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Clinical Practice Guidelines for
Orthodontics and
Dentofacial Orthopedics

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American Association of Orthodontists (AAO)
401 N Lindbergh Blvd
St. Louis, MO 63141
This document may not be copied or reproduced without
the express written permission of the AAO.

©American Association of Orthodontists
Created: 1996
Amended: 2001, 2009, 2010, 2012, 2014, 2016, 2017, 2019, 2021

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TABLE OF CONTENTS
Introduction
Evidence-Based Dentistry
Definition
Levels of Evidence
Evidence-Based Practice
Orthodontic Treatment Definition
Pretreatment Considerations
Examination
Diagnostic Records
ReferralDiagnosis and Treatment Planning
Diagnostic and Treatment Considerations for Anomalies of Jaw Size, Relationship of
Jaw to Cranial Base, Dental Arch Relationship and Dental Alveolus
Diagnostic and Treatment Considerations for Anomalies of Tooth Position,
Discrepancies of Tooth Size, Arch Length and Arch Form
Diagnostic and Treatment Considerations for Abnormalities of the Dentition (number,size, and shape), Vitality, Eruption Pattern, and Periodontal Support
Diagnostic and Treatment Considerations for Dentofacial Functional Abnormalities
Orthodontic Considerations for Craniofacial Anomalies, Cleft Lip and Palate
Treatment Objectives and Limiting Factors
Treatment Objectives
Limiting Factors
Treatment Consultation and Informed Consent
Risks Associated with Orthodontic Treatment
Sterilization and Infection Control
Orthodontic Treatment
Orthodontic Supervision
Dynamic Reassessment
Posttreatment Evaluation and Outcomes Assessment
Posttreatment Records
Retention
Recordkeeping
Transfer of Orthodontic Patients During Active Treatment
Recommendations to the Transferring Dentist
Recommendations to the Accepting Dentist
Appendix A
Historical Development
Updating of Clinical Practice Guidelines
Appendix B: Selected References

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Introduction

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Orthodontics and Dentofacial Orthopedics is a specialty area of dentistry recognized by the
National Commission on Recognition of Dental Specialties and Certifying Boards (NCRDSCB)
concerned with the supervision, guidance and correction of the growing or mature dentofacial
structures, including conditions requiring the movement of teeth or correction of malrelationships
and malformations of their related structures. This includes any adjustments to the relationships
between and among teeth and facial bones by the application of forces and/or the stimulation andredirection of functional forces within the craniofacial complex. Major responsibilities of orthodontic
practice include the diagnosis, prevention, interception and treatment of all forms of malocclusionin addition to malrelationships or dysfunction of associated supporting structures. Additionally,
orthodontists have specialized knowledge, skills, and experience that is beneficial in theinterdisciplinary team management and care of patients who have been diagnosed with
obstructive sleep apnea and other related breathing disorders. All measures to fulfill these
responsibilities, including interdisciplinary referral when required, should strive to establish andmaintain the best achievable outcome for healthy dental, occlusal, esthetic and physiologic
functions.

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A specialist in orthodontics and dentofacial orthopedics meets educational standards establishedby the Commission on Dental Accreditation and must possess advanced knowledge in biomedical,
clinical, and basic sciences. This knowledge includes a comprehensive understanding of thebiology of tooth movement, radiographic imaging and cephalometric measurements, orthodontic
diagnosis, treatment planning, surgical orthodontics, biomechanical principles, the effects ofgrowth and development on tooth movement, the application of orthopedic forces to dentofacial
structures, and patient management and motivation.

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The American Association of Orthodontists (AAO) is the leading national organization of dentists
who limit their practice to orthodontics and dentofacial orthopedics and is recognized by the ADA
as the sponsoring organization of the national certifying board, the American Board of
Orthodontics. The membership of the AAO includes the vast majority of practicing orthodontists in
the United States and Canada. The AAO has the background, expertise, and professional
responsibility to assist the dental profession and the public by developing clinical practiceguidelines for orthodontics and dentofacial orthopedics. The AAO recognizes its role in upholding
the public trust granted to it in part by presenting these clinical practice guidelines to help
practitioners develop judgments on diagnosis, treatment planning, and timing of orthodontic anddentofacial orthopedic therapy. The primary concern of the AAO is the provision of high-quality
orthodontic care and the protection of the public. The AAO recommends that every child shouldhave an orthodontic home by age 7 or sooner if certain developmental issues present. The childshould be able to function appropriately in an orthodontic setting and have an established dental
home to manage hygiene and dental caries.
Practice guidelines, as defined by the Institute of Medicine, are “systematically developed
statements to assist practitioner and patient decisions about appropriate health care for specificclinical circumstances.”
The Orthodontic Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics
presented in this document are condition-based and are related to the International Classificationof Diseases, Clinical Modification, 10th Edition (ICD 10 codes). This approach recognizes the needfor integrated treatment of oral and dentofacial conditions rather than isolated treatment

