I’m Simon Littlewood, Consultant & Specialty Lead in Orthodontics at St Luke’s Hospital, Bradford. I am also a Senior Clinical Lecturer at Leeds Dental Institute, University of Leeds
How does the work of a hospital-based consultant orthodontist differ from that of a practice-based orthodontist?
As a hospital-based consultant I am generally involved in treatments with patients who require input from other specialties, in addition to my orthodontic treatment. This includes specialties like maxilla-facial surgery, restorative dentistry, paediatric dentists, ENT surgeons, and sleep consultants. I am also heavily involved in teaching, for dentists training to be specialist orthodontists, and for orthodontists who want to be become consultants. One of the great things about my job is the variety, and I also get involved in some clinical research and providing advice about orthodontics to other clinicians and those involved in dental public health.
What most interests you about working in orthodontics?
Working in orthodontics is an incredibly rewarding career – this is why most orthodontists you come across are really happy! The changes that can be achieved with patients’ smile can make a real difference and almost inevitably patients are delighted with the result. This is not something you can say about all aspects of healthcare.
How would you describe your approach to working with new patients?
Working with new patients is about gathering information to make a diagnosis of the problem or problems. The information gathering includes collecting a history from the patient, examining the patient and undertaking any special investigations (like X-rays). A key part of the history is determining what the patient hopes to achieve from the treatment. As clinicians we need to understand this, because no matter how good a treatment might be, if it does not meet the patient’s hopes and expectations they are likely to be disappointed. Sometimes, of course, the patient may be asking for something that’s not achievable and our job is to be honest about this and let the patient know.
The first visit is key, as it also the time to get to know the patient, make them feel at ease and actively listen to them. The patient, or patient’s parent, will make a decision at this visit whether they like and trust you enough to go ahead with treatment. It is important to make the patient feel at ease. So much of orthodontics is reliant on patients following the orthodontist’s directions, and this compliance is built on trust and respect between the patient and the clinician.
What type of cases do you most enjoy working on?
The beauty of my job is the variety. I am very lucky as my hospital consultant post allows me to treat some really varied and complex malocclusions, often working with other specialties at the same time. I also have a small private practice that allows me to treat more routine cases, using techniques and appliances that may not be available on the NHS.
Could you describe the process a surgical patient goes through from the first appointment to completing treatment and how do you treatment plan for these surgical patients?
A large part of my hospital practice is treating patients who would benefit from a combination of orthodontics and surgical treatment. This is now regarded as routine treatment and is very successful, but it is a complex treatment that carries surgical risks and the total treatment time is often over 2 years. As a result, it is vital the patient is appropriately planned, with input from our orthodontic team, our psychologists and of course the maxillofacial surgeons. The typical patient journey starts with an initial assessment where we discuss with the patient that they may benefit from a combination of orthodontics and facial surgery. This may come as a surprise to patients, so this discussion needs to be handled carefully. We stress that this is an “elective” procedure, so the patient can choose whether to leave things as they are. At this first appointment, we provide them with information leaflets about the combined orthodontic and surgical treatment and refer them to an excellent online resource from the British Orthodontic Society called YourJawSurgery.com, which has real patients talking about their experience and explains the process in a patient-friendly way.
Following this first visit we will collect full records – photos, impressions, X-rays – and then use a computer programme to plan the surgery. The software allows us to morph photos of the patient’s face to predict the facial appearance after surgery. As a team – orthodontists, psychologists, and surgeons – we meet to discuss the cases in detail using these records, and then later the same day we meet the patient and their family, again as a team, to discuss the plan in detail.
We never put any pressure on patients to make a decision, and if they are unsure we will bring them back and discuss the options again. We appreciate that it is a big decision, and only when they are absolutely sure that they want to go ahead do we start the treatment.
I always say to patients there are 3 groups of patients at this stage: One group have fully understood the plan, accept the risks and commitment involved and definitely decided they would like to go ahead with treatment. Another group have decided they do not want this treatment. A third group may be quite keen but are not entirely sure yet. We only allow patients in the first group to progress with treatment.
Typically, the patient starts with the braces and then after about 12-18 months, depending on the type of case, more photos, impressions and X-rays are collected to plan for the surgery. The surgery can be planned on plaster models or on 3D scans called cone-beam scans.
The patient will then go for surgery, with the braces still on. The surgery is done under general anaesthetic and will involve a stay in hospital, followed by a recovery period at home. The orthodontist and surgeon will see the patient regularly for a few weeks after the surgery until everything is healed. The patient then usually has about 6 months more of the braces to complete the treatment, followed by retainers.
Does the fixed brace one of your patients wears differ from one fitted to non-surgical patients?
Essentially it is the same type of brace. The purpose of the fixed brace for surgical patients is to straighten the teeth but also to get the teeth in the right angulation once the jaws are in the right position. We also shape the upper and lower arches so that when the jaws are moved they fit together properly.
You worked with BOS on the launch of their #Holdthatsmile retainer campaign, what key messages would you like to convey to adult patients?
The Hold that Smile campaign was aimed at highlighting to patients the need for retainers at the end of any type of orthodontic treatment. In the past, patients were asked to wear retainers for a couple of years only. However, we now know that over a period of time teeth will become crooked again if the retainers are not worn in the long-term. This is partly due to teeth wanting to move back to where they originally came from, but also due to normal age changes in the mouth, which tends to cause teeth to become more irregular. In the campaign we produced videos aimed at patients (one normal film and one cartoon version for younger patients), so that patients are aware of the need to wear, look after and maintain retainers long-term. This is information they need to know about before they commit to orthodontic treatment. The videos can be accessed here.
How has the introduction of orthodontic therapists changed the experience for patients?
The first group of orthodontic therapists in the UK qualified 10 years ago in 2008. This started the biggest single change in the delivery of orthodontics in the UK. My own experience of working with orthodontic therapists is incredibly positive and my view is that patients really appreciate having their treatment undertaken by orthodontic therapists, while also meeting and being supervised by the orthodontist.
What do you see as being the next big advances in orthodontics?
There has been a gradual move to more digital orthodontics over the last few years, including scanning patients’ teeth rather than using the traditional approach of taking moulds of their teeth and producing plaster models. This production of 3D virtual models of patients’ teeth, along with other digital records, means that it will become increasingly easy to produce orthodontic appliances that are customised to the individual patient.
Finally, if you were not an orthodontist, what would you be?
It’s a hard question to answer, as I so enjoy my job that I can’t really imagine doing something else. But I would have liked to have been a professional footballer (but lacked the talent!) or a professional musician (also lacked the talent!)…looks like I will have to stick to the wonderful world of orthodontics…