Transcript Orthodontic treatment planning

In the name of GOD
Orthodontic treatment planning
Presented by:
Dr Somayeh Heidari
Orthodontist
Reference:
Contemporary Orthodontics
Chapter 7
William R. Proffit, Henry W. Fields, David M.Sarver. 2007. Mosby
Collection adequate database
Diagnosis
Problem-oriented approach
Treatment planning
The objective in treatment planning is to design the strategy that a wise clinician,
using his/her best judgment, would employ to address the problem while
maximizing benefit to the patient and minimizing cost and risk.
Avoid both missed opportunities (false negative or undertreatment) and
excessive treatment (false positive or overtreatment) while appropriately
involving the patient in the planning process.
Indications for orthodontic treatment
 Psychosocial indications
Remove, or at least alleviate, the social handicap created by an unacceptable dental
and/or facial appearance.
Enhance dental and facial appearance in individuals who already are socially
acceptable but wish to improve their quality of life.
Although the severity of the malocclusion correlates with its psychosocial effect,
measuring how much the teeth protrude or how irregular they are is not sufficient
to determine individual treatment need.
 Developmental indications
Maintain as normal a developmental process as possible.
Problems related to development of the dentition occur relatively frequently, and often
orthodontic treatment is needed to maintain dental health and continue normal
development.
These problems almost always should be corrected when noticed.
 Functional indications
Improve jaw function and correct problems related to functional impairment.
Sever malocclusion affects normal function, usually not by making it impossible, but
by making it more difficult for the affected individual to breath, incise, chew, swallow
and speak normally.
The reverse also is true: alteration or adaptation in function can be etiologic factors
for malocclusion, by influencing the pattern of growth and development.
 Trauma / Disease control indications
Reduce the impact on the dentition of trauma or disease.
Prevention of periodontal disease almost never is a reason for orthodontic treatment.
Correcting tissue impingement by the teeth can be a benefit from orthodontic treatment at
any age.
Although protruding incisors are more likely to be damage, only in the most accident-prone
child is this a valid reason for reducing overjet.
Adjunctive treatment indications
Facilitate other dental treatment, as an adjunct to restorative, prosthodontic or
periodontal therapy.
Orthodontic treatment almost always is elective,
but it can produce significant benefits in psychosocial well being, normal development,
jaw function, dental/ oral health and improve outcomes in the treatment of dental
disease.
Orthodontics is needed if it would produce these benefits--- and not needed if it would
not.
Type of treatment : Evidence – Based selection
Treatment process should be chosen on the basis of clear evidence that the selected
method is the most successful approach to that particular patient’s problem.
The better the evidence, of course, the easier the decision.
Problem – oriented approach
Identifying the patient’s problems
evaluating the possible solutions
those specific problems
The best way to evaluate alternative treatment methods is with a randomized clinical
trial, with great care is taken to control variables that might affect the outcomes.
A second acceptable way is careful study of treatment outcomes under well-defined
conditions.
Treatment goals : The soft tissue paradigm
If we accept that both goals and limitations of orthodontic treatment are established
more by soft tissue considerations than skeletal/dental relationships, treatment planning
inevitably is affected.
Primary goal of treatment
soft tissue relationships and adaptations
Facial proportions
Teeth – lip and Teeth – face relationships
Soft tissue adaptation to the position of teeth (stability)
Secondary goal of treatment
functional occlusion
arrange the occlusion to minimize the chance of injury
Solving the patient’s problems
Problem oriented diagnosis and treatment planning
Major issues in planning treatment
Once patient’s orthodontic problems identified and prioritized, three issues
must be faced as treatment planning begins:
 The complexity of the treatment that would be required
 The predictability of success with a given treatment approach
 The patient’s (and parent’s) goals and desires
complexity of treatment
Who should do the treatment?
predictability of treatment
If alternative methods of treatment are available, which one should be chosen?
Based on evidence
Patient input
Most important: treatment planning must be an interactive process.
Both ethically and practically, patient must be involved in the decision making process.
