You will appreciate that it is not possible to be totally prescriptive about what should be referred and when but we have tried to put down some simple guidelines which we hope are helpful. If in doubt though please do refer the patient and it is much better to do this too early than too late. Even is the patient is not yet ready for treatment, it is usually possible to provide an idea of how the occlusion is developing and predict the problems that are likely arise. Even if no treatment is planned for the near future, patients and parents usually appreciate knowledge in advance of what the options are likely to be.

We have divided this into three sections:

Features to refer early
Routine referral
Later referral

Please click on each section for more details.

Features to refer early

First permanent molars of dubious long-term prognosis

It is often in the patient's long-term interest to incorporate the loss of severely hypoplastic, carious or heavily restored teeth into the overall orthodontic treatment plan even if no active appliance therapy is indicated. It is helpful if the extractions can be timed to provide the maximum opportunity for spontaneous improvements to occur as this will reduce the amount of active appliance therapy needed later. If therefore the prognosis of the first permanent molars appears at all doubtful, it is helpful to see the patient as early as possible.

Ectopic canines

If it is not possible to palpate a maxillary canine teeth labially by the time the patient is 9-10 years old, there is a good chance that it is lying in an ectopic position. This affects about 1% of the population so is reasonably common. If this is spotted in time, interceptive treatment in the form of the removal of the deciduous precursors can be helpful and there is evidence to suggest that this reduces the probability of needing to resort to later surgical exposure. It is worthwhile therefore to radiographically assess the position of all canines which are not palpable at this age.

Hypodontia

As soon as it is apparent that any of the permanent teeth are or may be absent, it is worthwhile carrying out a full orthodontic assessment as early intervention can make later treatment less complicated. It is not justifiable to radiographically screen all patients for missing teeth but sometimes radiographs will have been taken for other reasons or the situation may be clinically apparent early e.g. the failure of the lateral incisors to erupt combined with a large midline diastema. Even if early treatment is not indicated, parents are often reassured to learn that this is quite a common problem (affecting approximately 6% of the population) and can be satisfactorily managed in the fullness of time.

Cross-bites

It is not uncommon for incisors to erupt into cross-bite and it is often a very simple task to correct this interceptively. As a general rule, the earlier this is carried out the better and this particularly relates to lateral incisors as the canine crowns can often take up a position labial to the roots of the lateral incisors at quite an early age. Successful interceptive anterior cross-bite correction normally promotes more normal development of the remaining dentition and may in some cases eliminate the need for further treatment.

Posterior cross-bites are more difficult to correct interceptively but it is still worthwhile seeing these patients early.

Large overjets

Research indicates that overjets greater than 6mm, especially when combined with lip incompetence, are associated with a much greater incidence of dental trauma. It is therefore worthwhile seeing these patients early so the option of early treatment to reduce the overjet can at least be discussed with the patient and parent.

Late eruption

There is of course a lot of biological variation with dental development and it is not therefore abnormal for teeth to erupt late in some individuals. The important factor is the chronological sequence of the eruption and as a basic rule of thumb, it is a tooth is more than 6 months later erupting than it's contra-lateral equivalent, it can be considered late. This may be due to a number of reasons, e.g. severe crowding , the presence of supernumary teeth or previous dental trauma having caused a dilacerated root, and is worth investigating radiographically.

Supernumary teeth

Supernumary teeth come in all shapes and sizes and can be present anywhere.

They are quite common affecting approximately 1% of the population. They may be spotted as a coincidental finding on a radiograph taken for other reasons or be suspected due to the late eruption of a tooth or the abnormal position of erupted teeth, e.g. the presence of a large diastema. Not all of them need to be removed but it is worth assessing the situation as soon as they are identified or suspected.

A particular desire to avoid the need for dental extractions.

Although we would never consider removing permanent teeth unless we feel it is in the patient's best interest, we appreciate that some parents do feel strongly about this. While we will not be persuaded to treat a patient non-extraction if we feel that this would be harmful, we will happily discuss the pros and cons of arch expansion in each particular case so at least they can make an informed decision. If this is likely to be an issue, an early referral will keep more options open.

Routine referral

Aside from the above mentioned features, it is appropriate to assess a new patient as the last successional teeth erupt. By this time, the patient will usually be able to judge any features they are not happy with and planning treatment at this early age keeps as many treatment options available as possible.

Orthodontic treatment can be justified for a number of reasons and these fall into one of two basic categories:

Aesthetic improvement

Although treatment to improve the appearance of some-one's smile can be loosely defined as "cosmetic", there is no doubt that some malocclusions can be quite disfiguring. There is plenty of research to show that the psychological health of a child during these formative years can be affected by the appearance of their teeth and treatment can therefore be very beneficial. The only point of contention is where to draw the line between what is worth improving and what is acceptable. The Department of Health have looked at this on more than one occasion but have to date seen no justification to ration NHS funding for orthodontic treatment. The only tool we can therefore use at the moment is a risk:benefit assessment, i.e. whether we feel the potential benefits of treatment outweigh the possible risks involved and both these are unique for each patient. Beauty after all is in the eye of the beholder.

Dental Health improvement

There is no doubt that certain malocclusions present a risk in terms of dental health and there are various indices available which attempt the quantify these. As with all clinical matters, there is an element of interpretation involved and so it is not possible to be totally prescriptive with what needs to be treated. The following are examples though:

Later referral

Despite all the best made plans and guidelines as to when it is best to treat which features of a malocclusion, some patients simply present late for treatment. This may be due to a child not previously attending to see a general dental practitioner, previously deciding not to have orthodontic treatment and then changing their mind or it may just be that the malocclusion has actually established itself late. Teeth rarely maintain their precise position and facial growth never completely ceases and it is fairly common for example for lower anterior teeth to become more crowded with time.

There is absolutely no reason why any patient should not consider orthodontic treatment either to improve the appearance of their teeth or to address a specific dental health concern. Some treatment options become less viable with age, particularly when growth is complete, but teeth can be safely orthodontically moved at any age, even if they are non-vital provided the periodontium is healthy.

We are finding that the number of adult patients seeking orthodontic treatment is approximately doubling every year and this trend is likely to continue as it has in the United States . The industry is also constantly evolving to find ways of making orthodontic treatment more acceptable to adult patients and it is now possible to use appliances which are virtually invisible. See our section on section on Different Appliance Types .