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procedures. These guidelines are also directed toward the process of patient care and outline
considerations related to diagnosis, treatment, and quality of care.
These guidelines were derived from a professional consensus, based on a review of relevant
clinical and scientific literature, the expert opinion of educators, and the clinical experience ofpracticing orthodontists. Similar documents written by other organizations and publications related
to guideline development were also reviewed.
There are various professionally accepted philosophies regarding orthodontic diagnosis,
treatment, and retention. The additional formal education of orthodontists makes them the best
qualified practitioners for management of orthodontic issues. To simplify the language and enableconsistent terminology throughout these guidelines, the term "dentist" will be used to encompass
all licensed dental practitioners providing orthodontic care. Because of the nature of the doctorpatient relationship, the licensed dental practitioner (hereinafter referred to as “dentist”), who isactively engaged in treating the patient, is in the most informed position to evaluate and interpretthe complexities, timing, and potential efficacy among the different philosophies and systems
available. Deviations from these guidelines may be appropriate based on professional judgment
and individual patient needs and preferences. Where a dentist chooses to deviate from theseguidelines (based on patient specific circumstances or for any other reason) the dentist is advised
to note in the patient's record the specific reason/reasons for following an alternative procedure.
Finally, it should be understood that adherence to these guidelines does not guarantee asuccessful treatment outcome.
The AAO recognizes that these guidelines may be used by insurance carriers and other payers,
attorneys in malpractice litigation, and various entities with an interest in orthodontics. The
Association encourages all interested persons to become familiar with the Guidelines. This
document was not developed to establish standards of care or to be used for reimbursement or
litigation purposes. The AAO cautions that these uses involve considerations that are beyond thescope of the Guidelines.
The professional conduct of members of the AAO is governed by the Principles of Ethics andCode of Professional Conduct of the AAO and the ADA.
Evidence-Based Dentistry
Definition
The following outline of orthodontic diagnostic and treatment considerations are evidence-based
recommendations. Evidence-based dentistry (EBD) is an approach to oral health care that
requires the judicious integration of systematic assessments of clinically relevant scientificevidence relating to the patient’s oral and medical condition and history, with the dentist’s clinicalexpertise and the patient’s treatment needs and preferences.
Levels of Evidence
Rating systems exist to evaluate the strength of various study designs. The Centre for Evidencebased Medicine provides background information on this topic, as well as a commonly used table
for the “Levels of Evidence.” In general, the levels of evidence, from strongest to weakest, are:Meta-analysis
Systematic Review

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Randomized Trial
Cohort Study
Case/Control Study
Case Series
Expert Opinion
Evidence-Based PracticeEvidence-based practice is assisted by critical evaluation of the body of literature on a specifictopic. In particular, well-conducted systematic reviews and meta-analyses can provide guidance
to assist dentists in clinical decision-making. Some resources for accessing evidence-based
literature are:1.

AAO Evidence Based Orthodontic Research Website: A collection of systematic
reviews, meta-analyses, practice guidelines, and summary statements on
orthodontic topics.

2.

The ADA Center for Evidence-based Dentistry: A website which houses
information on evidence-based dentistry, as well as a listing of systematic reviews
in dentistry. Additionally, this site provides links to other evidence-based resources.

3.

PubMed: PubMed comprises more than 30 million citations for biomedical literaturefrom MEDLINE, life science journals, and online books.

4.

Cochrane Collaboration: An international nonprofit organization that develops
evidence-based systematic reviews on health care interventions.

Orthodontic Treatment Definition
Orthodontic treatment is defined as a complex, professionally-guided, dynamic process that alters
the dentofacial complex. Aspects of treatment require recurring clinical assessments in addition toin-person interactions with each patient by an appropriately licensed dentist.
Pretreatment Considerations
Prior to the initiation of orthodontic or dentofacial orthopedic treatment, in order to enhance thehealth and safety of the patient, an in-person comprehensive dental and orofacial examination
should occur by a state-licensed dentist. That dentist shall be currently practicing, and have adental license in good standing, in the same state in which the comprehensive dental exam takes
place. That dentist shall be searchable in the same state-run database and be able to becontacted by the patient.
A screening examination may be performed to determine the nature of the orthodontic problem,
and to determine if and when treatment is indicated. When treatment is indicated, it isrecommended that a comprehensive examination be performed and include:
ExaminationA.

Chief Complaint
The chief complaint or the reason for seeking treatment as described by the patient, parent
or legal guardian.

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B.

Medical and Dental History
An appropriate medical and dental history be obtained as a part of the initial evaluation of
the patient. If treatment is to be delayed until a future date, an updated history may benecessary. Patients/parents/legal guardians should be requested to promptly advise thedentist of any change in the patient's health history.

C.

Clinical Examination
A comprehensive clinical examination including the following, with all findings recorded in
the patient's record:
1.

An extraoral assessment to determine facial form, symmetry, soft-tissue harmony,and status of the perioral musculature. This determines deviations from normal
regarding a patient's sagittal, vertical, and transverse maxillofacial relationships andto assess the relationship of the dentition to the facial structures.

2.

An intraoral examination to assess the condition of the hard and soft tissues of themouth (including the periodontium) and the static and functional status of thepatient's occlusion.

3.

An evaluation of the temporomandibular joint and associated musculature toassess function and disease.

4.

An assessment of perceived or reported oral parafunctional habits.

Diagnostic Records
Diagnostic records, along with a comprehensive examination and history, form the foundation
upon which a diagnosis and treatment plan with options are formulated.
Diagnostic records and tests will vary with the nature of the patient's condition but should be
sufficient to identify the problematic clinical conditions present, formulate a diagnosis, and allow
the development of an acceptable course of treatment with associated treatment goals. Where
limited orthodontic procedures are anticipated, diagnostic records may vary from those associatedwith comprehensive care. Limited or comprehensive treatment encompasses all treatment
techniques, including aligners or aligners in combination with fixed appliances and auxiliaries tosignificantly alter the alignment of teeth or occlusion and/or function.
Pretreatment unaltered diagnostic records for orthodontic treatment may include the following:
1.

Extraoral and intraoral still photographic or video images (may include digital orfilm-based images) to supplement the clinical findings.

2.

Plaster or digital dental models to assess the inter-arch and intra-arch relationshipof the teeth, to help determine arch length and width requirements, to assess archsymmetry and to coordinate with other dental professionals concerning anticipateddental procedures.

3.

