for Orthodontics and - AAO Members

40 Pages·2014·0.26 MB·English

ATTACHMENT A

1
2
3

4
Clinical Practice Guidelines
5
for
6
Orthodontics and
7
Dentofacial Orthopedics 2008
8
9
10
11
12
13
14
15 This document may not be copied or reproduced without the
16 express written permission of the AAO
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33 © 2008 2012 American Association of Orthodontists
34 Created: 1996
35 Amended: 2001, 2009, 2010, 2012, 2014
36 Date: September 9, 2008; Adopted May 2009
37 Amended May 2010
38 Amended May 2012
39
1
ATTACHMENT A

1 TABLE OF CONTENTS
2
3 Clinical Practice Guidelines for Orthodontics and 1
4 Dentofacial Orthopedics 2008 1
5 This document may not be copied or reproduced without the 1
6 express written permission of the AAO 1
7 Introduction…………………………………………………………………………………………………. 3
8 Pretreatment Considerations…………………………………………………………………………... 4
9 Examination………………………………………………………………………………………………… 4
10 Diagnostic Records……………………………………………………………………….………………. 5
11 Referral……………………………………………………………………………………………………... 5
12 Diagnosis and Treatment………………………………………………………………………………... 5
13 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and Dental
14 Alveolus…………………………………………………………………………………………………….. 6
15 Anomalies of Tooth Position, Discrepancies of Tooth Size and Arch Length………………………. 9
16 Abnormalities of Tooth Number Morphology, and Eruption Pattern………………………………….10
17 Dentofacial Functional Abnormalities……………………………………………………………………12
18 Craniofacial Anomalies, Cleft Lip and Palate…………………………………………………………...13
19 Treatment Objectives and Limiting Factors……………………………………………………………..14
20 Goals………………………………………………………………………………………………………...14
21 Limiting Factors…………………………………………………………………………………………….14
22 Treatment Consultation and Informed Consent………………………………………………………...14
23 Risks Associated with Orthodontic Treatment………………………………………………………….15
24 Risks Associated with Adjunctive Procedures in Orthodontics……………………………………….16
25 Post Treatment Evaluation and Outcomes Assessment………………………………………………16
26 Post Treatment Records…………………………………………………………………………………..16
27 Positive Outcomes of Treatment…………………………………………………………………………16
28 Negative Outcomes of Treatment………………………………………………………………………..17
29 Retention……………………………………………………………………………………………………17
30 Record Keeping…………………………………………………………………………………………….17
31 Transfer of Orthodontic Patients………………………………………………………………………….18
32 Recommendations to the Transferring Practitioner…………………………………………………….18
33 Recommendations to the Accepting Practitioner……………………………………………………….18
34 Patients Who Wish to Transfer because of Dissatisfaction with Current Orthodontist……………..19
35 Recommendations to the Transferring Practitioner…………………………………………………..19
36 Recommended Procedures for Accepting Orthodontist……………………………………………...19
37 Evidence-Based Dentistry………………………………………………………………………………...19
38 Definition…………………………………………………………………………………………………….19
39 Levels of Evidence…………………………………………………………………………………………20
40 Best Evidence………………………………………………………………………………………………20
41 Evidence-Based Clinical Recommendations……………………………………………………………20
42 HIPAA……………………………………………………………………………………………………….20
43 Appendix A: Historical Development ……………………………………………………..…………….22
44 Appendix B: Updating of Clinical Practice Guidelines…………………………………………………23
45 Appendix C: Clinical Practice Guidelines Members………………….………………………………..25
46 Selected References………………………………………………………………………………………25
47
2
ATTACHMENT A

