Identifying important prognostic factors and outcomes for autotransplantation of developing teeth: Clinicians' perspectives.

BACKGROUND/AIM: Variability in the outcome measures used to assess the success of tooth autotransplantation presents challenges for combining data to examine the success of the technique. Reaching agreement on the most important outcomes will enable routine procedural and follow-up data to be collected in a standardised way. In turn this will promote greater data synthesis to evaluate outcomes and examine which procedural techniques influence outcome. The aim of this study was to identify which prognostic factors and outcomes are most important to clinicians with experience in autotransplantation of developing teeth. METHODS: The Delphi method was used to build consensus on the most important prognostic factors and outcomes. Item identification involved a systematic literature review and review of current clinical datasets in use. A two-round Delphi questionnaire was undertaken with clinicians providing tooth autotransplantation, followed by a consensus meeting to finalise the most important items. RESULTS: Outcomes and prognostic factors were identified from the systematic review (82 studies and eight reviews), one guideline and three existing clinical datasets. Patient interviews and a clinician survey added a number of items that would not have been identified from the literature only. A total of 56 outcomes and 93 prognostic factors were included for rating in the Delphi questionnaire. The Delphi questionnaire was completed by 15 respondents in round one and 13 respondents in round two. The consensus meeting was attended by nine participants. The final items that were judged to be most important included 29 outcomes (25 clinical, three patient-reported and one service delivery) and 49 prognostic factors (18 patient characteristics, four presurgical, 17 surgical and 10 postsurgical). Clinical outcomes were consistently rated higher than patient-reported outcomes. CONCLUSIONS: The clinical outcomes rated as the most important were transplant survival and reason for failure, outcomes relating to pulp health, different types of resorption and evidence of infection (suppuration). Important patient-reported outcomes were satisfaction with overall treatment experience, and outcome and quality of life related to function of the transplanted tooth. Procedural information rated as being the most important related to the donor tooth: stage of root development, method for surgical removal and storage and condition of the donor tooth root surface following removal.

Personality differences in dental professionals: A cross-sectional survey.

INTRODUCTION: Despite its influence on occupational performance and team dynamics, there has been little research into the personality of dental professionals. Existing research does not typically use the prevailing five-factor model of personality. We aimed to measure the personality of dental professionals in the United Kingdom and investigate differences among groups. METHODS: The sample (n = 906) comprised dental nurses (n = 475), general dental practitioners (GDPs) (n = 182), orthodontists (n = 201), and oral and maxillofacial surgeons (OMFSs) (n = 48). Recruitment was via email and social media. The questionnaire collected data on demographic variables and contained the Big Five Inventory, a validated self-report personality test. Participants scored on extraversion, conscientiousness, agreeableness neuroticism, and openness. A one-way analysis of variance and post-hoc tests with Bonferroni correction were used to identify significant differences in personality between occupations. Hierarchical multiple regression determined the influence of occupation over and above demographic variables. RESULTS: On a 5-point scale, orthodontists had a mean conscientiousness score 0.23 points higher than GDPs (95% confidence interval [CI], 0.10-0.36). Dental nurses had a mean conscientiousness score 0.28 points higher than GDPs (95% CI, 0.17-0.39). Dental nurses had a mean agreeableness score 0.16 points higher than orthodontists (95% CI, 0.05-0.27) and 0.30 points higher than OMFSs (95% CI, 0.10-0.50). For neuroticism, orthodontists had a mean score 0.21 points lower than dental nurses (95% CI, 0.06-0.36), and OMFSs had a mean score 0.43 points lower than dental nurses (95% CI, 0.16-0.70). GDPs had a mean neuroticism score 0.43 points higher than OMFSs (95% CI, 0.14-0.71; P = 0.001). Differences were small to moderate in size (d = 0.35-0.45) and occupation was associated with personality after accounting for demographic variables. CONCLUSIONS: The personalities of dental nurses, GDPs, orthodontists, and OMFSs differed. Occupation was associated with differences in personality after accounting for demographic characteristics.