Radiographic imaging (intraoral radiographs, panoramic radiographs,
cephalometrics, CBCT, etc.) with interpretation to assess the condition anddevelopmental status of the teeth, hard tissue supporting structures, to identify any

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dental anomalies or pathology and make a screening assessment of the patient’s
upper airway.
ReferralDentists may make a recommendation for referral of patients to general dentists, dental
specialists, physicians, or other health care providers whenever, in the judgment of a dentist,
referral would be in the best interest of a patient.
Diagnosis and Treatment Planning
An in-person diagnosis of the patient’s oral health condition should be made by the dentist prior to
the initiation of orthodontic treatment. Such a diagnosis allows for the development of an
appropriate treatment plan that addresses the patient's chief complaint; medical and dental
history; dental, skeletal, facial, functional, and/or psychosocial problems.
After a diagnosis has been established, a treatment plan should be developed. Such a plan will
facilitate the coordination of the treatment objectives with the appropriate treatment modalities
available for addressing the patient specific treatment objectives. A well-documented treatment
plan should be based on the findings from the medical and dental history, clinical examination,
diagnostic records, a critical evaluation of the patient’s needs and preferences, and the dentist’s
professional judgment and preferences.
The detailed plan typically includes treatment objectives, appliance selection, sequencing andtiming of treatment, coordination with other health care providers, and retention.
The treatment plan should be periodically reassessed by the dentist throughout treatment with
progress records taken as deemed appropriate by the dentist. This reassessment should take into
consideration various limiting factors and establish short- and/or long-term objectives.
Diagnostic and Treatment Considerations for Anomalies of Jaw Size, Relationship of Jaw
to Cranial Base, Dental Arch Relationship and Dental Alveolus
The following conditions may indicate the need for orthodontic or dentofacial orthopedic treatment.
These conditions may be structural, functional and/or esthetic in nature and may appear in various
combinations and are not limited to the outline below. Frequently considered treatment options arelisted for each condition. Adjunctive procedures to those listed used to supplement anchorage
needs and improve treatment outcomes include but are not limited to: osseointegrated implants,mini-screw implants, miniplates and other temporary anchorage devices.
I.

Maxillary/Dentoalveolar Hyperplasia (Large Maxilla)A.

Diagnostic Considerations
1.

Anteroposteriora.
Midface protrusionb.
Dentoalvelolar protrusionc.
Distoclusiond.
Excess overjete.
Asymmetry

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B.

II.

2.

Verticala.
Increased lower anterior facial heightb.
Maxillary vertical excessc.
Excessive gingival displayd.
Deep overbitee.
Open bitef.
Lip incompetencyg.
Asymmetry

3.

Transversea.
Maxillary buccal crossbite (unilateral or bilateral; functional or
structural)b.
Occlusal plane cantc.
Asymmetry

Treatment Options
1.

Primary Dentition - Treatment indicated under certain circumstances,appliances vary

2.

Transitional Dentitiona.
Functional/orthopedic appliancesb.
Fixed or removable orthodontic appliancesc.
Space maintenance3.

Adolescent Dentitiona.
Functional/orthopedic appliancesb.
Fixed or removable orthodontic appliancesc.
Fixed orthodontic appliances adjunctive to orthognathic surgery(surgery usually performed after majority of growth completed)

4.

Adult Dentitiona.
Fixed or removable orthodontic appliancesb.
Fixed orthodontic appliances adjunctive to orthognathic surgery

Maxillary/Dentoalveolar Hypoplasia (Small Maxilla)A.

Diagnostic Considerations
1.

Anteroposteriora.
Midface deficiencyb.
Dentoalveolar deficiencyc.
Mesiocclusiond.
Anterior crossbite (functional or structural)e.
Asymmetry

2.

Verticala.
Decreased lower anterior facial heightb.
Dentoalveolar deficiencyc.
Deep overbited.
Open bite

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e.
f.
3.

B.

III.

Lip redundancy
Asymmetry

Transversea.
Posterior lingual crossbite (unilateral or bilateral; functional or
structural)b.
Occlusal plane cantc.
Asymmetryd.
Transverse deficiency without posterior crossbite

Treatment Options
1.

Primary Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliance2.

Transitional Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliance3.

Adolescent Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliance4.

Adult Dentitiona.
Fixed or removable orthodontic applianceb.
Fixed orthodontic appliance adjunctive to orthognathic surgery

Mandibular/Dentoalveolar Hyperplasia (Large Mandible)
A.

B.

Diagnostic Considerations
1.

Anteroposteriora.
Prognathic facial patternb.
Mesiocclusionc.
Anterior crossbite (functional or structural)d.
Macrogeniae.
Asymmetry

2.

Verticala.
Open biteb.
Deep overbitec.
Increased lower anterior facial height/steep mandibular plane angled.
Asymmetry

3.

Transversea.
Posterior crossbite (unilateral or bilateral; functional or structural)b.
Asymmetry

Treatment Options

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IV.

1.

Primary Dentition - Treatment indicated under certain circumstances,appliances vary

2.

Transitional Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliance3.

Adolescent Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliance4.

Adult Dentitiona.
Fixed or removable orthodontic applianceb.
Fixed orthodontic appliance adjunctive to orthognathic surgery

Mandibular/Dentoalveolar Hypoplasia (Small Mandible)
A.

B.

Diagnostic Considerations
1.

Anteroposteriora.
Mandibular retrognathic facial patternb.
Excess overjetc.
Distoclusiond.
Asymmetry

2.

Verticala.
Open biteb.
Deep overbitec.
Decreased lower anterior facial heightd.
Increased lower anterior facial height3.

Transversea.
Posterior crossbite (unilateral or bilateral; functional or structural)b.
Asymmetry

Treatment Options
1.

Primary Dentition - Functional/orthopedic appliance2.

Transitional Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliance3.

Adolescent Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliancec.
Fixed orthodontic appliance adjunctive to orthognathic surgery(surgery usually performed after majority of growth completed)

4.

Adult Dentitiona.
Fixed or removable orthodontic appliance

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b.
c.