1 Introduction
2
3 Orthodontics and Dentofacial Orthopedics is a the specialty area of dentistry concerned with the
4 supervision, guidance and correction of the growing or mature dentofacial structures, including
5 those conditions that require movement of teeth or correction of malrelationships and
6 malformations of their related structures and the adjustment of relationships between and among
7 teeth and facial bones by the application of forces and/or the stimulation and redirection of
8 functional forces within the craniofacial complex. Major responsibilities of orthodontic practice
9 include the diagnosis, prevention, interception, and treatment of all forms of malocclusion of the
10 teeth and associated alterations of their surrounding structures; the design, application, and
11 control of functional and corrective appliances; and the guidance of the dentition and its supporting
12 structures to attain and maintain optimal occlusal relations and physiologic and esthetic harmony
13 among facial and cranial structures.
14
15 A specialist in orthodontics and dentofacial orthopedics meets educational standards established
16 by the Commission on Dental Accreditation of the American Dental Association (ADA) and must
17 possess advanced knowledge in biomedical, clinical, and basic sciences. This knowledge includes
18 the biology of tooth movement, cephalometrics, orthodontic diagnosis, treatment planning, surgical
19 orthodontics, biomechanical principles, the effects of growth and development on tooth movement,
20 application of orthopedic forces to dentofacial structures, and patient management and motivation.
21
22 The American Association of Orthodontists (AAO) is the leading national organization of dentists
23 who limit their practice to orthodontics and dentofacial orthopedics and is recognized by the ADA
24 as the sponsoring organization of the national certifying board, the American Board of
25 Orthodontics. The membership of the AAO includes approximately 94% of practicing orthodontists
26 in the United States. The AAO has the background, expertise, and professional responsibility to
27 assist the dental profession and the public by developing clinical practice guidelines for
28 orthodontics and dentofacial orthopedics. The AAO recognizes its role in upholding the public trust
29 granted to it by presenting these clinical practice guidelines to help practitioners develop
30 judgments on diagnosis, treatment planning, and timing of orthodontic and dentofacial orthopedic
31 therapy. The primary concern of the AAO is the provision of high quality orthodontic care and the
32 protection of the public.
33
34 Practice guidelines, as defined by the Institute of Medicine, are “systematically developed
35 statements to assist practitioner and patient decisions about appropriate health care for specific
36 clinical circumstances.”
37
38 The Orthodontic Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics
39 presented in this document are condition based and are related to the International Classification
40 of Diseases, Clinical Modification, 9th Edition (ICD-9Codes). This approach recognizes the need
41 for integrated treatment of oral and dentofacial conditions rather than isolated treatment
42 procedures. These guidelines are also directed toward the process of patient care and outline
43 considerations related to diagnosis, treatment, and quality of care.
44
45 These guidelines were derived from a professional consensus, based on a review of relevant
46 clinical and scientific literature, the expert opinion of educators, and the clinical experience of
47 practicing orthodontists. Similar documents written by other organizations and publications related
48 to guideline development were also reviewed.
49
50 There are various professionally accepted philosophies regarding orthodontic diagnosis,
51 treatment, and retention. Because of the nature of the doctor-patient relationship, the practitioner,
3
ATTACHMENT A

1 who is actively engaged in treating the patient, is in the best position to evaluate and interpret the
2 complexities, timing, and potential efficacy from among different the many treatment philosophies
3 and systems available. Deviations from these guidelines may be appropriate based on
4 professional judgment and individual patient needs. Where a practitioner chooses to deviate from
5 these guidelines (based on the circumstances of a particular patient or for any other reason) the
6 practitioner is advised to note in the patient's record the reason for the procedure followed. Finally,
7 it should be understood that adherence to these guidelines does not guarantee a successful
8 treatment outcome.
9
10 The AAO recognizes that these guidelines may be used by insurance carriers and other payers,
11 attorneys in malpractice litigation, and various entities with an interest in orthodontics. The
12 Association encourages all interested persons to become familiar with the Guidelines. This
13 document was not developed to establish standards of care or to be used for reimbursement or
14 litigation purposes. The AAO cautions that these uses involve considerations that are beyond the
15 scope of the Guidelines.
16
17 The professional conduct of members of the AAO is governed by the Principles of Ethics and
18 Code of Professional Conduct of the AAO and the ADA.
19
20 Pretreatment Considerations
21
22 A screening examination may be performed to determine the nature of the orthodontic problem,
23 and to determine if and when treatment is indicated. When treatment is indicated, a
24 comprehensive examination must be performed that should include:
25
26 Examination
27
28 A. Chief Complaint
29 The chief complaint or the reason for seeking treatment should be recorded as described
30 by the patient, parent or legal guardian.
31 B. Medical and Dental History
32 An appropriate medical and dental history must be obtained as a part of the initial
33 evaluation of the patient. If treatment is to be delayed until a future date, an updated history
34 may be necessary. Patients/parents/legal guardians should be requested to advise the
35 orthodontist of any change in the patient's health history.
36
37 C. Clinical Examination
38 A comprehensive clinical examination should include the following with all findings
39 recorded in the patient's record:
40
41 1. An extraoral facial assessment to determine facial form, symmetry, soft-tissue
42 harmony, and status of the perioral musculature. This determines deviations from
43 normal regarding a patient's sagittal, vertical, and transverse maxillofacial
44 relationships and to assess the relationship of the dentition to the facial structures.
45 2. An intraoral examination to assess the condition of the hard and soft tissues of the
46 mouth, (including the periodontium) and the static and functional status of the
47 patient's occlusion.
48 3. An evaluation of the temporomandibular joint and associated musculature to
49 assess function and disease.
50
4
ATTACHMENT A