UK dental students' ability and confidence in applying the Index of Orthodontic Treatment Need and determining appropriate orthodontic referral.

INTRODUCTION: The aim was to assess the ability and confidence of UK undergraduate dental students in applying the Index of Orthodontic Treatment Need (IOTN) and determining appropriate orthodontic referral. MATERIALS AND METHODS: This was a cross-sectional survey using a case-based online questionnaire. Fourth and fifth year undergraduate dental students were recruited from UK dental schools through their university and social media. Six cases were presented and participants were asked to provide an IOTN score and judgement about referral. Participants were asked about their confidence, experience and orthodontic teaching. RESULTS: Sixty-nine responses were returned. A quarter of participants reported having used IOTN before in a clinical setting. Clinical experience with IOTN influenced confidence. Familiarity with making orthodontic referrals was low and only one participant reported having made an orthodontic referral. Correct IOTN scores were given by 68% of participants for a large 14 mm overjet (5a) case, 43% of participants for an impacted canine (5i) case and 26% of participants for an impacted premolar (5i) case. Incorrect IOTN was most common in hypodontia cases with only 19% correctly identifying mild hypodontia (4h) and 28% identifying severe hypodontia (5h). For the majority of cases, incorrect answers about referral were due to confusion between specialist practitioner and orthodontic consultant pathways. CONCLUSIONS: Dental students' ability and confidence in correctly applying the IOTN Dental Health Component and selecting the appropriate referral pathway was inadequate. Responses suggest a lack of clinical experience in assessing patients, applying the IOTN and making referrals. The low response rate is disappointing and limits the scope for making recommendations.

Sustainability in orthodontics: Challenges and opportunities for improving our environmental impact.

OBJECTIVE: To highlight the potential environmental impact of different aspects of orthodontic care in the United Kingdom, outline the major barriers and challenges to reducing this impact, and summarise the possible action that could help the orthodontic community to tackle the climate change crisis. IMPACT: Travel, procurement and supply, material use, waste management, energy use and water consumption within dentistry have a considerable effect on the environment. There are, however, marked knowledge gaps pertaining to the impact of orthodontic treatment. CHALLENGES: The lack of awareness of the NHS contribution to the carbon footprint and net-zero goals among healthcare workers, the NHS backlogs and budget cuts, and cross-infection control requirements particularly following the COVID-19 pandemic are some of the many challenges to making healthcare delivery more sustainable. OPPORTUNITIES: By considering the triple bottom line (social, environmental and economic), incorporating the four Rs (Reduce, Reuse, Recycle, Rethink), taking practical action, including steps to educate ourselves and the wider team, and to promote research on environmental sustainability, we can get one step closer to reaching the NHS net-zero goals. CONCLUSION: Climate change is a global health threat with multiple contributors associated with orthodontic treatment delivery, which can be tackled on an individual, organisational and system level.

Orthodontic retention experience of university students: A qualitative study.

OBJECTIVE: To explore university students' experience of retention and identify potential barriers and facilitators to long-term adherence. DESIGN: Cross-sectional qualitative study using virtual focus groups. SETTING: University of Leeds. PARTICIPANTS: Dental and non-dental students from the University of Leeds, who had previously undergone orthodontic treatment and had received removable retainers. METHODS: Students were invited to participate via email. Virtual focus groups were undertaken using Microsoft Teams. A topic guide was used to explore the experience of orthodontic retention including factors that influence long-term retainer wear. Focus groups were recorded and analysed using an inductive thematic approach. RESULTS: In total, 23 students participated in four focus groups, including 13 dental students. The period since the end of orthodontic treatment varied from 9 months to 10 years. Of the 23 participants, 8 (35%) were no longer wearing their retainers. Four themes were identified: (1) experience of orthodontic treatment including knowledge of relapse; (2) experience of retainer wear, including motivators and barriers; (3) role of others; and (4) increasing adherence. Key factors influencing use of retainers were the importance placed on maintaining treatment outcomes, awareness of unwanted tooth movement and understanding of the role of the retainer, access to replacement retainers, and ongoing support to encourage retainer wear. Greater knowledge and dental awareness reported by dental students did not necessarily increase adherence. CONCLUSION: Adherence to removable retainer wear is an important aspect of orthodontic treatment but it is recognised that long-term retainer wear is highly variable. The understanding of relapse and retention is variable. Challenges in gaining access to replacement retainers are a common cause of cessation of retainer wear. Dental professionals are perceived to be important in encouraging and supporting retainer wear and individuals reported they would like more follow-up.

