GENERAL CONSIDERATIONS �IN TREATMENT PLANNING
Dr MOHAMED JASIM O
SENIOR LECTURER
DEPT OF ORTHODONTICS
CONTENTS
INTRODUCTION
TREATMENT PLANNING IN ORTHODONTICS
SEQUENCE IN TREATMENT PLANNING
GOALS FOR ORTHODONTIC TREATMENT
ORTHODONTIC TRIAGE
TIMING OF ORTHODONTIC TREATMENT
INTRODUCTION
SEQUENCE IN TREATMENT PLANNING
ORTHODONTIC DIAGNOSIS
CORRECTION OF PATHOLOGIC PROBLEMS
ESTABLISH TREATMENT GOALS
DIFFERENTIATE MODERATE FROM SEVERE PROBLEMS
ANALYZE TREATMENT POSSIBILITIES FOR DIFFERENT PROBLEMS
TREATMENT PLANNING
1.CORRECTION OF PATHOLOGIC PROBLEMS.
ANY PROBLEMS OF DISEASES AND PATHOLOGY HAVE TO BE BROUGHT UNDER CONTROL BEFORE ORTHODONTIC TREATMENT.
EXAMPLES
• CONTROL OF SYSTEMIC DISEASES.
• PERIODONTAL THERAPY.
• RESTORATIONS OF DECAY.
• COMPLEX MEDICAL PROBLEMS – REFERRED TO SPECIALISTS.
2. ESTABLISHING TREATMENT GOALS OR PRIORITIES OF TREATMENT
ORTHODONTIC PROBLEM IS A MAJOR STEP IN ORTHODONTIC
PLANNING.
• IDENTIFY THE MOST IMPORTANT PROBLEMS.
• FOCUS SHOULD BE ON PATIENT’S CHIEF COMPLAINT.
THE USUAL ORDER OF SETTING GOALS FOR ORTHODONTIC TREATMENT IS:
1. IMPROVEMENT OF FACIAL APPEARANCE.
2. REDUCTION OF OVERJET
3. CORRECTION OF CROWDING
4. ESTABLISHING NORMAL OVERBITE
5. ESTABLISHING FUNCTIONAL OCCLUSION
6. CORRECTION OF MOLAR RELATIONSHIP
7. MAINTAINING STABILITY OF CORRECTION ACHIEVED.
3. DIFFERENTIATE MODERATE FROM SEVERE PROBLEMS OR ORTHODONTIC TRIAGE
A THOROUGH DATABASE AND COMPLETE PROBLEM LIST HELP IN DIFFERENTIATING SEVERE PROBLEMS.
DIFFERENTIATING INTO MILD, MODERATE OR SEVERE PROBLEMS HELPS IN PROPER TREATMENT PLANNING.
ORTHODONTIC TRIAGE:
TRIAGE IS THE PROCESS USED TO SEPARATE CASUALTIES BY THE SEVERITY OF THEIR INJURIES.
THIS HELPS IN THE FOLLOWING TWO WAYS:
1. TO SEGREGATE PATIENTS WHO CAN BE TREATED AT THE OFFICE AND WHO NEED TO BE REFFERED TO OTHER CENTRES
2. TO DEVELOP A SEQUENCE FOR HANDLING OR MANAGING PATIENTS
• ORTHODONTIC TRIAGE INVOLVES A LOGICAL SCHEME TO CATEGORIZE PATIENTS ON THE BASIS OF THE SEVERITY OF MALOCCLUSION AND THE COMPLEXITY OF TREATMENT.
• THE LESS SEVERE PROBLEMS CAN BE HANDLED BY THE ORTHODONTIST ALONE, MORE SEVERE PROBLEMS SHOULD BE HANDLED BY A TEAM INVOLVING MAXILLOFACIAL SURGEON.
FLOWCHART ORTHODONTIC TRIAGE.:
• AN ADEQUATE DATABASE AND A THOROUGH PROBLEM LIST ARE NECESSARY TO CARRY OUT TRIAGE PROCESS.
• PROPER CASE HISTORY, THOROUGH CLINICAL EXAMINATION, STUDY CASTS AND APPROPRIATE RADIOGRAPHS (PANORAMIC FILM, BITEWINGS, OCCLUSAL AND CEPHALOMETRIC) ARE ESSENTIAL TO PRACTICE ORTHODONTIC TRIAGE.
• SEVERE PROBLEMS MAY REQUIRE INVESTIGATIONS WITH COMPUTERIZED TOMOGRAMS AND MAGNETIC RESONANCE IMAGING.
•TEAM OR MULTIDISCIPLINARY APPROACH WILL BE THE KEY TO SUCCESS IN THE MANAGEMENT OF VERY SEVERE PROBLEMS.
