29/10/2014 GENERAL PRINCIPLES Of ORTHODONTIC TREATMENT PLANNING OF DENTAL

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29/10/2014GENERAL PRINCIPLES Of ORTHODONTIC
TREATMENT PLANNING OF DENTAL SKELETAL
MALOCCLUSIONTiming of Orthodontic Treatment

• DR. GYAN P.SINGH
• Associate Professor
• Department of Orthodontics Dentofacial
  Orthopaedics

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CONTENTS

• INTRODUCTION
• EVOLUTION OF TREATMENT PLANNING
• PRINCIPLES OF TREATMENT PLANNING
• ORTHODONTIC TRIAGE
• GROWTH MODULATION
• DENTAL CAMOUFLAGE
• MCQ

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INTRODUCTION

• Diagnosis and treatment planning is the most
  important aspect of any medical field.
• Diagnosis in orthodontics is based on collection
  of adequate database of information about the
  patient.

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Diagnosis

• In the development of a database and formulation
  of a problem list
• Diagnosis is based purely on scientific truth
• At this stage there is no room for opinion or
  judgment instead a totally factual appraisal of
  the situation is required

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DIAGNOSIS

• INTERVIEW
• CLINICAL EXAMINATION
  DATA BASE
• ANALYSIS OF DIAGNOSTIC
• RECORDS
  CLASSIFCATION
• 
  
• 
  PROBLEM
  LIST PATHOLOGY( CARIES, PERIO)
• CONTROL BEFORE ORTHO
• TREATMENT
  
• 
  
• OPTIMAL INTERACTION
  ORTHODONTIC PROBLEMS
• TREATMENT COMPROMISE ( IN
  PRIORITY ORDER) AND
• PLAN COST-RISK / BENEFIT THE
  POSSIBLE SOLUTIONS
• 
  TO INDIVIDUAL PROBLEMS
• MECHANOTHERAPY

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PROBLEM ORIENTED APPROACH

• In this approach, diagnosis and Treatment
  planning are carried out in a series of logical
  steps-
• Development of an adequate diagnostic database.
• Formulation of problem list which is the
  diagnosis from the database.

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Treatment planning

1. Prioritization of the items on the orthodontic
   problem list, so that most important problem
   receives highest priority for treatment.
2. Consideration of possible solutions to each
   problem list, to the individual problems.

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• 5. Evaluation of the interaction among possible
  solutions to the individual problems.
• 6. Synthesis of an optimum treatment plan
  calculated to maximize benefit to the patient and
  minimize risks, costs, and complexity.
• 7. Presentation of the plan to the patient in
  such a way that informed consent is obtained.

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Control of systemic disease
Control of dental disease
Control of acute conditions
Control of dental caries/ Endodontics
Initial control of periodontal disease
Initial restorations like fillings
Restoration of gingival health
Orthodontic Treatment
Final and permanent restorations including cast
restorations
Periodontal surgeries and maintenance therapy
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Treatment Planning

• Treatment planning can not be science alone
• Based on wisdom based scientific approach.
• Each case should be assessed as a separate entity
  .
• Customized treatment plan has to be formulated
  to suit the needs of that particular patient.

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FACTORS DETERMINING IN OPTIMAL TRETMENT PLAN

• The patients goal and desires.
• The complexity of the treatment
• Malocclusion and the timings of treatment.
• The predictability of success.
• Cost-benefit ratio.

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Patients goals and desires

• Jacksons triad
• Esthetic harmony
• Functional efficiency
• Structural balance

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ORTHODONTIC TRIAGE
This process was used in military and emergency
medicine. Triage was used to separate
causalities by the severity of their injuries.

• Medicine
• Dentistry
• Orthodontics

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ROLE OF TRIAGE IN DENTISTRY

• The process to distinguish moderate from severe
  problems.
• Patients are appropriately treated in General
  dental practice
• or the most appropriately referred to a
  specialist ( Orthodontist).

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STEPS IN ORTHODONTIC TRIAGE

1. Syndromes and developmental abnormalities
2. Facial disproportions and asymmetries
3. Antero-posterior and vertical problems

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• 4.Excessive dental protrusion or retrusion
• 5.Problems involving dental development
• 6.Problems involving crowding malalignment
• 7.Other tooth displacements

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• SEVERE PROBLEM MODERATE
  PROBLEM
• SYMMETRIC FACE
• 
  FACIAL PROFILE ANALYSIS
• 
  ANTEROPOSTERIOR OR
• VERTICAL
  JAW DISCREPANCIES
• 
  EXCESSIVE PROTRUSION OR
• 
  RETRUSION OF INCISORS
• CEPHALOMETRIC EVALUATION
• GROWTH MODIFICATION?
• EXTRACTION

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Timing of Orthodontic Treatment

• Can be carried out at any time.
• Comprehensive treatments -in adolescence as soon
  as the second molar erupts.
• Understand the importance of the treatment
• Self-motivated
• Cooperate during appointments
• Care the appliance and oral hygiene

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TIMINGS OF THE TREATMENT
AGE TREATMENT RECOMMENDED
Primary and Mixed dentition stage Preventive and interceptive procedures
Preadolescent patients in mixed dentition Growth modulation procedures
Young adolescent patients Comprehensive therapy with or without Camouflage
Adult patients Orthognathic surgeries
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TREATMENT PLANNING IN LATE MIXED AND
EARLY PERMANENT DENTITION

• Alignment Problems
• Transverse Problems
• Antero Posterior Problems
• Vertical Problems
• Eruption problems

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• skeletal problems can do occur in all 3 planes
  of space.
• 1) Anteroposterior problems
• - class II class III
  problems
• 2) vertical problems
• - skeletal open bite
• - skeletal deep bite
• 3) Transverse problems
• - skeletal cross bites

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• Growth modification, if possible, provides the
  ideal results.
• Growth potential an important factor that has
  to evaluated during treatment planning.
• Growth modulation is the best carried out to
  correct the developing malrelationship of the
  dental bases.