Public and dental professionals' use of social media to discuss amelogenesis imperfecta.

BACKGROUND: Amelogenesis imperfecta (AI) is an inherited disorder of enamel development that is challenging to treat and often associated with negative patient and parental outcomes. Social media provides a valuable perspective on patients' and dental professionals' experience of AI and dental care. AIM: To explore how the public and dental professionals use social media to discuss AI. DESIGN: A cross-sectional study involving a systemic search of eight social media platforms using the search term 'amelogenesis imperfecta'. Relevant posts were selected using predefined eligibility criteria. Word content of eligible posts was qualitatively analysed using a thematic framework approach. RESULTS: A total of 555 posts were identified, of which 144 were eligible for analysis. For dental professionals, the posts included case reports and seeking and sharing of information. For the public, the posts were related to individuals' experience of AI, dental treatment and outcome of treatment. CONCLUSIONS: Posts from individuals affected by AI suggest a need for better distribution of reliable information and greater support. Case reports indicate that dental professionals find it challenging to recognise AI and determine appropriate treatment options. Social media could potentially be used to inform and support people with AI and allow dental professionals to share information and learning with peers.

Laypeople's interpretation of, and preference for, orthodontic images.

BACKGROUND: Good communication is fundamental to provision of information and patient engagement in orthodontic treatment. Images can be used to support verbal and written information, but little is known about how laypeople interpret orthodontic images. OBJECTIVE: To explore laypeople's understanding and preferences for images (clinical photographs and medical illustrations) relating to orthodontic diagnoses and treatments. DESIGN: Cross-sectional survey. SETTING: UK. POPULATION: Laypeople aged ⩾16 years. METHODS: Participants were recruited through social media to complete an online questionnaire containing six pairs of images (clinical photograph and medical illustration) relating to orthodontic diagnoses and treatment. Photographs were selected from a bank with input from laypeople, then a matching medical illustration was created. Images were presented with questions relating to interpretation, preferences and reasons for preferences. RESULTS: A total of 898 people completed the questionnaire. Interpretation of images by laypeople was variable and, in some cases, normal intra-oral features and image orientation caused confusion. A combination of photograph and illustration were preferred for images representing diagnosis (by 41%-50% participants), whereas the illustration alone or both photograph and illustration together was preferred for explaining treatment (43%-48% and 35%-44%, respectively). Photographs were liked for their realism and relatability, while illustrations were often found to be clearer. Arrows aided participants' understanding of the images, but annotations were requested to further improve the value of images. Only 26% of participants reported having previously been shown dental images, but 96% felt they would be helpful to support verbal and written information. CONCLUSION: Laypeople may not interpret orthodontic images in the way that professionals expect, and unfamiliar intra-oral features may distract people from the intended focus of the image. A combination of photographs and illustrations together may improve the usefulness of images, alongside annotation or explanation.

The effectiveness of interventions to increase patient involvement in decision-making in orthodontics: A systematic review.

