This month Zaid Esmail, a specialist orthodontist at Total Orthodontics, part of Bupa Dental Care, discusses which patients would benefit from early referral.
Playing catchup post-pandemic means we must streamline and triage the referrals and prioritise the patients needing immediate attention.
One common question we get asked is when the GDP should refer early. Most of the orthodontic treatment carried out in the UK is in the early permanent dentition, thus an early referral would be described as a patient in the mixed dentition.
Furthermore, NHS funding for interceptive treatment expects the treatment would start before the patient’s 10th birthday.
This article will outline the patients that would benefit from an early referral and highlight the optimal referral age depending on the malocclusion.
Referrals in early mixed dentition
Anterior crossbite
This is one of the most common reasons for early referrals. An upper incisor in crossbite can be easily and quickly corrected with a short course of removable or fixed appliances. Furthermore, the resultant overbite and the occlusion allows the result to be stable.
Only upper central incisors that are in crossbite benefit from early correction. Maxillary lateral incisors that erupt in crossbite are usually because of crowding, and therefore there is less benefit in early correction.
In addition, a corrected anterior crossbite with a good overbite is self-retaining and doesn’t usually require any appliances to be worn to maintain the result.
With excellent compliance, an anterior crossbite can be corrected within three months.
Poor prognosis first molars
Patients who present with poor prognosis first molars benefit from an orthodontic assessment at the age of eight/nine. This will establish if early removal of said molars are beneficial in the long term.
The timing and indication of extractions of first molars are beyond the scope of this article.
Posterior crossbite
Posterior crossbites affecting the first molars often warrant a referral, especially if there is a marked displacement on closing. Occasionally, these can resolve on their own. This is because the cause of the displacement is sometimes the position of the deciduous canines, and as these exfoliate, the crossbite can self-correct.
Correction of a posterior crossbite is usually carried out by any expansion appliance. However, retention can be tricky as these movements are prone to relapse.
Early expansion treatment can be controversial as it is routinely carried out in many countries outside the UK. It is thought that this can reduce the extraction rate. However, some studies show that over 85% of gained expansion is lost when transitioning into the permanent dentition.
Space maintainers
Early loss of deciduous molars, especially second molars, can result in space loss as the adjacent first molar drifts into the space. Space maintainers can be used to maintain the space while the permanent successor erupts.
However, this should be assessed on a case-by-case basis. The second premolars don’t normally erupt until the age of 11-13. In addition, the space maintainer would need to be kept in place and monitored during this time.
This can be difficult to keep clean, and oral hygiene and diet would need to be scrupulous. Unfortunately, most patients with caries in the deciduous dentition that require extractions may not be able to maintain the levels of oral hygiene required; thus a space maintainer would be contraindicated.
Class II correction
Some evidence suggests early treatment of Class II malocclusions can increase self-esteem and reduce trauma risk. However, the biggest challenge of treating such patients is the burden of treatment and the time frame that is required.
Almost all patients that undergo early functional treatment will also benefit from a course of fixed appliances when they reach the permanent dentition. This is usually achieved by part-time wear of the appliance. However, fit issues arise as the deciduous teeth exfoliate and the permanent successors erupt.
Retention and transition to fixed
The biggest obstacle for early orthodontic treatment is retaining the result while the deciduous dentition exfoliates and the permanent dentition establishes.
Specific interventions, such as anterior crossbite correction, are self-retaining due to the overbite. However, retaining expansion and Class II correction can be difficult during the transition stage, and some relapse may be inevitable.
Impacted canines
Maxillary canines should be palpable in the buccal sulcus by the time the patient reaches ten years of age. There is some evidence to suggest that the early removal of the deciduous canine may improve the prognosis of the impacted canine.
A referral is warranted if the canines cannot be palpated.
Delayed eruption of a maxillary incisor
Further investigation and referral should be considered where one maxillary central incisor erupts and the adjacent incisor doesn’t appear within nine to 12 months. An unerupted supernumery may be impeding the eruption.
NHS orthodontics and early referrals
The NHS will fund an interceptive course of treatment. However, once the permanent dentition establishes, the NHS will only fund a comprehensive course of treatment subject to their IOTN.
It is not uncommon for a patient to undergo an interceptive course of treatment which then improves their IOTN, thus not qualifying for further treatment.
Interceptive orthodontic treatment should only be considered where it can negate the need or simplify future orthodontic treatment. A balance should be made between the risk of overburdening the patient with treatment over the benefit of any resulting treatment.
Read previous Total Orthodontics columns:
- Orthodontics to the rescue!
- Extracting poor prognosis first molars in mixed dentition
- What are fixed functional appliances?
- The ins and outs of DIY orthodontics
- IPR is nothing to fear.
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