Orthodontic treatment planning

ORTHODONTIC TREATMENT PLANNING:

*Concepts & Goals

*Major Issues

*Treatment Possibilities-Dental Crowding

-Transverse Maxillary Deficiency

-Class II Problems

-Class III Problems

*Reducing Uncertainty

Presented by:

Dr. Kristel

TREATMENT PLANNING:

*Concepts and Goals

*Major Issues

*Treatment Possibilities

1. Dental Crowding

a. EXPANSION

b. EXTRACTION

2. Skeletal Problems

a. TRANSVERSE MAXILLARY DEFICIENCY

b. CLASS II

c. CLASS III

d. VERTICAL PROBLEMS

3. Reducing Uncertainty

Treatment Planning Concepts & Goals*Treatment Planning- is the act or process of analyzing, making, or carrying out a series of method to come up with a solution on how an existing problem can be solve.*Concepts- are formed thoughts or ideas.*Goals- are desired result that a person plans and commits to achieve.*Diagnosis- an act of identifying a problem.

- In order for us to come up with a detailed treatment plan, a complete list of the patient’s problems must be considered. The treatment planning approach advocated here is specifically designed to avoid both missed opportunities ( The False Negative / Under treatment side of treatment planning) and excessive treatment ( The False Positive / Over treatment side).

Figure 7.1 The treatment planning sequence. In treatment planning, the goal is wisdom, not scientific truth – judgement is required. Interaction with the patient and parent, so that they are involved in the decisions that lead to the final plan, is the key to informed consent.

Problem List=

Diagnosis

Pathology(caries, perio, Etc…)

Control beforeOrthodontic Treatment

Orthodontic A A(DEVELOPMENTAL) B B problems C C Possible D D solutions etc etcPriority Order

Evaluate

InteractionCompromiseCost/BenefitOther factors

Patient-ParentConsult

AlternativePlans

Patient Input

InformedConsent Tx plan

concept

Effectiveness

Efficiency

Tx plandetails

Major Issues in Planning Treatment- There are 2 major issues in planning for your patient’s orthodontic treatment:1. Patient Input – both ethically and practically, the patients and parents are involved in the decision making process since they have the right to control what happens to them during the treatment. This is one critical issue in the success or failure of a treatment.2. Predictability and Complexity of Treatment- may affect treatment planning since sometimes, we referred patients to other specialist depending on the type of case and the extent of our knowledge.

Treatment Possibilities- For planning a comprehensive treatment, it is important to consider 2 controversial aspects of current orthodontic treatment planning: The extent to which arch expansion versus extraction is indicated as a solution for crowding in the dental arches & the extent to which growth modification versus extraction for camouflage or orthognatic surgery should be considered as solutions for skeletal problems.

*Dental Crowding: To Expand or Extract?For Esthetic Considerations:- Either to extract or to expand the teeth, facial esthetics can become acceptable or unacceptable. In soft tissue relationships, an individual with thick, full lips looks good with incisor prominence that would not be acceptable in someone with thin lips. Another is the size of the nose and chin which has a profound effect on relative lip prominences. For best esthetics, the lower lip should be atleast as prominent as the chin.

For Stability Considerations:- There is a limit on how much can arches be expanded in order to maintain a stable result. In cases of extraction, stability tends to be more stable than in those cases wherein nonextraction treatments are done.

Figure 7.2 Expansion of the dental arches tends to ,ake the teeth more prominent and extraction makes them less prominent. The choice between extraction and nonextraction (expansion) treatment is a critical esthetic decision for some patients who are towards the extremes of incisor protrusion or retrusion initially, but because there is an acceptable range of protrusion, many if not most can be treated satisfactory esthetics either way. This is especially true if expansion is managed so as not to produce too much incisor retraction. Similarly, expansion tends to make arches less stable and extraction favors stability, but the extraction/nonextraction decision probably is a critical factor in stability largely for patients who are toward the extremes of the protrusion-retrusion distribution.

Either acceptable

EstheticsFlat Lips Full Lips

A

Either acceptable

StabilityMore Stable Less Stable

Extraction Non Extraction

B

Contemporary Extraction GuidelinesIn Class I crowding cases can be summarized as follows:

1. Less than 4mm arch length discrepancy- Extraction is rarely indicated. In some cases, this amount of crowding can be managed without arch expansion by slightly reducing width of selected teeth, being careful to coordinate the amount of reduction in the upper and lower arch.2. Arch length discrepancy of 5 to 9mm- Extraction or Nonextraction treatment possible. Nonextraction treatment usually requires transverse expansion across the molars and premolars.

3. Arch length discrepancy of 10mm & up- Extraction almost required. The amount of crowding virtually equals the amount of tooth mass being removed, and there would be little or no effect on lip support and facial appearance.

ExtractionRELIEF OF INCISOR

CrowdingINCISOR RETRACTION

Maximum Minimum

POSTERIOR FORWARD

Maximum Minimum

Central IncisorLateral IncisorCanine Incisor1st Premolar2nd Premolar1st Molar2nd Molar

5565332

3 23 25 35 23 02 01 0

1 01 02 05 26 48 6- -

Space from Various Extractions*

*Transverse Maxillary Deficiency- If the maxilla is narrow relative to the rest of the face, a skeletal expansion probably is appropriate with the use of an adjustable jackscrew or an implant supported bone screw. Pont’s index is the method used to diagnose maxillary deficiency.