OBJECTIVES: To examine the effectiveness of interventions that aim to increase patient involvement in treatment decisions in orthodontic, orthognathic and cleft treatment, based on patient-reported outcomes and patient knowledge. DESIGN: Systematic review. DATA SOURCES: OVID databases (MEDLINE, EMBASE and EBM reviews), CENTRAL, WHO's International Clinical Trials Registry Platform and reference lists of included studies. DATA SELECTION: Studies were selected by two reviewers independently and in duplicate based on pre-defined eligibility criteria: Population: People considering or undergoing orthodontic, orthognathic or cleft treatment. Intervention: Any intervention that aims to increase patient involvement in decision-making. Outcomes: Patient-reported outcomes and patient knowledge. Studies: All experimental studies published in English from January 2000 to October 2019 were eligible. DATA EXTRACTION: Standardised data extraction of study information and assessment of risk of bias using the Cochrane Risk of Bias Tool for RCTs and ROBINS-I for non-randomised studies of interventions. DATA SYNTHESIS: 13 randomised controlled trials were included. Due to heterogeneity in the studies, a narrative synthesis was undertaken. The majority (n=11) of studies involved orthodontic patients, with one study of cleft patients and one study of orthognathic and orthodontic patients. Six included studies reported significant differences between intervention and control groups with improved patient knowledge or better patient-reported outcomes. CONCLUSIONS: A variety of different interventions and outcome measures were used making data synthesis challenging. There is some evidence that interventions to increase patient involvement in decision-making can improve patient-reported outcomes and patient knowledge.

Assessing dentist and dental student knowledge of and attitudes towards shared decision-making in the United Kingdom.

INTRODUCTION: Shared decision-making (SDM) is a partnership between healthcare professionals and patients when choosing care. AIM: To measure knowledge of, and attitudes to, SDM amongst undergraduate dental students and dentists in the UK. DESIGN AND SETTING: Cross-sectional online questionnaire for 4th and 5th year dental students and dentists in the UK. MATERIALS AND METHODS: The questionnaire included attitudinal questions, knowledge of SDM relative to the evidence base and preferred approach to decision-making. The questionnaire identified perceived learning needs and preferred method for SDM teaching for dentists and dental students. Respondents were invited to participate via social media, mailing lists and CPD courses. RESULTS: Respondents included 266 undergraduates and 130 dentists. SDM was defined by the people involved, components of the discussion, approach to decision-making and expected outcome. Attitudes to SDM were generally positive although concerns were expressed about patients wanting professionals to make the decision, straying from the professionals' preferred option and compatibility with clinical guidelines. Respondents reported a preference for decision-making to involve patients, but this tended to be an informative rather than deliberative approach. Respondents were least sure of the evidence about the impact of SDM on adherence, choices and health outcomes, and the best approach to risk communication. Respondents from both groups reported an interest in learning more about SDM and its integration into clinical practice. CONCLUSION: Knowledge of, and attitude to, SDM in UK dentists and dental undergraduates is generally positive; however, a demand for further SDM training was identified.

A study of the reporting of patient and public involvement and engagement (PPIE) in orthodontic research.

INTRODUCTION: Patient and public involvement and engagement (PPIE) in research is an essential component of high-quality research. Patients and the public can identify which research topics are most relevant to them, contribute to study design, and interpretation and dissemination of findings. While inclusion of PPIE is widely adopted in medical research, awareness within the dental research community is more limited. AIM: To examine patient and public involvement and engagement in orthodontic research activity. DESIGN: Identification and appraisal of use of PPIE in orthodontic research reporting and funding applications using a systematic approach. METHODS: Three sources of information were examined: (1) research articles published between September 2018 and September 2019 in four major orthodontic journals. Articles were examined for reported PPIE; (2) common funding bodies for orthodontic research were assessed to establish whether PPIE was mandated (National Institute for Health Research, Medical Research Council, Wellcome Trust, Chief Scientist Office (Scotland), Health and Care Research Wales, British Orthodontic Society Foundation, Royal College of Surgeons and CLEFT); and (3) publication guidance for authors in these journals was examined to identify whether reporting of PPIE was included. RESULTS: Of the 363 research articles, 2 (0.6%) mention patient/public involvement. None of the 363 research articles mention patient/public engagement. Of nine funding bodies, 2 (22%) request evidence of patient/public involvement as a condition of receiving funding with one (11%) expecting evidence of public engagement to be provided as a condition of receiving funding. None of the four major orthodontic journals include patient/public involvement and/or engagement in their guidance for authors. CONCLUSION: There is currently: (1) a notable lack of reporting of PPIE in orthodontic research; (2) variability in the requirements of funding bodies for researchers to include PPIE in funding applications and throughout the research process; and (3) no stipulation in journals' instructions for authors.

