of orthodontic treatment outweigh the possible<br />
disadvantages. Patient education and the selection of<br />
appropriate treatment plans for individuals reduce this risk<br />
considerably. The most important aspect of orthodontic<br />
care is to have an extremely high standard of oral hygiene<br />
before and during orthodontic treatment 21 .<br />
i. Early tooth decay: poor oral hygiene (tooth<br />
brushing) can lead to damage of the teeth around<br />
orthodontic braces. Early tooth decay (decalcification) will<br />
occur when plaque accumulates around a fixed brace in<br />
the presence of frequent sugar intake. Thorough dietary<br />
advice, excellent oral hygiene and the use of fluoride<br />
supplements are used routinely by orthodontists to<br />
minimise this risk.<br />
ii. Root Resorption: mild loss of tooth root tissue<br />
(dissolving) is very commonly seen as a consequence of<br />
tooth movement but this does not cause any long-term<br />
problems for the vast majority of patients.<br />
iii. Loss of Periodontal Support: if a patient’s oral<br />
hygiene is poor during treatment, orthodontics may<br />
exacerbate gingival inflammation and susceptibility to<br />
periodontal (gum) disease. Patients who have undergone<br />
orthodontic treatment do not have any increased predisposition<br />
to developing periodontal disease 22 .<br />
10
6. Demand for orthodontic treatment<br />
Orthodontics has played an increasing role in dentistry<br />
over recent years and this trend is likely to continue in<br />
the future. Recent surveys of the long-term effects of<br />
orthodontic treatment reveal that the vast majority of<br />
individuals who have undergone orthodontic treatment<br />
feel that they benefited from the treatment and are<br />
pleased with the result. Many patients will demonstrate<br />
dramatic changes in their dental and facial appearance.<br />
It is well known that not all patients with malocclusion,<br />
even those with extreme deviations from normal, seek<br />
orthodontic treatment. The perceived need for treatment<br />
is influenced by both social and cultural factors and<br />
currently the demand for treatment greatly exceeds the<br />
resources available. There has been a marked increase in<br />
demand from both children and adults seeking treatment<br />
since the 1980s as a result of more dental awareness<br />
by the public in conjunction with an increased social<br />
acceptance of fixed braces.<br />
7. What is the best time to carry out<br />
orthodontic treatment?<br />
Each year, in excess of 130,000 patients (most of whom<br />
are children under the age of 18 years) have braces fitted<br />
under the NHS in England & Wales. There is a wide range<br />
of opinion on the best time to start orthodontic treatment<br />
but the vast majority is carried out on children who have<br />
lost all their baby (deciduous) teeth and have most of<br />
their adult teeth (except for wisdom teeth) present in<br />
the mouth. This means that the earliest the majority<br />
of children commence their orthodontic treatment is<br />
between 11-12 years of age.<br />
Orthodontic treatment provided whilst many baby teeth<br />
are still present in the mouth, i.e. at age 7-9 years, is<br />
regarded as early or interceptive treatment. A common<br />
example of this type of orthodontic treatment is in<br />
cases with anterior and/or lateral crossbites with jaw<br />
displacement on mouth closure 23, 24 . Simple expansion<br />
appliances (removable or fixed types) are usually<br />
employed to deal with this clinical situation over a<br />
11
few months. Another example of valid interceptive<br />
orthodontic treatment is where the timely removal of<br />
a baby tooth can enable the spontaneous (natural)<br />
correction of a dental centreline shift or allows an “offtrack”<br />
(ectopic) adult tooth to erupt into its correct<br />
position in the mouth without the need for braces.<br />
Most UK orthodontists do not favour early treatment<br />
to correct increased overjets, deep overbites or severe<br />
dental crowding and prefer to carry out this treatment<br />
at the more “ideal” age of 10-12 years or later. Early<br />
treatment for increased overjets is commonplace in<br />
the USA and mainland Europe. It is described as “two<br />