Fixed orthodontic appliance adjunctive to orthognathic surgery
Functional/orthopedic appliances

Diagnostic and Treatment Considerations for Anomalies of Tooth Position, Discrepanciesof Tooth Size, Arch Length, and Arch Form
These conditions may appear in various combinations and are not limited to the following.
Frequently considered treatment options, which may include the removal of primary or permanent
teeth, are listed for each condition. Adjunctive procedures to those listed include modification of
tooth size, restorative replacement, surgical exposure, and appropriate soft tissue surgery.
I.

Deficient Arch Length (Crowding)A.

Diagnostic Considerations
1.
Labial/lingual displacement
2.
Supra/infra eruption
3.
Rotations4.
Impactions
5.
Axial inclination of teeth (Anterior or Posterior)
6.
Tooth size
7.
Premature loss of primary teeth
8.
Ankylosis
9.
Supernumeraries/hypodontia/oligodontia
10.
Soft tissue considerations
11.
Complete/incomplete transpositions
12.
Skeletal deficiencies
13.
Age

B.

Treatment Options
1.

Primary Dentitiona.
Fixed or removable space maintainerb.
Extraction of primary teeth

2.

Transitional Dentitiona.
Functional/orthopedic applianceb.
Fixed or removable orthodontic appliancec.
Serial extraction

3.

Adolescent Dentitiona.
Fixed or removable orthodontic applianceb.
Functional/orthopedic appliancec.
Extractions of permanent or remaining primary teethd.
Exposure of impacted teeth for spontaneous eruption or orthodontic
repositioninge.
Management of periodontal concerns

4.

Adult Dentitiona.
Fixed or removable orthodontic applianceb.
Extraction of permanent teeth

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c.
d.
5.
II.

Interdisciplinary referral may be appropriate in each treatment option listed

Excessive Arch Length (Spacing)A.

Diagnostic Considerations
1.
2.
3.
4.
5.
6.
7.
8.

B.

III.

Exposure of impacted teeth for spontaneous eruption or orthodontic
repositioning
Management of periodontal concerns

Skeletal arch size
Tooth size
Supernumeraries/hypodontia/oligodontia
Axial inclination of teeth
Facial/lingual displacement
RotationsFibrous gingival hyperplasia
Frenal attachments

Treatment Options
1.

Primary Dentition
Treatment rarely indicated2.

Transitional Dentitiona.
Fixed or removable orthodontic applianceb.
Management of periodontal concerns

3.

Adolescent Dentitiona.
Fixed or removable orthodontic applianceb.
Management of periodontal concerns

4.

Adult Dentitiona.
Fixed or removable orthodontic applianceb.
Management of periodontal concerns

5.

Interdisciplinary referral may be appropriate in each treatment option listed

Discrepancies of Arch FormA.

Diagnostic Considerations
1.
2.
3.
4.

B.

Asymmetry
Interarch coordination
Abnormal occlusal planes: Curves of Wilson, Spee or cants
Dual occlusal planes

Treatment Options
1.

Primary Dentition - Fixed or removable orthodontic appliance

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2.

Mixed Dentitiona.
Fixed or removable orthodontic applianceb.
Functional/orthopedic appliance3.

Adolescent Dentitiona.
Fixed or removable orthodontic applianceb.
Functional/orthopedic appliance4.

Adult Dentitiona.
Fixed or removable orthodontic applianceb.
Fixed orthodontic appliance adjunctive to orthognathic surgery

5.

Interdisciplinary referral may be appropriate in each treatment option listed

Diagnostic and Treatment Considerations for Abnormalities of the Dentition (number, size,and shape), Vitality, Eruption Pattern, and Periodontal Support
Anomalies of tooth number, morphology or eruption pattern should be diagnosed and managed assoon as reasonably practical according to the particular requirements of each clinical situation.
These conditions may appear in various combinations, and may indicate the need for orthodontic
or dentofacial orthopedic treatment. Some of the frequently used treatment options listed below
may also require an interdisciplinary approach.
A.

Diagnostic Considerations
1.
2.

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
B.

Supernumerary teeth
Missing teetha.
Congenital (anodontia)b.
Pathologicc.
Traumaticd.
Extracted
Ectopic eruption of teeth
Impacted teeth
Eruption anomalies
Over-retained primary teeth
Ankylosed teeth
Transposition
Atypical crown morphology
Premature loss of primary teeth
Atypical root morphology
Root resorption
Carious or fractured teeth
Character of hard and soft tissue supporting structures
Tooth vitality

Treatment Options
1.

Supernumerary teetha.
Surgical interventionb.
Extraction
c.
Fixed or removable orthodontic appliance

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d.

No treatment

2.

Missing Teetha.
Space maintenance/space regainingb.
Prosthetic replacement of teeth/implantsc.
Transplantationd.
Maintenance of primary teethe.
Space closuref.
Fixed or removable orthodontic appliance3.

Ectopic Teetha.
Extractionb.
Surgical interventionc.
Fixed or removable orthodontic appliance4.

Impacted Teetha.
Surgical interventionb.
Extraction
c.
Fixed or removable orthodontic applianced.
No treatment

5.

Eruption Anomaliesa.
Surgical interventionb.
Retention with or without coronal modificationc.
Extractiond.
Fixed or removable orthodontic appliancee.
Referral for medical evaluation

6.

Over-retained Primary Teeth
Extraction

7.

Ankylosed Teetha.
Extractionb.
Surgical luxation and/or repositioningc.
Fixed or removable orthodontic applianced.
Retention with or without coronal modification

8.

Transpositiona.
Extractionb.
Retention with or without coronal modificationc.
Transplantationd.
Fixed or removable orthodontic appliance9.

Atypical Tooth Morphologya.
Retention with or without coronal modificationb.
Extraction
c.
Fixed or removable orthodontic appliance

10.