1 Diagnostic Records
2
3 Diagnostic records and tests will vary with the nature of the patient's condition but must be
4 sufficient to identify the problems, formulate a diagnosis, and allow the development of an
5 acceptable course of treatment. Where limited orthodontic procedures are anticipated, diagnostic
6 records may vary from those associated with comprehensive care. Pretreatment unaltered
7 diagnostic records for comprehensive orthodontic treatment should include the following to
8 establish a baseline for documenting treatment and/or growth changes:
9
10 1. Extra and intraoral images (may include digital or video images) to supplement the
11 clinical findings.
12 2. Dental casts (or digital models) to assess the inter-arch and intra-arch relationship
13 of the teeth, to help determine arch length and width requirements, and to assess
14 arch symmetry.
15 3. Intraoral and/or panoramic radiographs to assess the condition and developmental
16 status of the teeth and associated structures, and to identify any dental anomalies
17 or pathology.
18 4. Cephalometric radiographs to permit evaluation of the size, shape, and positions of
19 the craniofacial structures and dentition, and to aid in the identification of skeletal
20 anomalies or pathology. Three-dimensional cone-beam computer tomography
21 (CBCT) may be used as an alternate (imaging) source to obtain dentofacial
22 information.
23 5. The AAO recognizes that while there may be clinical situations where a cone-beam
24 computed tomography (CBCT) radiograph may be of value, the use of such
25 technology is not routinely required for orthodontic radiography.
26
27 Referral
28
29 Practitioners must make a recommendation for referral of patients to general dentists, other dental
30 specialists, physicians, or other health care practitioners whenever, in the judgment of a
31 practitioner, referral would be in the best interest of a patient. Technological advances such as
32 CBCT scans fall in this category and should be assessed/read in their entirety by a qualified
33 professional; the entire area encompassed by the scan may be the responsibility of the
34 practitioner.
35
36 Diagnosis and Treatment
37
38 Prior to the initiation of orthodontic treatment, a diagnosis of the patient's oral health condition
39 must be made. A diagnosis allows for the development of a treatment plan that addresses the
40 patient's chief complaint; medical and dental history; and dental, facial, skeletal, functional, and/or
41 psychosocial problems.
42
43 After a diagnosis has been established, a treatment plan must be developed. Such a plan will
44 facilitate coordination of the treatment objectives and the various methods available for addressing
45 them. The plan should include:
46
47 1. A list of the patient's dental, facial, skeletal, functional, and/or psychosocial
48 problems.
49 2. A differential diagnosis which coordinates the patient/parents/legal guardian's chief
50 complaint with the clinical findings.
5
ATTACHMENT A

