Australasian Dentist Magazine Sept-Oct 2021

Category 124 Australasian Dentist columnists Orthodontic Clinicians’ Corner Welcome to this month’s edition of Orthodontic Clinician’s Corner, where Dr Geoff Hall will answer orthodontic questions asked by general dentists. If you have an orthodontic question you would like answered, forward your question to geoff@orthoed.com.au By Dr Geoff Hall Dr Geoff Hall Q1 Dear Geoff, I am fairly new to orthodontics, and have started a few aligner cases but I understand it’s not compulsory to include radiographs when submitting an aligner case. I have also been told that I don’t need to have a lateral cephalometric radiograph or perform a lateral cephalometric analysis. I understand there a several different types of cephalometric analysis and I am unsure which one is required. I would really like to hear your opinion on this to assess the 4 major areas. I.E the sagittal skeletal etc Dr DR, Melbourne Response 1 Dear DR, A great question – and from a historical point of view, lateral cephalometric radiographs were exceptionally important. Back in the 1950s most orthodontic diagnoses were based on a cephalometric radiograph and orthodontic study models. However, today, the clinical evaluation is without doubt the most important aspect of the orthodontic diagnosis, however as in general dentistry, radiographs do not diagnose the problem but should confirm the clinical diagnosis. There are a lot of myths with regards to lateral cephalometric radiographs and the traditional two-dimensional cephalometric analysis. Every analysis has its issues in finding the cephalometric landmarks and many of these are not based on sound orthodontic research. I have developed my own cephalometric analysis for OrthoED, determining the most appropriate angular and linear measurements for orthodontic purpose. Firstly, one needs to understand exactly what a cephalometric analysis actually analyses – and there are only four points of interest from a cephalometric radiograph – these being: a. Identifying the sagittal skeletal discrepancy, e.g., Is it a Class I, Class II or Class III skeletal relationship? b. The skeletal vertical component; i.e., Is it a mesofacial, brachyfacial or an extreme dolichofacial growth tendency? c. The position and angulation of the upper incisors. d. The position and angulation of the lower incisors. In my humble opinion, making a diagnosis purely from the 2D lateral cephalometric radiograph is totally fraught with issues. Firstly it can be very difficult to evaluate and locate many of the points, or even accurately locate the position of the tip and root of the central incisor. Having said that, with CBCT now commonly used in general and orthodontic practice, 3D cephalometric analysis is actually available – but it is rarely, if ever, used in the orthodontic or the general dental community. I think this is a great mistake, as so much good information can be gained diagnostically from the information provided from a 3D analysis. Having said all that, even though a cephalometric analysis and radiograph is not critical to an orthodontic diagnosis today – it still is required to confirm one’s clinical evaluation, diagnosis and problem list. It would still be considered by conventional Orthodontists as a standard of care in orthodontic diagnosis – not too dissimilar to when orthodontic study models were considered as a standard of care, however now, excellent photographs could suffice. So to answer your question DR, I believe from a medico-legal aspect and adhering to good diagnostic principals, a lateral cephalometric radiograph should be obtained for every patient, and used to confirm a clinical diagnosis – but it’s very important that one understands its limitations as well, so that a misdiagnosis does not occur ,as some conventional cephalometric measurements may be totally inaccurate. Q2 Dear Geoff, I have been doing orthodontics for approxi­ mately five years now and for the first time I have a patient who has completed all of their payments but is still in active orthodontic therapy. The concern I now have, is that this patient is moving interstate, and she is asking for a significant refund for treatment as she needs to be transferred to another treating dentist. How do I go about this, and how do I provide a fair assessment of what should be refunded? Dr PW, Canberra Response 2 Dear PW, This has been a vexing question for Orthodontists for the last 40 years. What is fair to refund to the patient or provide the ongoing treating clinician with a fair remuneration for treatment that needs to be performed? In fact, this is even now more complicated with newer orthodontic treatments such as Invisalign, which has a very high laboratory fee, and this fee also needs to be sufficiently covered for those doctors commencing an aligner therapy case This is not only an issue for the patient who has paid in full – but could also be an issue for any active orthodontic patient .For example a patient who is 12 months into treatment and they’ve had possibly a payment plan of only 18 months, and yet their treatment still requires a further 12 months to be completed – What would be a fair fee for the remaining 12 months of treatment? Not only does the remaining treatment need to be addressed , but also the supervision of at least 2 years of retention following the completion of active treatment . This question has been addressed by the Australian Society of Orthodontists in the past– and they have determined what they believe is a fair remuneration of transferring a patient to another appropriately trained clinician.