Premature Loss of Primary Teetha.
Space maintenanceb.
Fixed or removable orthodontic appliance

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11.

Atypical Root Morphologya.
Monitor radiographicallyb.
Extraction

12.

Root Resorptiona.
Monitor radiographicallyb.
Extractionc.
Stabilizationd.
Treatment alternative of initiating rest periods

13.

Carious or Fractured Teetha.
Reposition tooth or rootb.
Monitor radiographicallyc.
Extractiond.
Fixed or removable orthodontic appliance

14.

Periodontal Support
Management of periodontal concerns

15.

Interdisciplinary referral may be appropriate in each treatment option listed

Diagnostic and Treatment Considerations for Dentofacial Functional Abnormalities
Dentofacial functional abnormalities may occur in combination with other dentofacial conditions
and should be diagnosed, managed, and when necessary, interdisciplinary care coordinated by
the dentist according to the particular requirements of each clinical situation. Correction or control
of functional problems may involve alteration of behavior patterns and may require
orthodontic/dentofacial orthopedic treatment, and/or an interdisciplinary approach to treatment.
The influence of functional abnormalities on dentofacial development is variable and multifactorial.
A.

Diagnostic Considerations
1.

Lip size and function

2.

Tongue Size and Functiona.
Abnormal tongue functionb.
Ankyloglossiac.
Microglossia or macroglossia

3.

Deleterious Habitsa.
Thumb, finger or lip suckingb.
Pacifier suckingc.
Tongue thrust/suckingd.
Clenching/bruxisme.
Lip/cheek bitingf.
Nail bitingg.
Foreign objects (e.g., pipes, pens, pencils, musical instruments)h.
Smoking and/or drug usage

4.

Airway Obstructiona.
Nasopharyngeal morphology

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b.
c.
d.

B.

Sleep apnea
Allergies
Pathology5.

Speech Disorders

6.

Mandibular Dysfunctiona.
Dental interferencesb.
Skeletal abnormalitiesc.
Neuromuscular abnormalitiesd.
Temporomandibular dysfunction

7.

Trauma8.

Temporomandibular Disorders
Temporomandibular disorders represent a broad range of conditions which involve
medical, dental, and psychological factors. Such disorders may be associated withstress, habits, emotional disorders, structural malrelationships, oro-facial pain,
trauma to the face or head, occlusal disharmonies, and medical problems
associated with osteoarthritis, rheumatoid arthritis, or viral disease. These factors
may be associated with temporomandibular disorders in one individual with nosymptomatology or pathology in another.

Treatment Options
1.

Lip Size and Functiona.
Fixed or removable orthodontic applianceb.
Therapeutic exercises/myofunctional therapyc.
Functional/orthopedic applianced.
Surgery2.

Tongue Size and Functiona.
Fixed or removable orthodontic applianceb.
Therapeutic exercises/myofunctional therapyc.
Functional/orthopedic applianced.
Surgical reductione.
Lingual frenectomy

3.

Deleterious Habitsa.
Behavior managementb.
Functional/orthopedic appliancec.
Therapeutic exercisesd.
Fixed or removable orthodontic appliance4.

Airway Obstructiona.
Referral for evaluation/treatment/surgeryb.
Functional/orthopedic appliancec.
Orthognathic surgery

5.

Speech Disordersa.
Fixed or removable orthodontic appliance

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b.

Referral for evaluation/treatment/myofunctional therapy

6.

Mandibular Dysfunctiona.
Occlusal equilibration (modification of tooth form)b.
Fixed or removable orthodontic appliancec.
Fixed orthodontic appliance adjunctive to surgeryd.
Functional/orthopedic appliance7.

Temporomandibular Disorders (TMD)
TMD’s are multifactorial in nature. Harmonious functional occlusion and muscularbalance can enhance the health and stability of the temporomandibular joints. This
alone may not relieve TMD symptoms, however. Numerous treatment modalities,
including orthodontics, have produced beneficial results in the management of
temporomandibular disorders. However, no singular treatment modality may
necessarily be definitive for any particular patient. There is no reliable method forpredicting or preventing future temporomandibular disorders in any particular
individual. Often, treatment of such disorders is best approached from aninterdisciplinary perspective.

Orthodontic Considerations for Craniofacial Anomalies, Cleft Lip and Palate
Management of patients with these and other anomalies is, in many cases, most effective whenprovided by an interdisciplinary team of dentists, physicians and other healthcare professionals.
The optimal time for the first evaluation of these patients is within the first few days of life, andreferral for team evaluation and management is appropriate at any age. Treatment plans should
be developed and implemented on the basis of team recommendations. The orthodontist, as amember of the Craniofacial Team, should obtain pretreatment diagnostic records sufficient to
identify the problems, formulate a diagnosis and assist in treatment planning. Orthodontic
treatment should take into account those factors that may influence surgical and other applicableaspects required for optimal Craniofacial Team management of the patient.
For patients at risk for developing malocclusion or maxillomandibular discrepancy, similarly
sufficient and obtainable diagnostic records should be collected at appropriate intervals.
Depending on the goals to be accomplished, alternating periods of treatment and retention may benecessary beginning at birth. For example, patients with cleft lip and cleft palate may require
presurgical maxillary orthopedics to improve the position of the maxillary alveolar segments prior
to lip and palate closure. Later in life, timing of bone grafting of alveolar clefts to unify the clefted
dentoalveolar segments should be determined by the stage of dental development and withcollaboration between the orthodontist and surgeon in addition to other Team members.
Treatment Objectives and Limiting Factors
Treatment Objectives
The objectives of orthodontic treatment are optimum dentofacial function, health, stability andesthetics. While these objectives are desirable, it should be recognized that individual patients
have specific problems, concerns and conditions which may prevent the attainment of optimal
results in every case. Therefore, the inability to achieve some of the objectives of orthodontic
treatment in a particular patient is not an indication of negligence by the dentist even when nolimiting factors are reasonably evident or foreseeable.