1 3. A written documented plan for therapy which includes treatment goals, appliance
2 selection, sequencing and timing of treatment, coordination with other health care
3 providers, and retention.
4
5 The treatment plan should be periodically reassessed throughout treatment. This reassessment
6 should take into consideration various limiting factors and establish short- and/or long-term
7 objectives.
8
9 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and
10 Dental Alveolus
11
12 The following conditions may indicate the need for orthodontic or dentofacial orthopedic treatment.
13 These conditions may be structural or functional, may appear in various combinations, and are not
14 limited to the following. Frequently used treatment options, which may include the removal of
15 primary or permanent teeth, are listed for each condition. Moreover, devices including headgear,
16 osseointegrated implants, mini-screw implants, miniplates and other temporary anchorage devices
17 may be used as adjuncts to improve facilitate the treatment outcome, in particular where maximum
18 anchorage would be beneficial.
19
20 I. Maxillary/Dentoalveolar Hyperplasia (Large Maxilla)
21
22 A. Diagnostic Considerations
23
24 1. Anteroposterior
25 a. Excess Overjet
26 b. Distoclusion
27 c. Asymmetry
28 d. Mid-Face Protrusion
29 2. Vertical
30 a. Long Face Height
31 b. Deep Overbite
32 c. Open Bite
33 d. Lip Incompetency
34 e. Asymmetry
35 3. Transverse
36 a. Buccal Maxillary Cross-bite (unilateral or bilateral; functional or
37 structural)
38 b. Asymmetry
39
40 B. Treatment Options
41
42 1. Primary Dentition - Treatment Indicated Under Certain Circumstances,
43 Appliances Vary
44 2. Mixed Dentition
45 a. Functional/Orthopedic Appliances
46 b. Fixed or Removable Orthodontic Appliances
47 3. Adolescent Dentition
48 a. Functional/Orthopedic Appliances
49 b. Fixed or Removable Orthodontic Appliances
50 c. Fixed Orthodontic Appliances Adjunctive to Orthognathic Surgery
51 (surgery usually performed after majority of growth completed)
6
ATTACHMENT A

1 4. Adult Dentition
2 a. Fixed or Removable Orthodontic Appliances
3 b. Fixed Orthodontic Appliances Adjunctive to Orthognathic Surgery
4
5 II. Maxillary/Dentoalveolar Hypoplasia (Small Maxilla)
6
7 A. Diagnostic Considerations
8
9 1. Anteroposterior
10 a. Mesiocclusion
11 b. Anterior Cross-bite (functional or structural)
12 c. Asymmetry
13 d. Mid-Face Deficiency
14 2. Vertical
15 a. Short Face Height
16 b. Deep Overbite
17 c. Open Bite
18 d. Lip Redundancy
19 e. Asymmetry
20 3. Transverse
21 a. Lingual Posterior Cross-bite (unilateral or bilateral; functional or
22 structural)
23 b. Asymmetry
24
25 B. Treatment Options
26
27 1. Primary Dentition
28 a. Functional/Orthopedic Appliance
29 b. Fixed or Removable Orthodontic Appliance
30 2. Mixed Dentition
31 a. Functional/Orthopedic Appliance
32 b. Fixed or Removable Orthodontic Appliance
33 3. Adolescent Dentition
34 a. Functional/Orthopedic Appliance
35 b. Fixed or Removable Orthodontic Appliance
36 4. Adult Dentition
37 a. Fixed or Removable Orthodontic Appliance
38 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery
39
40 III. Mandibular/Dentoalveolar Hyperplasia (Large Mandible)
41
42 A. Diagnostic Considerations
43
44 1. Anteroposterior
45 a. Prognathic Facial Pattern
46 b. Mesiocclusion
47 c. Anterior Cross bite (functional or structural)
48 d. Macrogenia
49 e. Asymmetry
50 2. Vertical
51 a. Open Bite
7
ATTACHMENT A

1 b. Deep Overbite
2 c. Long Lower Facial Height
3 d. Asymmetry
4 3. Transverse
5 a. Posterior Cross-bite (unilateral or bilateral; functional or structural)
6 b. Asymmetry
7
8 B. Treatment Options
9
10 1. Primary Dentition - Treatment Indicated Under Certain Circumstances,
11 Appliances Vary
12 2. Mixed Dentition
13 a. Functional/Orthopedic Appliance
14 b. Fixed or Removable Orthodontic Appliance
15 3. Adolescent Dentition
16 a. Functional/Orthopedic Appliance
17 b. Fixed or Removable Orthodontic Appliance
18 4. Adult Dentition
19 a. Fixed or Removable Orthodontic Appliance
20 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery
21
22 IV. Mandibular/Dentoalveolar Hypoplasia (Small Mandible)
23
24 A. Diagnostic Considerations
25
26 1. Anteroposterior
27 a. Mandibular Retrognathic Facial Pattern
28 b. Excess Overjet
29 c. Distoclusion
30 d. Asymmetry
31 2. Vertical
32 a. Open Bite
33 b. Deep Overbite
34 c. Short Lower Face Height
35 d. Long Lower Face Height
36 3. Transverse
37 a. Posterior Cross-bite (unilateral or bilateral; functional or structural)
38 b. Asymmetry
39
40 B. Treatment Options
41
42 1. Primary Dentition - Functional/Orthopedic Appliance
43 2. Mixed Dentition
44 a. Functional/Orthopedic Appliance
45 b. Fixed or Removable Orthodontic Appliance
46 3. Adolescent Dentition
47 a. Functional/Orthopedic Appliance
48 b. Fixed or Removable Orthodontic Appliance
49 c. Appliance Adjunctive to Orthognathic Surgery (surgery usually
50 performed after majority of growth completed)
51 4. Adult Dentition
8
ATTACHMENT A

