> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Orthodontics
> How to document orthodontic assessments, fixed brace treatment, clear aligner progression, and retainer fitting using Clinical Procedures and Patient Encounters.
Orthodontic treatment runs over months or years, with regular short adjustment appointments interspersed with longer review visits. The system tracks each appointment and procedure, building a longitudinal record of tooth movement from the initial assessment through to the retainer stage.
***
## Before You Start
* Clinical Procedure Templates for orthodontic procedures must be set up.
* The orthodontist must have a Healthcare Practitioner record.
* An orthodontic assessment (full clinical examination + OPG + study models) must be completed before treatment begins.
* You need the **Healthcare Practitioner** role to document orthodontic procedures.
***
## Setting Up Orthodontic Procedure Templates
| Template Name | Notes |
| --------------------------------------- | ------------------------------------------------------ |
| Orthodontic Consultation and Assessment | Initial full assessment - charged at consultation rate |
| Fixed Brace Bond-Up (Full Arch Upper) | Upper bracket and wire placement |
| Fixed Brace Bond-Up (Full Arch Lower) | Lower bracket and wire placement |
| Orthodontic Adjustment (Upper + Lower) | Monthly/6-weekly adjustment appointment |
| Wire Change (Upper) | New wire at progression stage |
| Wire Change (Lower) | New wire at progression stage |
| Bracket Rebond (per bracket) | Rebonding a debonded bracket |
| Elastics Check and Replacement | Intermaxillary elastics check |
| Brace Removal (Upper + Lower) | Debond appointment |
| Retainer Impression (Upper + Lower) | Impressions for removable retainers |
| Retainer Fit (Hawley - Upper) | Fit of removable upper retainer |
| Retainer Fit (Vacuum-formed - Lower) | Fit of vacuum-formed lower retainer |
| Bonded Retainer Placement (Lower) | Placement of wire bonded retainer behind front teeth |
| Aligner Issue (per set) | Issue of clear aligner set to patient |
| Aligner Review | Review of aligner progress and issue of next set |
| Attachment Placement for Aligners | Composite attachments for clear aligner systems |
***
## Step 1: Orthodontic Assessment
The initial orthodontic assessment is documented as a Patient Encounter with appointment type "Orthodontic Consultation".
**Record in the Patient Encounter:**
**Dental and Skeletal Assessment:**
* Skeletal pattern: Class I / Class II (retrognathic mandible) / Class III (prognathic mandible)
* Facial symmetry
* Soft tissue profile (lip competence, mentolabial fold)
* Incisor relationship: Class I / II div 1 / II div 2 / III
* Overbite: reduced / average / increased / complete
* Overjet: specify in mm
* Arch form: tapered / square / ovoid
* Crowding: mild / moderate / severe, specify which teeth are displaced
* Spacing: generalised / localised, specify
* Crossbite: anterior / posterior, specify teeth
* Missing teeth: congenitally missing, extracted (record reason)
* Impacted teeth (especially canines)
* Dental midline shift
**Records Required Before Treatment:**
1. OPG (panoramic X-ray) - ordered from the encounter (see [Dental Radiography](/health-wellness/dental-clinic/dental-radiography))
2. Lateral cephalogram (if available for cephalometric analysis)
3. Study models (upper and lower alginate impressions poured in plaster - sent to lab)
4. Clinical photographs (extraoral and intraoral)
**Treatment Plan Recorded in the Encounter:**
* Type of appliance: fixed braces (metal / ceramic) / clear aligners / removable appliance
* Extractions required: which teeth, timing
* Estimated treatment duration
* Proposed outcome
* Retention plan (type of retainer, duration)
* Fees and payment plan
***
## Step 2: Bond-Up (Brace Placement)
When treatment begins, record the bond-up as a Clinical Procedure:
1. Open the Clinical Procedure record for "Fixed Brace Bond-Up (Full Arch Upper/Lower)"
2. In the Notes field, record:
```
Date: [date]
Upper arch bond-up:
- Bracket system: [Brand], MBT prescription, 0.022" slot
- Brackets bonded to: 14, 13, 12, 11, 21, 22, 23, 24
- Molar bands: 16, 26 (cemented with glass ionomer cement)
- Initial wire: 0.014" NiTi, continuous
- Ligation: elastomeric modules, colour [patient's choice: grey/silver/blue etc.]
Lower arch bond-up:
- Brackets bonded to: 34, 33, 32, 31, 41, 42, 43, 44
- Initial wire: 0.014" NiTi, continuous
- Ligation: elastomeric modules
No bracket repositioning required.
Patient given oral hygiene instruction for braces (interdental brushes, Waterpik advice).
Dietary advice given: avoid hard/sticky foods.
Emergency contact card given.
Review in 6 weeks.
```
***
## Step 3: Regular Adjustment Appointments
At each adjustment appointment:
1. Create or open a Patient Encounter (appointment type: "Orthodontic Adjustment")
2. Record a brief assessment of current progress in the encounter notes:
* Which spaces are closing
* Which teeth are moving as planned
* Any pain or problems since last visit
* Oral hygiene status (gum health with brackets)
* Elastics compliance (if elastics are being worn)
3. Create a Clinical Procedure record for the adjustment:
**Adjustment notes to record:**
```
Date: [date]
Upper arch:
- Old wire: 0.018" NiTi removed
- New wire: 0.018 x 0.025" NiTi, continuous
- Modules changed: blue
- Space remaining: 2mm upper left
Lower arch:
- Wire ligated back in: 0.014 x 0.025" SS
- Elastics: 3/16" medium, Class II pattern - patient instructed on fitting
- Oral hygiene: fair - instructed again on interdental cleaning, particularly 32-33 area
Next appointment: 6 weeks - review wire and consider 0.019 x 0.025" SS
```
***
## Step 4: Clear Aligner Treatment
For patients using clear aligner systems (such as Invisalign or a similar system):
1. At each aligner issue appointment, create a Clinical Procedure record for "Aligner Issue"
2. Record in the notes:
```
Date: [date]
Aligners issued: Set 7 of 22 (upper and lower)
Attachments: No new attachments. Existing attachments intact.