PONT’S ANALYSIS – Gives an approximate indication of the degree of narrowness of the dental arches in cases of malocclusion and also the amount of lateral expansion required for the arch to be of sufficient size to accommodate the teeth in perfect alignments.

Note: Expected arch width in the premolar region is SI/80x100. - If the measured value is less than the calculated value then, it indicates a need for expansion.

Expected arch width in the molar region is SI/64X100. - If the measured value is less than the calculated value then, it indicates a need for expansion.

SI (Sum of Incisors) – the mesiodistal widths of each maxillary incisors summed up all together.

PALATAL EXPANDER

-In a child up to age 9 or 10, almost any device will tend to separate the mid palatal suture easily.

-In adolescents, expansion can be done in three ways:1. Rapid expansion with a jackscrew device attached to the maxillary posterior teeth, typically at the rate of 0.5-1mm/day.2. Slow expansion with the same device at the rate of approximately 1mm/week.3. Expansion with a device attached to bone screw or implants so that pressure is directly applied to the bone and not against the teeth.

*Class II Problems- Extraoral force to the maxilla (headgear) was utilized in the late 1800s which was later on abandoned, not because it did not work, but because Angle and his contemporaries thought that Class II elastics would cause the mandible to grow forward and that this would produce an easier and better correction. It was reintroduced in the 1940’s and came to be widely used in Class II treatment. In the late 1950’s were cephalometric aids in the studies of the clinical success of functional appliances, but questions remained as to whether these appliances could really stimulate mandibular growth.

- In 1990’s, 2 major projects using randomized clinical trial methodology were carried out. The data from all trials show 3 important things: (1) on average, children treated prior to adolescence with either headgear or a functional appliance had a small but statistically significant improvement in their jaw relationship than those untreated control children. (2) changes in the skeletal relationships created during early treatment were at least partially reversed by later compensatory growth, in both the headgear & functional appliance.

(3) At the end of comprehensive treatment during adolescence, there were no significant differences between the early treatment patients and the previously untreated controls.

- Orthodontic Camouflage: when the jaw discrepancy is no longer apparent, malocclusion is corrected and the facial appearance is acceptable.The ff. 3 patterns of tooth movement can be used to correct a Class II malocclusion:1. Nonextraction treatment with Class II elastics.

2. Retraction of the upper incisors into a premolar extraction space.3. Distal movement of the upper teeth.Note: In the absence of favorable growth, treating a Class II relationship in adolescents is difficult. Fortunately, even though growth modification cannot be expected to totally correct an adolescent Class II problem, some forward movement of the mandible relative to the maxilla does contribute to successful treatment of the average patient. When little or no growth can be expected, orthognathic surgery to advance the mandible may be necessary to achieve a satisfactory result.

“Orthognathic Surgery”

*Class III Problems- Growth modification for Class III patients is just the reverse of Class II: what is needed is differential growth of the maxilla relative to the mandible.

- Horizontal Vertical Maxillary Deficiency: Delaire and his coworkers in France showed that forward positioning of the maxilla could be achieved with a reverse (pull) headgear, not during the early age but before the age of 8. Long term follow up suggests then that treatment should begin by age 10 at the latest.

The chance of successful forward movement is essentially zero by the time sexual maturity is achieved. The ideal patients for this treatment would have both:(1) Normally positioned or retrusive, but not protrusive, maxillary teeth. (2) Normal or short, but not long, anterior facial vertical dimensions.

- Mandibular Excess: children who have Class III malocclusion because of excessive growth of the mandible are extremely difficult to treat. The possible treatment approaches are combinations or all of the ff.: Class III functional appliances, extraoral force to a chin cup, and Class III elastics to skeletal anchors.

- Class III Camouflage: in treating a patient with a case wherein, the chin is very prominent, it is necessary to advance the mandibular incisors as much as possible rather than retracting it to an

extraction space while proclining the maxillary incisors. A treated patient would have: (1) Reverse overjet largely due to protrusive mandibular incisors and retrusive maxillary incisors, with more maxillary deficiency than mandibular prognathism. (2) Short anterior face height, so that downward-backward rotation of the mandible would improve both antero-posterior and vertical facial problems.

- Vertical Problems: Skeletal vertical problems, both short-face and long-face patterns, cannot be treated alone by camouflage(tooth movement). For short-face patients, functional appliances can be quite successful while for a long-face pattern, the only successful treatment approach required orthognathic surgery.

*Reducing Uncertainty- Even when excellent data from clinical trials are available, it is difficult to predict how any individual will respond to a particular treatment.- In orthodontics, 2 interrelated factors should be taken into consideration: The px’s growth pattern and the effect of treatment on the expression of growth.- One way to reduce uncertainty in planning treatment for children is to use the approach known as “Therapeutic Diagnosis”.

In practice, it involves implementing a conservative treatment plan initially and reevaluating the patient after a few months to observe the response of the treatment. The disadvantage of the evaluation period is that it may take a longer time if surgery or extraction decision had been made initially. The advantage is a decrease in the number of incorrect decisions.

ENDTHANK YOU