Transcript TREATMENT PLANNING IN ORTHODONTICS

29/10/2014
GENERAL PRINCIPLES Of
ORTHODONTIC TREATMENT PLANNING
OF DENTAL& SKELETAL
MALOCCLUSION:
Timing of Orthodontic Treatment
DR. GYAN P.SINGH
Associate Professor
Department of Orthodontics & Dentofacial Orthopaedics
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CONTENTS
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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
ANALYSIS OF DIAGNOSTIC
RECORDS
DATA BASE
CLASSIFCATION
PROBLEM
LIST
PATHOLOGY( CARIES, PERIO)
CONTROL BEFORE ORTHO
TREATMENT
OPTIMAL
TREATMENT
PLAN
INTERACTION
COMPROMISE
COST-RISK / BENEFIT
ORTHODONTIC PROBLEMS
( IN PRIORITY ORDER) AND
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:1. Development of an adequate diagnostic
database.
2. Formulation of problem list which is the
diagnosis from the database.
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Treatment planning
3. Prioritization of the items on the
orthodontic problem list, so that most
important problem receives highest priority
for treatment.
4. 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 restorations like fillings
Initial control of periodontal disease
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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Patient’s goals and desires
 Jackson’s triad
1. Esthetic harmony
2. Functional efficiency
3. 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.
A. Understand the importance of the treatment
B. Self-motivated
C. Cooperate during appointments
D. 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
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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
provides the ideal results.
possible,
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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Case[Developing Class III]
S. Y.; 7.5 yrs /M
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Radiographs (Pre-treatment)
Orthopantomogram
PA Cephalogram
Lateral Cephalogram
Upper Occlusogram
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Problem list
Etiology
• Mesial Step.
•Cross-bite of the anteriors.
Genetic{father has
midface deficiency}
Diagnosis-Developing Angle’s 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
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Midface Deficiency
Father
Son
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Fabrication of Modified Tandem appliance[Klempner,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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Pre-Treatment
Facial
Appearance
Of the
Patient
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:
1.
A prognathic maxilla ( maxillary excess)
2.
A retrognathic mandible
3.
A combination of both
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Case[Angle’s
Class II Div.1
H.A.
14 Yrs/Male
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Problem List
Treatment objectives
 Protrusion of Upper jaw .
 Overjet and overbite correction
 Class II Molar relationships.  Class II molars correction.
 Increased
Overjet  To achieve the aesthetically
(8mm);Overbite(3mm).
and normal functional occlusion.
 Incompetent U&L lips.
 Unaesthetic smile.
Diagnosis-Angle’s 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
P
O
E
S
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T
T
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R
E
A
T
R
E
T
A
M
E
N
T
T
M
E
N
T
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P R E-T R E A T M E N T
Facial appearance
of the patient
following
treatment after
1Yrs and 9
months
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
(A) Taking impression in three stages
(B) Planning anchorage
(C) A dental compromise of the skeletal problems
(D) None of the above
2. Camouflage is
(A) A dental compromise of the skeletal problems
(B) Consideration of extraction
(C) Planning anchorage
(D) Disscussion on the records of the patient.
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3.Jackson’s triad is comprises of all except.
(A) Esthetic
(B) Molar relationship
(C) Functional efficiency
(D) Structural balance
4. The commonest tooth is extracted for Orthodontic purpose
(A) Incisor
(B) Molar
(C) Premolar
(D) Canine
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5.Serial extraction procedure should be the best done during
(A) Primary dentition
(B) Mixed dentition
(C)Young adolescent
(D)Adult
6. All the matching statement is true except
(A) Interceptive and preventive procedures-Primary and early
mixed dentition
(B) Growth modification-Mixed or early permanent dentition
(C) Camouflage-Neonatal stage
(D) Orthognathic surgeries-Adult patient
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7.Space is required in Orthodontic management except
(A) Decrowding
(B) Overjet reduction
(C) Derotation of anterior teeth
(D) Derotation of posterior teeth
8. The more complex Orthodontic cases would bereffered to specialist
except
(A) Skeletal posterior cross-bite
(B) Anterior complex open bite
(C) Midline diastemas of more than 2 mm after permanent canine eruption
(D) 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
(A) Treatment objectives and possible solutions
(B) Interview,clinical examination and diagnostic records
(C) Patient-parents consultation
(D) Patient should not be given any role in decision making process
10. Serial extraction procedure involves removal of teeth except
(A) First permanent premolar
(B) Primary first molar
(C) Primary canine
(D) Permanent canine
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REFERENCES
1. Graber TM:Principles and Practicce Orthodontics,WB
Saunders,1988
2. Profitt.Contemporary Orthodontics,Elsevier India.3rd
ed.,2000
3. E Moyers.handbook of Orthodontics,4th ed. Year Book
Medical publishers,inc.,1988
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