4. TREATMENT POSSIBILITIES
• THE OBJECTIVE OF THIS STAGE OF TREATMENT PLANNING IS TO MAKE SURE THAT ALL THE POSSIBILITIES OF TREATMENT ARE ANALYSED.
• THERE ARE OCCASIONS WHEN ONE PROBLEM CAN BE CORRECTED BY TWO OR THREE METHODS.
• THE BEST POSSIBLE METHOD WHICH IS FEASIBLE SHOULD BE UNDERTAKEN FOR THE PATIENT.
A. DEEP BITE CORRECTION
1. EXTRUSION
• EXTRUSION OF POSTERIOR TEETH CAN CAUSE OPENING OF THE BITE.
• THIS, IN TURN, WILL ROTATE THE MANDIBLE DOWNWARD AND BACKWARD.
• SO, BITE OPENING BY EXTRUSION OF POSTERIOR
IS CONTRAINDICATED IN HIGH-ANGLE CASES.
• IN LOW-ANGLE CASE, IT IS ADVISABLE.
2. INTRUSION
• BITE OPENING CAN BE ACHIEVED BY ABSOLUTE INTRUSION OF UPPER AND LOWER INCISORS.
• INTRUSION IS USUALLY DONE IN PATIENT WHO ALREADY HAVE GUMMY SMILE.
• INTRUSION IS DONE FOR PATIENTS WITH HIGH ANGLE.
3. RELATIVE INTRUSION
• IN RELATIVE INTRUSION, THE INCISORS ARE HELD IN THEIR POSITION, ALLOWING THE POSTERIOR TEETH TO ERUPT ALONG WITH GROWTH OF MANDIBLE.
• RELATIVE INTRUSION CANNOT BE EXPECTED IN AN INDIVIDUAL WHO IS ABOVE 17 YEARS OF AGE.
Deep bite correction: (A) Absolute intrusion, (B) relative intrusion, and (C) extrusion
B. CROWDING
CROWDING CAN BE CORRECTED BY:
1. PROXIMAL SLICING: THIS IS INDICATED IN MINIMAL SPACE DISCREPANCY CASES
2. EXPANSION: THIS IS INDICATED IN PATIENTS WHO ALREADY HAVE FLATTENED FACIAL PROFILE AND NARROW ARCHES.
3. EXTRACTION: THIS IS INDICATED IN SEVERE ARCH LENGTH DISCREPANCY.
C. SKELETAL TENDENCY
THE METHODS OF CORRECTING SKELETAL PROBLEMS ARE:
• GROWTH MODULATION
• CAMOUFLAGE
• SURGERY
5. TIMING OF ORTHODONTIC TREATMENT
ORTHODONTIC TREATMENT IN MAJORITY OF CASES IS STARTED DURING LATE MIXED DENTITION. BUT MANY TIMES EARLY TREATMENT IS REQUIRED.
TREATMENT TIMING
EARLY TREATMENT – PRIMARY DENTITION AND EARLY MIXED PERIOD.
LATE TREATMENT – LATE MIXED AND EARLY PERMANENT DENTITION PERIOD.
VERY LATE – ADULT.
ADVANTAGES OF EARLY TREATMENT | DISADVANTAGES OF EARLY TREATMENT |
Early treatment of deleterious habits is easier. Rapid change in skeletal and dental structures is seen when treatment is done on primary or early mixed dentition. Moderate biomechanical forces are effective. Significant correction of jaw problems can be achieved. Growth modification is effective. There are psychological advantages to early treatment in some children. | Continuous growth nullifies the effects of treatment. Child behavior management may be difficult. Usually requires second phase of treatment. Therefore, there is lengthened treatment time. |
MIXED DENTITION STAGES
MORE MALOCCLUSIONS ARE BEST TREATED DURING MIXED DENTITION OR EARLY PERMANENT DENTITION.
IT IS THE TIME OF GREATEST OPPORTUNITY FOR OCCLUSAL GUIDANCE AND INTERCEPTION OF MALOCCLUSION.
ADVANTAGES OF MIXED DENTITION TREATMENT | DISADVANTAGES OF MIXED DENTITION TREATMENT |
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OVERVIEW OF TREATMENT PLANNING
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CONTENTS
TREATMENT PLANNING FOR PRESCHOOL CHILDREN
TREATMENT PLANNING IN PREADOLESCENTS
TREATMENT PLANNING FOR ADOLESCENTS
TREATMENT PLANNING FOR ADULTS
ANALYSES AND TREATMENT APPROACH OF ARCH LENGTH DISCREPANCY
TREATMENT APPROACH TO ARCH LENGTH DISCREPANCY
PRINCIPLES OF GROWTH MODIFICATION
TREATMENT PLANNING FOR PRESCHOOL CHILDREN/PRIMARY DENTITION
1. ALIGNMENT PROBLEMS
• SPACING IN PRIMARY DENTITION IS NORMAL AND DESIRABLE AS THE CHANCES FOR DEVELOPMENT OF CROWDING IN THE PERMANENT DENTITION IS LESS.