phase” treatment as it involves a period of early active<br />
treatment with a functional or removable appliance<br />
followed by a second phase with fixed braces once all<br />
the adult teeth are present in the mouth. This compares<br />
with “one phase” treatment of adult teeth where the<br />
functional and fixed brace treatments are combined<br />
thereby reducing the overall treatment time and possibly<br />
cost. The optimal timing for treatment of children with<br />
increased overjets remains controversial 25 and needs to<br />
be based on individual indications for each child. Good<br />
communication skills can identify specific children whose<br />
psychological well being can be improved by early<br />
treatment 26 .<br />
8. Providers of orthodontic care<br />
In the United Kingdom (UK), orthodontic care is provided<br />
within the state funded NHS at no direct cost to the<br />
patient or their parents. All Specialist Orthodontists are<br />
Dentists but only about 3% of Dentists are Orthodontists.<br />
An Orthodontist is a specialist in the diagnosis, prevention<br />
and treatment of dental irregularities and facial growth<br />
anomalies. An Orthodontic Specialist must complete<br />
an initial 5-year dental undergraduate programme at a<br />
University Dental School and then successfully complete<br />
an additional 3-year post-graduate programme of<br />
advanced education in orthodontics. By the completion<br />
of their specialist training, trainees will have undertaken<br />
a Masters Degree and the Membership in Orthodontics<br />
from one of the Royal Colleges. Currently, hospital and<br />
university trainees complete two years of additional<br />
12
training before they can become eligible to apply for<br />
consultant posts.<br />
At present, there are approximately 1200 orthodontic<br />
specialists in the UK. These are made up of specialist<br />
practitioners, hospital consultants and community<br />
orthodontists. Compared with the rest of the developed<br />
world, the UK is severely short of qualified orthodontists.<br />
The UK is 15th out of 17 European countries in terms of<br />
orthodontic provision with 1 orthodontist per 73,000<br />
population - only Spain and Turkey are worse off.<br />
Germany and Austria top the table with 1 per 30,000<br />
- the average is 1 in 55,000. Many other European<br />
countries utilise orthodontic therapists to work along<br />
side orthodontists as part of the orthodontic team. The<br />
number of funded training places and the very recent<br />
introduction of orthodontic therapists in the UK will<br />
influence the future availability of orthodontic care.<br />
There is a wealth of evidence to show that orthodontic<br />
treatment is more likely to achieve a pleasing, successful<br />
result if fixed appliances rather than removable appliances<br />
are used 27-30 and if the operator has had some postgraduate<br />
training in orthodontics 31, 32 . The likelihood that<br />
orthodontic treatment will benefit a patient is increased<br />
if a malocclusion is severe 28 and if appliance therapy is<br />
planned and carried out by an experienced orthodontist 29 .<br />
However, the likelihood of either a health or psycho-social<br />
gain is reduced if the malocclusion is mild and treatment<br />
is undertaken by an inexperienced operator 33 .<br />
13
References<br />
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Summary Report Office for National Statistics: March 2005.<br />
2. Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. European Journal of<br />
Orthodontics, 1989; 11: 309-320.<br />
3. Richmond S, Shaw WC, O’Brien KD, Buchanan IB. et al. The development of the PAR index: reliability and<br />
validity. European Journal of Orthodontics, 1992; 14: 125-139.<br />
4. De Oliveira CM, Sheiham A, Tsakos G and O’Brien KD. Oral health-related quality of life and the IOTN<br />
index as predictors of children’s perceived needs and acceptance for orthodontic treatment. British Dental<br />
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5. Holmes A. The Prevalence of Orthodontic Treatment Need. British Journal of Orthodontics, 1992; 19:<br />
177-182.<br />
6. Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of the relationship between<br />