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There are situations where it is appropriate to plan the treatment to address the patient’s limited
objectives provided that such limited treatment is not detrimental to the patient. Any treatment planthat does not align with the optimal goals of orthodontic treatment should be acknowledged by thepatient in an informed consent.
For example, a patient may present with a highly complex problem that will require lengthy andexpensive treatment to fully resolve. The patient may prefer to resolve only specific aspects of the
problem thereby reducing the scope of treatment to make it simpler, shorter, less expensive. In
doing so the patient achieves some positive outcomes which satisfy the patient’s objectives forseeking treatment.
Limiting Factors
Orthodontic treatment results may be affected by extenuating circumstances beyond thepractitioner's control. These limiting factors should be documented in the patient's record when
they are recognized and the patient/parent/guardian should be informed. The following are somealthough not all, potential limiting factors affecting orthodontic therapy:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Severity of the pretreatment condition
Mutual agreement to pursue limited treatment objectives
Abnormal skeletal morphology or growth, during or after treatment
Abnormal size, shape, or number of teeth
Aberrant tooth eruption patterns
Patient's failure to initiate timely treatment, continue or complete treatment
Compromised periodontal tissues
Persistent deleterious habits or abnormalities of muscle function relating to thedentofacial complex
Inability or unwillingness of the patient to cooperate with treatment (e.g., the wear
and/or care of appliances, oral hygiene measures, diet, keeping appointments, etc.)
Failure to complete all recommended aspects of treatment
Poor quality, untimely or inappropriate integration of other recommended or
required interdisciplinary dental and/or medical services
Disclosed or undisclosed medical complications or underlying systemic conditions
Transfer of patient care to or from another dentist during orthodontic treatment
Limitations of, or relapse following orthognathic surgical procedures
Patients failure to schedule and follow up with other specialists or their general
dentist following a referral from their orthodontist for specific conditions stated inthat referral

Treatment Consultation and Informed Consent
A discussion should be held with the patient/parents/legal guardian utilizing lay terminology toprovide sufficient information for the responsible party to accept or reject the proposed treatment
plan. The informed consent should be documented. Though requirements vary by jurisdiction, thedentist should consider including the following in the discussion:
1.
2.
3.

A description of the diagnosis and treatment plan.
A discussion of reasonable alternative treatments.
The relevant risks, compromises, and limitations associated with the proposed
treatment plan and reasonable alternative treatments.

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4.

5.
6.

7.
8.

A discussion of any portion of the treatment plan that will require the services ofother dental or medical health care providers and the anticipated effects of suchinterdisciplinary services on the orthodontic treatment plan.
The prognosis related to treatment plan options, including the option of notreatment.
A discussion of the patient's responsibility relating to the care (e.g., maintaining
periodic recall visits with their general dentist, compliance with adjunctive devices
such as elastics, headgear, retainers, and other removable appliances, etc.).
An estimate of the duration of active treatment and retention.
The AAO also recommends that financial arrangements be considered at this time.

Risks Associated with Orthodontic Treatment
All forms of medical and dental treatment, including orthodontics, involve risks and/or limitations.
Fortunately, in orthodontics, serious complications are infrequent. The dentist should discuss all
reasonably anticipated risks with the patient in the exercise of sound professional judgment given
the clinical condition of the patient. Due to the length of orthodontic treatment, conditions may
arise which are coincident, but not caused by orthodontic treatment. Some of the risks associatedwith orthodontic treatment include but are not limited to:
1.
2.

3.
4.
5.
6.
7.
8.
9.
10.

11.
12.
13.
14.
15.
16.

Tooth decay, or permanent markings (decalcification).
The length of the roots of teeth may become shortened. In some cases root
shortening may be pre-existing and should be documented in the pretreatment
record.
The health of the bone and periodontal support of the teeth may be affected.
The teeth and/or jaws may have a tendency to change their positions after
treatment.
Temporomandibular joint problems may appear concurrently with orthodontic
treatment,but may be unrelated to the treatment.
The vitality of a tooth may be compromised.
Orthodontic appliances may irritate or damage the oral tissues and may cause
injury if accidentally swallowed or aspirated.
Dental materials, instruments, and equipment may inadvertently result in damage
or injury to the oral tissues, face and/or eyes.
Accidents unrelated to treatment or patient misuse of orthodontic appliances may
result in injury to the oral tissues, face and/or eyes.
Oral surgery, orthognathic surgery or other adjunctive medical, surgical or dental
procedures may be recommended and/or necessary in conjunction with orthodontic
treatment. Associated treatments carry additional risks, limitations and additional
informed consent issues which must be discussed with the patient/parents/legal
guardian by the health care practitioner providing the service.
Orthodontic appliances may cause attrition, flaking or fracturing of tooth structure.
When orthodontic appliances are removed, fracture and/or damage to the teeth
may result.
Medical or psychosocial conditions may result in compromised results ordissatisfaction with treatment.
Orthodontic materials may cause allergic reactions in some individuals.
Patients may be dissatisfied with their dental or facial esthetics at the conclusion oftreatment due to unrealistic expectations or perceptions.
Abnormal growth during or after treatment may produce undesirable results or
posttreatment changes.

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17.
18.

19.

Treatment time may be extended and results compromised due to unforeseen
circumstances and/or poor patient cooperation.
Tooth movement during orthodontics may be adversely affected for patients
receiving certain pharmaceuticals as they have the potential to slow tooth
movement and may lengthen treatment time. The effects of these medications may
be severe enough to stop tooth movement which may result in removal of
appliances regardless of tooth positions. The effects of certain pharmaceuticals on
an individual are not always predictable.
The use of orally applied drugs, especially certain drugs of abuse such as cocaine
or amphetamines, may seriously compromise the periodontal tissue around teeth
which can be exacerbated by orthodontic treatment.