• EXPANSION OF PRIMARY ARCHES IS DONE IN CASES WHERE FUTURE CROWDING IS EXPECTED.
LOSS OF PRIMARY TEETH, ITS EFFECT AND MANAGEMENT:
• LOSS OF INCISORS DOES NOT REQUIRE SPACE MAINTENANCE. PARTIAL DENTURE FOR AESTHETIC PURPOSE CAN BE GIVEN.
• LOSS OF PRIMARY CANINE CAUSES THE DISTAL DRIFT OF INCISORS WHICH CREATES A MIDLINE SHIFT AND DENTAL ASYMMETRY.
• LOSS OF FIRST MOLAR LEADS TO DENTAL ASYMMETRY. SPACE MAINTENANCE IS REQUIRED VERY EARLY.
• LOSS OF SECOND MOLAR BEFORE THE ERUPTION OF FIRST PERMANENT MOLAR: DISTAL SHOE SPACE MAINTAINER IS INDICATED TO PREVENT THE ERUPTION OF FIRST PERMANENT MOLAR IN SECOND PREMOLAR SPACE.
2. INCISOR PROCLINATION/RETROCLINATION
• INCISOR PROCLINATION IS CAUSED BY DELETERIOUS SUCKING HABITS. INCISOR PROCLINATION IS SELF CORRECTING AT THIS STAGE, IF THE HABIT IS STOPPED.
• ANTERIOR CROSSBITE IN PRIMARY DENTITION IS EXTREMELY RARE. IF IT IS DUE TO OCCLUSAL PREMATURITIES, SELECTIVE GRINDING WILL CORRECT THE PROBLEM.
3. POSTERIOR CROSSBITE
•SUCKING HABITS PRODUCE CONSTRICTED UPPER ARCH.
• OCCLUSAL PREMATURITIES SHOULD BE CORRECTED BY SELECTIVE GRINDING.
• IF THERE IS BILATERAL CONSTRICTION OF MAXILLA, EXPANSION OF ARCH IS INDICATED.
4. ANTEROPOSTERIOR DISCREPANCIES
• ANY SAGITTAL DEVIATION WHICH IS VERY EXTREME, GROWTH MODIFICATION IS ATTEMPTED.
5. VERTICAL PROBLEMS
A. DEEP BITE – SELF-CORRECTING
B. OPEN BITE – DUE TO SUCKING HABITS CAN BE TREATED WITH HABIT BREAKING APPLIANCE.
TREATMENT PLANNING IN PREADOLESCENTS
CHILDREN IN EARLY MIXED DENTITION STAGE BELONG TO FOLLOWING CATEGORY.
1. MODERATE PROBLEMS
CHILDREN WITH ONLY DENTAL PROBLEMS ARE CONSIDERED AS PATIENTS WITH MODERATE PROBLEMS.
2. SEVERE PROBLEMS
TREATMENT PLANNING FOR ADOLESCENTS (LATE MIXED AND EARLY PERMANENT DENTITIONS)
ADOLESCENT IS THE IDEAL TIME FOR CORRECTION OF CROWDING AND MALALIGNMENT WITH FIXED APPLIANCE MECHANOTHERAPY.
TREATMENT PLANNING FOR ADULTS
ANALYSES AND TREATMENT APPROACH OF
ARCH LENGTH DISCREPANCY
ARCH LENGTH: ARCH LENGTH IS THE MEASURED DISTANCE FROM THE FIRST PERMANENT MOLAR FROM ONE SIDE TO THE OPPOSITE SIDE.
TOOTH MATERIAL: THE SUM OF ALL THE MESIODISTAL WIDTH OF THE TEETH FROM FIRST PERMANENT MOLARS.
CALCULATION OF ARCH LENGTH AND TOOTH SIZE DISCREPANCY IS DONE BY FINDING THE DIFFERENCE BETWEEN THE AVAILABLE ARCH LENGTH AND TOTAL TOOTH MATERIAL OF 12 TEETH.
➤ THE DIFFERENCE CAN BE EITHER TOOTH MATERIAL EXCESS/ARCH LENGTH DISCREPANCY OR ARCH LENGTH EXCESS.
➤ ARCH LENGTH EXCESS USUALLY PRESENTS AS SPACING. MACROGNATHIA OR MICRODONTIA COULD BE THE CAUSE FOR ARCH LENGTH EXCESS.