overjet size and traumatic dental injuries. European Journal of Orthodontics, 1999; 21: 503-515.<br />
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195: 433-437.<br />
9. Geiger A, Wasserman B, Turgeon L. Relationship of occlusion and periodontal disease. Part 8:<br />
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Periodontology, 1974; 45: 43-49.<br />
10. Davies T, Shaw W, Worthing H. et al. The effect of orthodontic treatment on plaque and gingivitis.<br />
American Journal of Orthodontics & Dentofacial Orthopedics, 1988; 93: 423-428.<br />
11. Sadowsky C. Risk of orthodontic treatment for producing temporo-mandibular disorders: A literature<br />
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12. Luther F. Orthodontics and the TMJ: Where are we now? Angle Orthodontist, 1998; 68: 295-318.<br />
13. Todd J, Dodd T. Children’s dental health in the United Kingdom. London: Office of Population Census<br />
and Surveys, 1985.<br />
14. Harrison JE, O’Brien KD, Worthington HV. Orthodontic treatment for prominent upper front teeth in<br />
children. Cochrane Database of Systematic Reviews, 2007; Issue 3.<br />
15. Shaw WC, Meek SC, Jones DS. Nicknames, teasing harassment and the salience of dental features<br />
among school children. British Journal of Orthodontics, 1980; 7: 75-80.<br />
16. De Oliveira CM, Sheiham A. The relationship between normative orthodontic treatment need and oral<br />
health-related quality of life. Community Dentistry Oral Epidemiology, 2003; 31: 426-436.<br />
17. O’Brien C, Benson PE, Marshman Z. Evaluation of a quality of life measure for children with<br />
maloccluson. Journal of Orthodontics, 2007; 34: 185-193.<br />
14
18. Johal A, Cheung MYH, Marcenes W. The impact of two different malocclusion traits on quality of life.<br />
British Dental Journal, 2007; 202: E6.<br />
19. Shaw WC, Richmond S, Kenealy PM, Kingdon A, Worthongton H. A 20-year cohort study of health<br />
gain from orthodontic treatment: Psychological outcome. American Journal of Orthodontics & Dentofacial<br />
Orthopedics, 2007; 132: 146-157.<br />
20. Turpin DL. Orthodontic treatment and self-esteem (Editorial)<br />
American Journal of Orthodontics & Dentofacial Orthopedics, 2007; 131: 571-572.<br />
21. Travess H, Robert-Harry D, Sandy J. Orthodontics. Part 6: Risks in orthodontic treatment. British Dental<br />
Journal, 2004; 196: 71-77.<br />
22. Sadowsky C, BeGole EA. Long term effects of orthodontic treatment on periodontal health. American<br />
Journal of Orthodontics, 1981; 80: 156-172.<br />
23. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database of Systematic<br />
Reviews, 2001; Issue 1.<br />
24. Pietilä I, Pietilä T, Pirttiniemi P. et al. Orthodontists’ views on indications for and timing of orthodontic<br />
treatment in Finnish public oral care. European Journal of Orthodontics, 2008; 30: 46-51.<br />
25. Tulloch JFC, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II<br />
treatment. American Journal of Orthodontics & Dentofacial Orthopedics, 2004; 125: 657-667.<br />
26. O’Brien K. et al. Effectiveness of early orthodontic treatment with the Twin-Block appliance: a multicenter,<br />
randomized, controlled trial. Part 2: Psychosocial effects. American Journal of Orthodontics &<br />
Dentofacial Orthopedics, 2003; 124: 488-494.<br />
27. Jones ML. The Barry Project – a three-dimensional assessment of occlusal treatment change in a<br />
consecutively referred sample: Crowding and arch dimensions. British Journal of Orthodontics, 1990; 17:<br />
269-285.<br />
28. Richmond S, Shaw WC, Stephens CD, Webb WG, Roberts CT, Andrews M. Orthodontic standards in the<br />
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within the General Dental Services. British Journal of Orthodontics, 1997; 24: 217-221.<br />
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33. Mitchell L. 2007 Chapter 1.6 ‘The effectiveness of treatment’, page 5, in ‘An Introduction to<br />
Orthodontics’ 3rd edition, Oxford University Press, England.<br />
15
Produced by the Clinical Standards Committee of the<br />
British Orthodontic Society 2008<br />
British Orthodontic Society<br />
12 Bridewell Place London EC4V 6AP<br />
Email: ann.wright@bos.org.uk www.bos.org.uk Telephone: 020 7353 8680 Fax: 020 7353 8682<br />
Registered Charity No: 1073464<br />
CB 1 July 09