1 a. Fixed or Removable Orthodontic Appliance
2 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery
3
4 Anomalies of Tooth Position, Discrepancies of Tooth Size and Arch Length
5
6 These conditions may appear in various combinations and are not limited to the following.
7 Frequently used treatment options for these anomalies may include modification of tooth size,
8 surgical exposure, extraction of primary or permanent teeth, and appropriate soft tissue surgery.
9
10 I. Deficient Arch Length (Crowding)
11
12 A. Diagnostic Considerations
13
14 1. Facial-Lingual Displacement
15 2. Supra/Infra Eruption
16 3. Rotations
17 4. Impactions
18 5. Axial Inclination of Teeth (Anterior or Posterior)
19 6. Tooth Size
20 7. Premature Loss of Primary Teeth
21 8. Ankylosis
22
23 B. Treatment Options
24
25 1. Primary Dentition
26 Fixed or Removable Space Maintainer
27 2. Mixed Dentition
28 a. Functional/Orthopedic Appliance
29 b. Fixed or Removable Orthodontic Appliance
30 c. Serial Extraction
31 3. Adolescent Dentition
32 a. Fixed or Removable Orthodontic Appliance
33 b. Functional/Orthopedic Appliance
34 4. Adult Dentition
35 Fixed or Removable Orthodontic Appliance
36
37 II. Excessive Arch Length (Spacing)
38
39 A. Diagnostic Considerations
40
41 1. Facial-Lingual Displacement
42 2. Axial Inclination of Teeth
43 3. Fibrous Gingival Hyperplasia
44 4. Frena
45 5. Tooth Size
46
47 B. Treatment Options
48
49 1. Primary Dentition - Treatment Rarely Indicated
50 2. Mixed Dentition - Fixed or Removable Orthodontic Appliance
51 3. Adolescent Dentition - Fixed or Removable Orthodontic Appliance
9
ATTACHMENT A

1 4. Adult Dentition - Fixed or Removable Orthodontic Appliance
2
3 III. Discrepancies of Arch Form
4
5 A. Diagnostic Considerations
6
7 1. Asymmetry
8 2. Interarch Coordination
9 3. Abnormal Occlusal Planes: Curves of Wilson and Spee
10
11 B. Treatment Options
12
13 1. Primary Dentition - Fixed or Removable Orthodontic Appliance
14 2. Mixed Dentition
15 a. Fixed or Removable Orthodontic Appliance
16 b. Functional/Orthopedic Appliance
17 3. Adolescent Dentition
18 a. Fixed or Removable Orthodontic Appliance
19 b. Functional/Orthopedic Appliance
20 4. Adult Dentition
21 a. Fixed or Removable Orthodontic Appliance
22 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery
23
24 Abnormalities of Tooth Number Morphology, and Eruption Pattern
25
26 Anomalies of tooth number, morphology or eruption pattern should be diagnosed and managed as
27 soon as reasonably practical according to the particular requirements of each clinical situation.
28 These conditions may appear in various combinations, and may indicate the need for orthodontic
29 or dentofacial orthopedic treatment. Some of the frequently used treatment options may require a
30 multidisciplinary approach and may include the extraction of primary or permanent teeth.
31
32 A. Diagnostic Considerations
33
34 1. Supernumerary Teeth
35 2. Missing Teeth
36 a. Congenital (Anodontia)
37 b. Pathologic
38 c. Traumatic
39 d. Extracted
40 3. Ectopic Erupting Teeth
41 4. Impacted Teeth
42 5. Eruption Anomalies
43 6. Over-Retained Primary Teeth
44 7. Ankylosed Teeth
45 8. Transposition
46 9. Atypical Crown Morphology
47 10. Premature Loss of Primary Teeth
48 11. Atypical Root Morphology
49 12. Root Resorption
50 13. Carious or Fractured Teeth
51
10