Knowledge of, and attitudes to, shared decision-making in orthodontics in the UK.

OBJECTIVE: To establish UK orthodontic treatment providers' knowledge of, and attitudes to, shared decision-making (SDM). SDM involves patients as equal partners in decisions about treatment. DESIGN: Cross-sectional survey. SETTING: Online survey across the UK. POPULATION: Dentists and orthodontists providing orthodontic treatment in the UK. METHODS: Potential participants were contacted through the British Orthodontic Society mailing lists. An online survey was developed to examine knowledge of, and attitudes to, SDM using a combination of evidence-based statements and free text boxes. Questions regarding previous training in SDM and preferences for further training were also included. RESULTS: The survey was completed by 210 respondents, yielding an approximate response rate of 15%. Respondents were mainly consultants (34%) and specialist orthodontists (42%). SDM was well described in terms of the people involved in this process, how it is approached, the components and topics of discussion, and the overall purpose of SDM. Generally, there was consistency in attitudinal responses, with the largest variance in responses to questions about the professional-patient partnership, the interface between SDM and clinical guidelines, and accepting a decision that is discordant with the professional's opinion. Fifty-one respondents reported having some previous teaching/training in SDM, with the majority (87%) indicating that they would like more training. CONCLUSION: Clinicians providing orthodontic treatment in the UK have a good understanding of the meaning of shared decision-making. Concerns raised about using SDM and knowledge gaps suggest there is value in providing SDM training for the orthodontic team and that orthodontic providers would welcome it.

Patient-reported experience and outcomes from orthodontic treatment.

OBJECTIVE: To measure patient-reported impact of orthodontic treatment in terms of pre-treatment concerns, treatment experience and treatment outcome. SETTING: Four sites in Yorkshire, including two secondary care settings (Leeds Dental Institute and St Luke's Hospital, Bradford) and two specialist orthodontic practices. DESIGN: Cross-sectional survey. PARTICIPANTS: NHS orthodontic patients (aged 12+ years) who have completed comprehensive orthodontic treatment, excluding orthognathic surgery and craniofacial anomalies. METHODS: Participants were opportunistically identified by the direct clinical care team during scheduled appointments and those eligible were invited to participate. Data were collected using the Orthodontic Patient Treatment Impact Questionnaire (OPTIQ), a validated 12-item measure with questions relating to pre-treatment experience, impact of treatment and outcome from treatment. RESULTS: Completed questionnaires for analysis included 120 from primary care and 83 from secondary care. The most common pre-treatment concerns were alignment (89%) and being embarrassed to smile (63%). The most common expectations from orthodontic treatment were improved confidence to eat (87%) and smile (72%) in front of others, improved appearance of teeth (85%) and reduced teasing/bullying (63%). Only 67% respondents recalled receiving written information and the lowest recall related to retainer type and length of retention. The most commonly reported complications were sore mouth (68%), fixed appliance breakage (61%) and gingivitis (39%). Treatment caused greatest impact in relation to pain, limitations in eating and effect on speech. Overall satisfaction with orthodontic treatment was reported by 96% of respondents, 87% would have orthodontic treatment again (if needed) and 91% would recommend treatment to a friend. CONCLUSIONS: The OPTIQ is a useful patient-reported tool to identify pre-treatment concerns and expectations, treatment experience and outcome. Orthodontic treatment leads to high levels of satisfaction.

Shared decision-making in orthodontics: Are we there yet?

