Orthodontic Treatment

Policy

Referral for any NHS orthodontic procedure will only be accepted if the following criteria are met:

IOTN dental health component score = 3 and aesthetic component score 6 or above or specialist believes
that patient will benefit from treatment

Plus

Good oral health, hygiene and dental attendance

Child under 18 years on referral from GDP

ProposedpathwayfororthodonticreferralsinNWL

Criteria for complex cases requiring treatment by a consultant are to be developed in conjunction with consultants
and specialists.
Criteria for consultant-led treatment in acute providerError!Referencesourcenotfound.

For treatment too complex for primary care setting; where treatment is not progressing as planned.

Malocclusions requiring interdisciplinary orthodontics and orthognathic surgery skeletal abnormalities and/or
asymmetries.

Malocclusions requiring interdisciplinary orthodontics and restorative treatment eg Hypodontia, ankylosed

teeth, developmental anomalies affecting tooth structure eg amelogenesis imperfecta, dentinogenesis
imperfecta, severe tooth surface loss, previously traumatised anterior teeth.

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 PolicyContinued

Malocclusions requiring interdisciplinary orthodontics and surgical treatment such as impacted/ectopic teeth,
ankylosed teeth.

Children with physical or mental disability / special needs growth related problems.

Individuals with cleft lip and/or palate, or other craniofacial anomalies.

Case suitable for training (threshold number to be agreed).

Background

Orthodontics is the branch of dentistry devoted to managing the development of the jaws and teeth (British
Orthodontic Society). Orthodontic treatment improves the appearance, position and function of crooked or
abnormally arranged teeth or abnormal jaws (malocclusion). Malocclusion can affect a persons ability to bite,
maintain oral hygiene, and affect speech development and jaw development. Prominent teeth are not just less
aesthetically pleasing, but are more vulnerable to damage through trauma. Orthodontic treatment aims to
improve dental, oral and psycho-social wellbeing.

Evidence base

The IOTN2 is an objective scale developed from the assessment of orthodontic treatment need and is made up a
dental component (DC) and an aesthetic component (AC). The DC goes from Grade 1 (almost perfect teeth) to
Grade 5 (severe dental problems) and only DC or 4 or 5 are recommended for NHS funded treatment. Children
with a DC of 3 and AC of 6 or more (AC ranges from 0-10) are also considered appropriate for treatment. In a UK
survey of 2003 using the IOTN 35% of 12 year olds were deemed to require orthodontic treatment; however only
42% of parents of children identified recognised the treatment need. Conversely, around 8% of parents felt there
was a treatment need when professionals did not recognise it. There is no significant difference in orthodontic
need between deprived and non-deprived areas (unlike caries), however children must have good oral health to
benefit from orthodontic treatment. More complex cases, requiring multidisciplinary input may need to be treated
in secondary care.
Outcome of orthodontic treatment is measured using the PAR (Peer Assessment Rating) index which offers a
uniform and standardised method for measuring the changes in dentition as a result of the treatment3. There is
limited robust evidence to support an improvement in oral health related quality of life following orthodontic
treatment (due to low levels of research in this area).
IOTN
The Dental Health Component (DHC) has 5 Grades.

Grade 1 is almost perfection,

Grade 2 is for minor irregularities such as:
slightly protruding upper front teeth
slightly irregular teeth
minor reversals of the normal relationship of upper and lower teeth which do not interfere with normal
function.

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 BackgroundContinued

Grade 3 is for greater irregularities which normally do not need treatment for health reasons.
upper front teeth that protrude less than 4 mm more than normal
reversals of the normal relationship of upper teeth which only interfere with normal function to a minor
degree; by less that 2 mm.
irregularity of teeth which are less than 4 mm out of line
open bites of less that 4 mm
deep bites with no functional problems

Grade 4 is for more severe degrees of irregularity and these do require treatment for health reasons.
upper front teeth that protrude more than 6 mm
reversals of the normal relationship of upper teeth which interfere with normal function greater than 2 mm
lower front teeth that protrude in front of the upper more than 3.5 mm
irregularity of teeth which are more than 4 mm out of line
less than the normal number of teeth (missing teeth) where gaps need to be closed
open bites of more than 4 mm
deep bites with functional problems
more than the normal number of teeth (supernumerary teeth)

Grade 5 is for severe dental health problems

when teeth cannot come into the mouth normally because of obstruction by crowding, additional teeth or
any other cause.
a large number of missing teeth.
upper front teeth that protrude more than 9 mm
lower front teeth that protrude in front of the upper more than 3.5 mm and where there are functional
difficulties too
cranio-facial anomalies such as cleft lip and palate.

The Aesthetic Component (AC).

The Aesthetic Component is a scale of 10 colour photographs showing different levels of dental attractiveness.
The grading is made by the orthodontist matching the patient to these photographs. The photographs were
arranged in order by a panel of lay persons. In the NHS, the AC is used for border-line cases with Grade 3 DHC.
If the case has a high AC score, NHS treatment is permissible as there are likely benefits.

References

Patient information leaflet

http://www.dentalhealth.org.uk/faqs/leafletdetail.php?LeafletID=53
http://www.cks.nhs.uk/patient_information_leaflet/orthodontics

References
1.

2.

3.
4.
5.

Department of Health, 2006. Strategic Commissioning of Primary Care Orthodontic Services. Gateway Document
7105
Brook PH, Shaw WC, 1989. The development of an index of orthodontic treatment priority. Eur J Orthod; 11: 30920.
Richmond S, Shaw WC, OBrien KD, Buchanan IB, Jones R, Stephens CD, Roberts CT, Andrews M, 1992. The
development of the PAR Index (Peer Assessment Rating): reliability and validity. Eur J Orthod; 125-139.
Cunningham S et al. 2000. ABC of oral health: Improving occlusion and orofacial aesthetics: orthodontics. BMJ.
;321:288-290, doi: 10.1136/bmj.321.7256.288.
Roberts-Harry D, Sandy J, 2003-4. Orthodontics - Parts 1 to 12. British Dental Journal. 195(8);433-433 to
196(8);449-455

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ReferencesContinued

6. Chestnutt I, Pendry L, Harker R, 2004. The Orthodontic Condition of Children from Childrens Dental Health in the UK

7.
8.

9.

2003, Office of National Statistics, London.

Liu Z; McGrath C; Hagg U, 2009. The Impact of Malocclusion/Orthodontic Treatment Need on the Quality of Life: A
Systematic Review Angle Orthod. 79: 585591.
British Orthodontic Society, 2008. The Justification for Orthodontic Treatment
British Orthodontic Society, 2008. Guidelines for Referrals for Orthodontic Treatment.

NHS NW London Planned Procedures with a Threshold Policy. Version 2.1 (April 2012)
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