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• CaseDeveloping Class III S. Y. 7.5 yrs /M

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Radiographs (Pre-treatment)
Orthopantomogram
PA Cephalogram
Upper Occlusogram
Lateral Cephalogram
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Problem list

• Mesial Step.

• Etiology
• Geneticfather has midface deficiency

• Cross-bite of the anteriors.
• Diagnosis-Developing Angles Class III
  malocclusion

• Treatment Plan
• Tandem Appliance( Klempner ,JCO/JUNE 2011)
• (1.)Upper fixed maxillary component.
• (2.) Lower fixed component with bite plane.
• (3.)Face bow and Elastics as a removable
  components.

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Midface Deficiency
Son
Father
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Fabrication of Modified Tandem applianceKlempner,
1999
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Installation of the Appliance
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Delaire Petit Tandem
Less bulky, more esthetic and patient friendly
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Protraction of Maxillary Segment
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Correction of Cross-bite Harmonious Growth Of
Maxilla
Initial
After 1 month
After 2 months
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Facial Appearance Of the Patient
Pre-Treatment
Stage after 3 months.....contd.
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• Orthodontic treatment by camouflage acceptable in
  moderate skeletal discrepancies.
• Camouflage- A dental compromise for skeletal
  problems.
• Skeletal discrepancy can be masked or concealed
  by orthodontic tooth movement.

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Class II malocclusion

• A class II malocclusion can be because of
• A prognathic maxilla ( maxillary excess)
• A retrognathic mandible
• A combination of both

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CaseAngles Class II Div.1H.A. 14 Yrs/Male
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• Problem List

• Treatment objectives

• Protrusion of Upper jaw .
• Class II Molar relationships.
• Increased Overjet (8mm)Overbite(3mm).
• Incompetent UL lips.
• Unaesthetic smile.

• Overjet and overbite correction
• Class II molars correction.
• To achieve the aesthetically
• and normal functional occlusion.

Diagnosis-Angles class II Div.1 malocclusion
Treatment Plan-Extraction of Upper first
premolars and Lower second premolars. Fixed Roth
022 slot Appliance .
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Enmasse Retraction of Upper and Lower Anterior
Teeth
Preformed T.P.A.Molar stabilization
K-Sir Retraction Spring
NiTi Retraction spring
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Intra-oral photographs of the patient following
treatment after 1Yrs and 9 months
P R E _ T R E A T M
E N T
P O S T _ T R E A T
M E N T
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Facial appearance of the patient following
treatment after 1Yrs and 9 months
P R E - T R E A T M E N T
P O S T - T R E A T M E N T
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Compromise

• In many cases the three goals of Jackson triad
  (esthetics ,Function and stability) may be
  difficult to achieve.
• The Orthodontist should strike a balance in
  fulfilling the major esthetic desires of the
  patient within the bounds of keys that stand for
  stability.

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Re-Evaluation

• The treatment plan is a continuous process and
  should be evaluated at regular intervals during
  the active phase of treatment.
• This is to confirm how far the objectives that
  were set up at the time of initiation of
  treatment are being fulfilled.
• Treatment plan has to changed if the desired
  results are not taking place.

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• MCQ
• 1.TRIAGE is the process of
• Taking impression in three stages
• Planning anchorage
• A dental compromise of the skeletal problems
• None of the above
• 2. Camouflage is
• A dental compromise of the skeletal problems
• Consideration of extraction
• (C) Planning anchorage
• (D) Disscussion on the records of the patient.

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• 3.Jacksons triad is comprises of all except.
• Esthetic
• Molar relationship
• Functional efficiency
• Structural balance
• 4. The commonest tooth is extracted for
  Orthodontic purpose
• Incisor
• Molar
• (C) Premolar
• (D) Canine

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• 5.Serial extraction procedure should be the best
  done during
• Primary dentition
• Mixed dentition
• (C)Young adolescent
• (D)Adult
• 6. All the matching statement is true except
• Interceptive and preventive procedures-Primary
  and early mixed dentition
• Growth modification-Mixed or early permanent
  dentition
• Camouflage-Neonatal stage
• Orthognathic surgeries-Adult patient

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• 7.Space is required in Orthodontic management
  except
• Decrowding
• Overjet reduction
• Derotation of anterior teeth
• Derotation of posterior teeth
• 8. The more complex Orthodontic cases would
  bereffered to specialist except
• Skeletal posterior cross-bite
• Anterior complex open bite
• Midline diastemas of more than 2 mm after
  permanent canine eruption
• Midline diastemas of less than 2 mm after
  permanent canine eruption

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• 9. Logical steps of diagnosis and treatment
  planning are comprises of all except
• Treatment objectives and possible solutions
• Interview,clinical examination and diagnostic
  records
• Patient-parents consultation
• Patient should not be given any role in decision
  making process
• 10. Serial extraction procedure involves removal
  of teeth except
• First permanent premolar
• Primary first molar
• Primary canine
• Permanent canine

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REFERENCES

• Graber TMPrinciples and Practicce
  Orthodontics,WB Saunders,1988
• Profitt.Contemporary Orthodontics,Elsevier
  India.3rd ed.,2000
• E Moyers.handbook of Orthodontics,4th ed. Year
  Book Medical publishers,inc.,1988

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