Sterilization and Infection Control
Because of ever increasing numbers of infectious diseases in today’s society, it is important for an
orthodontic office to be aware of current Centers for Disease Control (CDC) guidelines for theirrecommendations for personal protective equipment and the management of staff and patients inthe office to minimize the risk of transmission of such diseases.
1.

2.

The guidance for orthodontic procedures that do and do not produce high levels ofaerosols can be found at the state, regional and national levels throughorganizations like state dental associations, regional dental boards, and nationalorganizations such as the CDC and the AAO.
Orthodontists and their office team members are encouraged to become
familiar with and implement guidelines issued by CDC as well as the state's
Department of Health, ADA and other entities that have applications todentistry.

Orthodontic Treatment
Orthodontic treatment is a complex, professionally guided dynamic process that alters thedentofacial complex. Regardless of the specific intervention, orthodontic treatment has a specificpoint at which it begins and ends. Between these two time points lie the bulk of orthodontic
therapy. It is critical that the dentist manage the applied therapy using appropriate means
consistent with orthodontic educational standards, ethical guidelines and legal requirements.
Due to the protracted nature of orthodontic therapy and since each patient will respond totreatment in a unique manner, orthodontic treatment requires supervision, dynamic reassessment,
and case management to achieve the treatment goal.
Orthodontic Supervision
Supervision can be defined as monitoring the treatment progress and guiding the patient. Some
aspects of supervision may be delegated to auxiliary personnel, depending on applicable laws.
Certain aspects of treatment require face-to-face, in-office interaction with the patient toappropriately apply the chosen intervention.
Dynamic Reassessment
Dynamic reassessment occurs when the dentist monitoring treatment initiates a modification in the
protocol or mechanics required for continued treatment progress. Therapeutic staging is an

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intrinsic part of orthodontic treatment. Unforeseen or unanticipated provisional outcomes also
require clinical judgment and experienced remediation. All of this is part of dynamic reassessment
during which the dentist evaluates progress and applies essential modifications to achieve thedesired treatment outcomes. Dynamic reassessment is fundamental to all forms of orthodontic
treatment and requires the direct, professional judgment of a dentist. Referral for adjunctive dental
or specialty treatment may at times be part of the process.
Posttreatment Evaluation and Outcomes Assessment
The effects of orthodontic treatment may be evaluated retrospectively with reference to thepretreatment condition. Consistent re-evaluation of treatment results along with continued reviewof treatment modalities and their effectiveness will serve to provide the public with the highest
quality of orthodontic care. Assessments of the outcome of treatment are dependent in part upon
the treatment goals and objectives, the condition being treated, the stage of the patient's
dentofacial development, the treatment provided and the patient’s compliance as well as tissue
response to the therapy performed. Limiting factors should be considered when evaluating
treatment outcomes.
Posttreatment Records
Posttreatment unaltered records provide information for the quantitative and qualitative
assessment of treatment changes as well as for education, research, and quality assurance.
Posttreatment records may include, but are not limited to:
1.
2.
3.

4.

Extraoral and intraoral images (digital, still or video images)
Dental casts (hard copy or digital format)
Radiographic imaging (intraoral radiographs, panoramic radiographs,
cephalometrics, CBCT, etc.) to permit relative evaluation of the size, shape, andpositions of the relevant hard and soft tissue craniofacial structures including thedentition.
Other indicated procedures or tests

Retention
1.
2.
3.
4.

A retention plan should be established after reviewing the patient's original
condition, treatment objectives, the results achieved, and/or any limiting factors.
Successful completion of orthodontic treatment does not ensure the stability of theresult. Future treatment may be recommended when posttreatment changes occur.
Posttreatment changes may be minimized with an indefinite retention wear
protocol.
The explanation to the patient regarding his or her responsibilities for retaining theoutcome of their orthodontic treatment should be clearly communicated and thepatient should acknowledge their understanding of the information that has been
provided to them.

Recordkeeping
The keeping and preserving of a patient's dental record is a part of providing high quality
orthodontic treatment. Prudent recordkeeping is the foundation for planning and maintaining thecontinuity of patient care. It also provides documentary evidence of the evaluation and diagnosisof the patient's condition, the treatment plan, informed consent, the treatment provided, referrals

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made, and follow up care. It also documents communications with the patient, other health careproviders and any other third parties. The dental record also protects the legal interests of allparties. In addition, a patient's dental record may, as authorized by the patient or legal guardian orwith appropriately redacted identifying information, provide material for continuing education,
research, administrative oversight, billing, and quality assurance. When creating the patient’s
dental record, dentists should keep in mind the following:
1.

2.

3.

4.

Treatment procedures, changes in the treatment plan, patient compliance,
treatment difficulties, and other important aspects of treatment should be recorded
and maintained. Copies of related correspondence, informed consent andappropriate release forms should be maintained as part of the patient's record.
Documentation should be written, dictated, or computer annotated and maintained
concurrently with treatment provided. This documentation should be dated and kept
chronologically with any subsequent additions or changes conspicuously noted.
The original records are usually considered the property of the practitioner. Laws
regarding patient record access, duplication and transfer vary from state to state.
Dentists can obtain further clarification from their state regulatory agency.
Electronic/digital records have the potential to be altered. Alteration of original
electronic/digital records must be avoided. Credible computer software either
prevents this or records any alteration of an original electronic/digital record.
However, enhancement of images is allowed as long as these are duly labeled andsaved as separate images. Enhancement of other electronic/digital records, suchas radiographs, to enable better identification of landmarks and/or dentoskeletal
anomalies is permissible; however, the original cannot be altered. It is the
responsibility of the dentist to protect the sanctity of all patient records asprescribed by all applicable local, state and federal laws.