Shared decision-making (SDM) is the process of making decisions 'with' rather than 'about' patients. This review outlines key stages of SDM, discusses some of the main barriers to SDM and identifies areas where further evidence is needed to support full integration of SDM into orthodontics.

Can the current hypodontia care pathway promote shared decision-making?

OBJECTIVE: To determine the extent to which the current care pathway in hypodontia promotes shared decision-making (SDM). DESIGN: Exploratory cross-sectional study using qualitative methods. SETTING: Orthodontic department of two NHS teaching hospitals in Yorkshire. PARTICIPANTS: Young people aged 12-16 years with hypodontia of any severity and at any stage of treatment, and their parents and guardians. METHODS: (1) Observation and audio-recording of interdisciplinary consultation in hypodontia clinics (n = 5) without any researcher interference; (2) short, structured interviews with young people with hypodontia (n = 8) and their parent (n = 8) using a topic guide to explore themes around decision-making. Audio-recordings were transcribed and analysed using a thematic framework. RESULTS: Consultations were used as an opportunity for interdisciplinary discussion, information provision and treatment planning. Evidence of good communication was observed but patient engagement was low. The decision to be made was usually stated and treatment options discussed, but time constraints limited the scope for adequate information exchange and assessment of understanding. No methods were used to establish patient and family preferences or values. Interviews suggested parents expect the dental team to make decisions and young people rely on parental advocacy. Despite little evidence of SDM, participants reported satisfaction with their treatment. CONCLUSIONS: The current care pathway for hypodontia does not support clinicians in the steps of SDM. Recommendations for improving SDM processes include support to identify preference-based decisions, greater access to comprehensive and accessible patient information to enable preparation for consultation, alternative methods for effective communication of complex information and use of preference elicitation tools to aid value-driven decision-making.

PLATOON: Premature Loss of bAby Teeth and its impact On Orthodontic Need - protocol.

OBJECTIVE: To investigate the impact of premature extraction of primary teeth (PEPT) on orthodontic treatment need in a cohort of children participating in the Born in Bradford (BiB) longitudinal birth cohort. DESIGN: Observational, cross-sectional cohort. PARTICIPANTS: We aim to recruit 1000 children aged 7-11 years: 500 with a history of PEPT and 500 matched non-PEPT controls. METHODS: After informed consent/assent, orthodontic records will be collected, including extra and intra-oral photographs and alginate impressions for study models. Participants will also complete a measure of oral health-related quality of life (COHIP-SF 19). The records will be used to quantify space loss, identify other occlusal anomalies and assess orthodontic treatment need using the Index of Orthodontic Treatment Need. For each outcome, summary statistics will be calculated and the data for children with and without PEPT compared. The records of the children identified to be in need of orthodontic treatment will be examined by an expert orthodontic panel to judge if this treatment should be undertaken at the time of the records or delayed until the early permanent dentition. Collecting robust records in the mixed dentition provides the clinical basis to link each stage of the causal chain and enable the impact of PEPT on orthodontic need to be characterised. This study is the first to provide the foundations for future longitudinal data collection allowing the long-term impact of PEPT to be studied.

Identification and appraisal of outcome measures used to evaluate hypodontia care: A systematic review.