ARCH LENGTH DISCREPANCY: IT IS MANIFESTED IN THE FORM OF CROWDING, ROTATIONS OR PROCLINATION. MICROGNATHIA AND MACRODONTIA ARE THE REASONS FOR ARCH LENGTH DISCREPANCY.
TREATMENT APPROACH TO ARCH LENGTH DISCREPANCY
1. CHANGING THE INCLINATION OF TEETH: CHANGING THE AXIAL INCLINATION OF THE INCISORS COMPENSATES FOR SMALL SIZE DIFFERENCE BETWEEN ARCH LENGTH AND TOOTH SIZE.
2. PROXIMAL SLICING: REDUCING THE WIDTH OF FEW TEETH BY PROXIMAL SLICING IS DONE IN CASES WITH SMALL ARCH SIZE DIFFERENCE.
3. EXTRACTION OR EXPANSION: WHEN THE SPACE DISCREPANCY IS MORE, EXTRACTIONS ARE CARRIED OUT. THE CHOICE OF EXTRACTION DEPENDS ON THE INDIVIDUAL PROBLEM. MINOR SPACE DISCREPANCY CONDITIONS CAN BE CORRECTED BY EXPANSION.
4. BUILD UP THE WIDTH OF SMALL TOOTH: SOMETIME A SMALL PEG LATERAL WILL CREATE A PERMANENT SPACE. IN THIS SITUATION, BUILDING UP OF THE WIDTH OF THAT TOOTH IS A REMEDY.
5. ACCEPT A SMALL SPACE: ACCEPTANCE OF SMALL SPACE IN CONDITIONS WHERE EVERYTHING IS NORMAL EXCEPT A SMALL SPACE. USUALLY, A SMALL SPACE IS SEEN DISTAL TO MAXILLARY LATERAL INCISORS.
PRINCIPLES OF GROWTH MODIFICATION
INTRODUCTION
➤ THE MOST IDEAL METHOD OF TREATING A PATIENT WITH JAW DISCREPANCY IS TO INCREASE THE GROWTH TO THE NORMAL LEVEL.
➤ THE EXTENT OF CORRECTION OF JAW DISCREPANCY BY GROWTH MODIFICATION DEPENDS ON FACTORS LIKE TIMING OF TREATMENT, COOPERATION OF THE PATIENT AND RESPONSE OF THE PATIENT DUE TO THE VARYING GROWTH PATTERN.
➤ THE IMPORTANT LOGIC IN GROWTH MODIFICATION IS THAT GROWTH CAN BE MODIFIED ONLY WHEN IT IS OCCURRING.
1. TRANSVERSE MAXILLARY DEFICIENCY
CLINICAL FEATURES
• MAXILLA IS NARROW WHEN COMPARED TO THE REST OF THE FACE.
• POSTERIOR CROSSBITE IS PRESENT.
• TEETH ARE NOT TIPPED INTO CROSSBITE.
Principle of maxillary expansion
2. Prognathic maxilla��• Prognathic maxilla is a condition in which maxilla is prominent or protrusive.��• In preadolescent patients with skeletal class II base due to prognathic maxilla, headgear can be used to hold the maxilla from downward and forward growth.����
��• Mandibular growth expresses itself and class II correction is normally achieved in 12–18 months.��• Force value is 350–450 g/side but not to exceed 1000 g in total duration of wearing for 10–12 h/day.��
3. Retrognathic maxilla��• Retrognathic maxilla can be corrected by two ways– reverse-pull headgear and functional appliances.��Correction with reverse-pull headgear��• Elastic traction pulls the maxilla forward.��Force value: Initial force of 300 g/side, two weeks later 450–500 g/side.��Force direction: Force applied 20° downward to the occlusal plane produces translation of maxilla forward. ��Elastics parallel to the occlusal plane produce an upward rotation along with forward movement of maxilla. �
��Functional appliances: Functional appliances are used in the management of class III due to retrognathic maxilla in a growing child.��Examples: FR III, reverse bionator, twin block.
4. Prognathic mandible��Prognathic mandible is corrected using chin cup therapy.��a. Occipital-pull chin cup��• Occipital-pull chin cup is used in cases of skeletal class III due to mild to moderate mandibular prognathism with horizontal growth pattern.��
b. Vertical-pull chin cup��• Vertical-pull chin cup is used to correct anterior open bite conditions.��• In this chin cup, headgear is near the coronal suture, and there is a horizontal strap to the back of the head.��• The vertical force reduces the anterior facial height by rotating the mandible up.��• Elastic strap is attached to the hook on the chin cup.
5. Retrognathic mandible��• Retrognathic mandible is corrected by functional appliance.��• The basic idea of functional appliance is by forcing the patient to function with the � lower jaw forward, it would stimulate mandibular growth, and thereby corrects class II � skeletal problem due to retrognathic mandible.���• Functional appliance produces growth acceleration.���
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