Transfer of Orthodontic Patients During Active Treatment
Because of the time required to complete orthodontic treatment, the transfer of care from one
dentist to another is a common occurrence.
Recommendations to the Transferring Dentist
1.

2.

3.

Dentists should attempt to arrange for the continuation of orthodontic treatment of
their patients with as little interruption as possible. Regardless of reason fortransfer, reasonable efforts of both the transferring and accepting dentist arenecessary to effect an orderly transfer. It is recommended, and in some statesrequired, to obtain a written release from the patient/parents/legal guardian prior to
the transfer of a copy of the patient's records. It is preferable to send copies of
pertinent records directly to the new dentist. The use of electronic media may
facilitate this process. It is acceptable, but less desirable, to provide these records
to the patient/parents/legal guardian. A copy of patient records cannot be withheld
due to an outstanding balance.
The transferring dentist should ensure that all appliances are in good order. The
patient/parents/legal guardian should be advised that extended periods of active
orthodontic treatment without supervision can be detrimental, and an appointment
with the new dentist should be scheduled as soon as possible.
The patient/parents/legal guardian should be informed that there may be different
approaches to treatment by different dentists.

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4.
5.
6.
7.

The patient/parents/legal guardian should be informed that there may be different
fees with treatment by different dentists.
The transferring dentist should make no statements that would undermine theestablishment of a sound doctor-patient relationship with the accepting dentist.
The transferring dentist should be available for consultation with the accepting
dentist.
The transferring dentist should provide appropriate financial information in advanceor immediately upon request to the accepting dentist.

Recommendations to the Accepting Dentist
1.

2.
3.

4.

The accepting dentist should review the patient's records, including the previous
financial arrangements, if available, prior to the development of a plan forcontinuation of treatment. In addition, the estimated time required to complete
treatment and the financial arrangement for continuation of treatment should be
discussed as soon as possible. Patients should be informed about their present oral
health status without defamatory statements that are both untrue and damaging
comments about the patient’s prior treatment.
Appropriate records documenting the status of the patient at the time of transfer
should be made.
A dentist is not obligated to accept an orthodontic transfer patient and may exercise
discretion in selecting a patient into his/her practice, provided refusal to accept apatient is not because of the patient’s race, creed, color, sex, national origin,disability, HIV seropositive status, or other legally recognized protected class. If adentist is unable or unwilling to accept the transfer patient, the dentist may assist
the patient/parents/legal guardian in finding another dentist.
At the patient/parents/legal guardian's request, a dentist may remove appliancesfrom a patient not of record. It is advisable to consult with the previous dentist or
dentists, if possible, prior to removal of appliances or cessation of treatment.

Dentists should be aware of the following documents written by the AAO Legal Counsel:
1.
Second Opinions
2.
Terminating the Doctor/Patient Relationship3.
Patient Records and Record Keeping

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Appendix A
Historical Development
At its November 1993 meeting, the AAO Board of Trustees directed the AAO Council on
Orthodontic Health Care (COHC) to study the feasibility of developing clinical practice guidelines
for orthodontics. The council met in January 1994 and proposed a business plan for thedevelopment of Guidelines, which was considered at the February 1994 meeting of the AAO
Board of Trustees. It was the consensus of the AAO Board of Trustees to develop guidelines
utilizing the expertise within the AAO. A task force was appointed.
The task force met three times between July 1994 and January 1995 and wrote draft guidelines. A
copy of draft guidelines was sent to all active AAO members in April 1995 for review. Open forums
were held at the 1995 AAO Annual Session and at the meetings of all eight AAO constituent
societies during August-November 1995. The task force met again in December 1995 to revise thedraft guidelines based on feedback received in 1995. The December 1995 revised draft guidelines
were widely circulated in January 1996 for comment. The task force reviewed the comments and arevised draft of the guidelines was distributed to the AAO House of Delegates members, the Boardof Trustees and other leaders of organized orthodontics in April 1996. An open forum was held at
the 1996 AAO Annual Session for comments on the revised draft guidelines. The revised draft
guidelines were approved by the Board of Trustees, a House of Delegates Reference Committee
and by the House of Delegates. The Clinical Practice Guidelines were printed in 1996 and weremade available to AAO members.
Updating of Clinical Practice Guidelines
The American Association of Orthodontists considers its Clinical Practice Guidelines to be a living
document. The existence of this document is intended to stimulate improvement in the practice oforthodontics by identifying areas where knowledge is incomplete or inadequate. The AAO
recognizes the dynamic nature of orthodontics and dentofacial orthopedics and the necessity for
updating the guidelines to reflect the evolving science and art of orthodontics. Revisions to the
document, with opportunities for AAO member input, will occur periodically.

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Appendix B
Selected References
Introduction
American Association of Orthodontists. Bylaws of the American Association of Orthodontists. St.
Louis: American Association of Orthodontists; amended through 2018.
American Association of Orthodontists. Principles of ethics, code of professional conduct andadvisory opinions of the American Association of Orthodontists. St. Louis: American Association of
Orthodontists; 2017, amended through 2018.
American Association of Orthodontists. Glossary of dentofacial orthopedic terms. St. Louis:
American Association of Orthodontists; 2017.
American Dental Association. Council on Ethics, Bylaws and Judicial Affairs. Principles of ethics
and code of professional conduct with official advisory opinions revised to September 2018.
Chicago: American Dental Association; 2018. Available at:https://www.ada.org/~/media/ADA/Member%20Center/Ethics/ADA%20Code%20Of%20Ethics%20
Book%20With%20Revised%20Advisory%20Opinions%20to%20September%202018.pdf?la=en.
Accessed October 30, 2018.
American Dental Association. Commission on Dental Accreditation. Accreditation Standards for
Advanced Specialty Education Programs in Orthodontics and Dentofacial Orthopedics. Chicago:
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