INTRODUCTION: Identification and appraisal of the outcome measures that have been used to evaluate hypodontia treatment and deliver services are essential for improving care. A lack of alignment between outcomes and patient values can limit the scope for patient-centered care. Our objectives were to identify and appraise the outcomes selected to evaluate hypodontia care. METHODS: Data sources included 10 electronic databases and grey literature, searched using terms for hypodontia and its treatment methods. Study eligibility included mixed study designs to ensure comprehensive identification of outcomes, excluding case reports and case series with fewer than 10 participants and nonsystematic reviews. Participants and interventions involved people with hypodontia receiving any dental treatment to manage their hypodontia. Simulated treatment, purely laboratory-based interventions, and future treatments still in development were excluded. Research outcomes were identified and synthesised into 4 categories: clinical indicators, and patient-reported, clinician-reported, and lay-reported outcomes. No synthesis of efficacy data was planned, and consequently no methodologic quality appraisal of the studies was undertaken. RESULTS: The search identified 497 abstracts, from which 106 eligible articles were retrieved in full. Fifty-six studies and 8 quality-improvement reports were included. Clinical indicators were reported in 49 studies (88%) including appearance, function, dental health, treatment longevity, treatment success and service delivery. Patient-reported outcomes were given in 22 studies (39%) including oral health-related quality of life, appearance, function, symptoms of temporomandibular dysfunction, and patient experience. Clinician-reported outcomes were limited to appearance. Variability was seen in the tools used for measuring outcomes. CONCLUSIONS: There is a lack of rationale and consistency in the selection of outcome measures used to evaluate hypodontia care. Outcomes are largely clinician and researcher-driven with little evidence of their relevance to patients. There was a paucity of outcomes measuring access to care, quality of care, and cost. Evidence from hypodontia research is clinician-focused and likely to have limited value to support patients during decision making. Attempts to synthesise the evidence base for translation into practice will be challenging. There is a need for a core outcomes set with a patient-centric approach to drive improvements in health services.

Allergy to acrylate in composite in an orthodontic patient: a case report.

Acrylate allergies have been reported in dental professionals as a result of repeat exposure to various acrylate monomers and in dental patients with removable prostheses or longstanding composite restorations. To date, there is only one report of an allergic reaction in a young patient from small volumes of resin-based orthodontic adhesive. This case report demonstrates a recent case of gingival inflammation and lip oedema attributed to an acrylate allergy arising from the composite adhesive used with fixed appliances. The impact on orthodontic treatment is reported and the wider implications for dentistry are discussed.

Orthodontic treatment for a patient with hereditary angiodema: a case report.

BACKGROUND: Hereditary angiodema (HAE), also known as C1 esterase inhibitor deficiency, causes sufferers to experience episodic subcutaneous and submucosal oedema. These episodes can be triggered by dental treatment and manifest as life-threatening oedematous swelling in the head and neck region. CASE REPORT: This case report reviews an adolescent with hereditary angiodema whose malocclusion required orthodontic intervention. Due to her complex and unpredictable reaction to dental treatment, various options were explored before determining the appropriate care pathway for this patient. Trial placement of a sectional fixed appliance tested the tissue reaction prior to comprehensive treatment including extractions and fixed orthodontic appliances. CONCLUSION: This report demonstrates successful interdisciplinary management facilitating orthodontic care in a patient with HAE.

Limitations of a method used for adolescent assessment of smile aesthetics.

AIMS: To establish whether adolescent orthodontic patients with hypodontia have a preference between the aesthetic outcomes of two treatment strategies for lateral incisor agenesis. MATERIALS/METHODS: Standardized photographs of pre-orthodontic patients with missing lateral incisors were manipulated to produce images that represented space opening and tooth replacement in the lateral incisor space and space closure with canine substitution into the lateral incisor space. Adolescent orthodontic patients with hypodontia were recruited to assess the aesthetics of the images. A control group of subjects without tooth agenesis was recruited. Each examiner undertook two tests to assess the smile aesthetics of the images: (1) rating attractiveness using visual analogue scale (VAS) and (2) choice of preference between pairs of images. RESULTS: Difficulties experienced with image manipulation and poor intra-examiner reliability of the VAS make interpretation of the results challenging. Care should be taken if findings are used to aid clinical decisions, as the validity of the main findings is questionable. Results suggest that although adolescents perceive a difference in the aesthetic result of space opening and space closure for missing lateral incisors, the impact on the smile attractiveness is not clinically significant. When forced to choose between the aesthetics of space opening or space closure, the majority of examiners chose space opening with tooth replacement. No difference was found in smile ratings or preferences between adolescents with hypodontia and those with no missing teeth. CLINICAL IMPLICATIONS: The methods used in this study may not be reliable for adolescent assessment of aesthetics.