Refinements: Not required at this stage.
Compliance: Patient reports 20-22 hours/day wear of previous aligners.
Progress: Upper midline correcting well. Lower right canine movement as planned.
Next set issue: 2 weeks. Review in 8 weeks.
```
For aligner reviews where progress is assessed:
* Check that teeth are tracking the aligner (no gaps between aligner and tooth indicate tracking issues)
* Check attachment position and integrity
* Check oral hygiene under attachments
* Issue next sets
***
## Step 5: Brace Removal (Debond)
At the debond appointment, the brackets and bands are removed. Create a Clinical Procedure record:
```
Date: [date]
Brace removal: Fixed brace upper and lower debonded.
Technique: Bracket debond with debonding plier, residual adhesive removed with ultrasonic scaler and polishing.
All teeth confirmed clean, no demineralisation noted.
Post-debond study models / photographs taken.
Impressions taken for:
- Upper removable Hawley retainer (sent to lab, return expected in 10 days)
- Lower vacuum-formed retainer (in-house fabrication, issued same day)
Bonded retainer: 0.0175" TW wire bonded to lower 33-43.
Post-treatment discussion:
- Retention plan explained: Hawley upper night retainer, lower fixed retainer (permanent).
- Patient instructed to wear upper retainer every night indefinitely.
- Patient given retainer care instructions.
Review: 3 months.
```
***
## Step 6: Retainer Fitting and Review
After the laboratory returns the retainer:
1. Book the patient for a "Retainer Fit" appointment
2. Create a Clinical Procedure record for the fit
3. Record:
```
Date: [date]
Retainer fitted: Upper Hawley retainer.
Fit: Good fit on model and in mouth. No rocking. Clasps engaging properly.
Adjustments: Minor adjustment to Adams clasp at 16.
Occlusion: No interference from retainer in normal intercuspation.
Instructions: Wear every night. Remove for eating. Clean with cold water and toothbrush.
Bring to every review appointment.
Next review: 3 months.
```
At each retainer review:
* Assess tooth position (has there been any relapse?)
* Check retainer fit and condition
* Reinforce wearing instructions
***
## Monitoring Orthodontic Progress
Use the Clinical Procedure list to track all orthodontic procedures for a patient:
* Filter by Patient Name to see the full sequence of adjustments
* Use the patient history timeline to review the chronological record
The diagnosis recorded in each encounter (e.g., "Class II Division 1 malocclusion") feeds the Diagnoses dashboard chart, allowing you to see what the most common orthodontic presentations are at your clinic.
***
## Field Guide: Patient Encounter (Orthodontic Visit)
| Field | Description |
| ----------------- | ----------------------------------------------------------------------------------- |
| Patient | The orthodontic patient |
| Appointment | Linked adjustment or review appointment |
| Symptoms | Patient-reported concerns (pain, wire poking, loose bracket) |
| Examination | Progress assessment: tooth positions, space closure, midline, hygiene |
| Diagnosis | Primary orthodontic diagnosis (Class I crowding, Class II Div 1 malocclusion, etc.) |
| Treatment Notes | This visit's progress summary |
| Drug Prescription | Analgesia if needed after adjustment (rarely required) |
| Status | Draft → Submitted |
***
## Best Practices
* Take clinical photographs at the bond-up and at regular intervals (every 3-6 months) during treatment - these are invaluable for tracking progress, for consent documentation, and for before/after comparisons at the end of treatment
* Warn patients at each adjustment that they may experience soreness for 1-2 days after the wire is changed - this normalises the experience and reduces unnecessary emergency calls
* Oral hygiene deteriorates under fixed braces - check gum health at every visit and refer to the hygienist if significant gingivitis develops; proceeding with orthodontics in the presence of active gum disease causes permanent damage
* Retention is for life - explain this clearly at the start of treatment and again at debond; patients who stop wearing retainers will experience relapse, and relapse disputes are a common source of complaints
* For any bonded retainer, check the bond at every review - a partially debonded bonded retainer is worse than no retainer (selective relapse of unretained teeth)
***
## Troubleshooting
**A patient has missed multiple adjustment appointments and treatment is prolonged**
Document each missed appointment in the patient record. If significant time has passed, a re-examination may be needed to see if the braces are still working. Discuss with the patient whether they wish to continue or to debond early.
**A patient's teeth are not tracking the aligners**
Check compliance (not wearing aligners for the required hours). Check for missing attachments. If tracking issues persist, order a refinement scan to get new aligners made to accommodate the current tooth position.
**A bonded retainer has debonded partially**
Book the patient urgently. Identify which teeth are no longer retained. Rebond the wire. Check for relapse of the unretained teeth. Document fully.
***
## Related Features
* [Dental Examination](/health-wellness/dental-clinic/dental-examination): Orthodontic assessments are Patient Encounters
* [Dental Radiography](/health-wellness/dental-clinic/dental-radiography): OPG is a mandatory record for orthodontic assessment
* [Laboratory](/health-wellness/dental-clinic/laboratory): Study models and retainers are sent to the dental laboratory
* [Billing and Finance](/health-wellness/dental-clinic/billing-finance): Orthodontic treatment is commonly billed on a payment plan