Orthodontic Triage :
Distinguishing moderate from complex treatment problems
An adequate database and a through problem list are necessary do the triage process.
Orthodontic Triage
Step1 : Syndromes and Developmental Abnormalities
Sever problems
moderate problems
Unusual facial appearance
Analysis of full-face proportions
Craniofacial deformity or syndrome
(cleft lip or palate, hemifacial microsomia,
Crouzon’s syndrome, Treacher- Collin’s syndrome, …)
Complete evaluation by
Special team with
medical consultants
Developmental status
< 3% or > 97%
P.A Ceph, history of trauma?
Excess or deficient growth?
- comprehensive orthodontics
- surgery required
True facial asymmetry
Multidisciplinary treatment approach
Cleft lip and palate
Treacher- Collin’s syndrome
Crouzon’s syndrome
Hemifacial microsomia
Orthodontic Triage
Step2 : Facial Profile Analysis
Sever problems
moderate problems
Symmetric face
Facial profile analysis
Antero-Posterior or Vertical jaw discrepancies
Skeletal Class II and Class III
Long face and short face
Cephalometric analysis
- Growth modification or surgery?
- Extraction?
Excessive protrusion or
retrusion of incisors
Excessive protrusion or retrusion of incisor teeth often accompanies skeletal jaw
discrepancies (skeletal problem)
It is possible for an individual with good skeletal proportions to have protrusion of
incisors teeth rather than crowding.
Bimaxillary protrusion ( excessive protrusion of incisors without excessive overjet)
usually is an indication for premolar extraction and retraction of protruding incisors:
complex and prolonged treatment
Because of the profile changes produced by adolescent growth, it is better for most
children to defer extraction until late mixed dentition or early permanent dentition.
It is definitely an error to begin extraction early and then allow the permanent molars
to drift forward, because this will make effective incisor retraction impossible.
Orthodontic Triage
Step3 : dental development
Sever problems
Good facial proportions
Review intra-oral radiographs for abnormalities
of dental development
Monitor: selective extraction?
Asymmetric dental development
Retain primary? Prosthetic replacement?
Extract, allow permanent teeth to drift?
Extract, orthodontic space closure?
Missing permanent teeth
Ankylosed permanent teeth
Combined surgical-orthodontic treatment
Primary failure of eruption
Extract supernumerary, reposition other teeth
Supernumerary teeth
complicated by position or number
Problems involving dental development usually need treatment as soon as they are
discovered, typically during the early mixed dentition, and often can be handled in
family practice.
Asymmetric dental development
 if the difference is 6 months or more
 careful monitoring of the situation is needed
 often requires selective extraction
 can prevent a sever asymmetry problem at a later time
 few patients have a history of childhood radiation therapy to head and neck
Missing permanent teeth
 is an actual (primary predecessor is missing or lost) or potential (primary tooth is
still present)
 most likely: mandibular second premolars and maxillary lateral incisors
 making the correct decision requires a careful assessment of facial profile, incisor
position, space requirements and the status of the primary teeth
 ankylosed permanent teeth fall into the same
category as missing teeth
Supernumerary teeth
 in the anterior segment of the maxilla: 90%
 multiple, inverted or malformed supernumerary teeth: often displaced adjacent
teeth
 multiple supernumerary: complex problem, perhaps syndrome or congenital
abnormality
 early removal: carefully to minimize damage to adjacent teeth
 if causes displacement: surgical exposure, adjunctive periodontal surgery, and
possibly mechanical traction
Orthodontic Triage
Step3 : dental development
Moderate problems
Good facial proportions
Review intra-oral radiographs for abnormalities
of dental development
Single supernumerary
with uncomplicated position
Retained or ankylosed
primary teeth
Ectopic eruption
extract supernumerary
Monitor:
Extract and maintain space if
space loss or vertical displacement
Monitor:
Reposition?
Extract, space regain?
Orthodontic Triage
Step 4 : Space problems
Sever problems
moderate problems
Normal Dental Development
Space analysis
Prematurely missing primary canine
or molar, adequate space
space maintenance
Localized space deficiency due to early
Loss of primary canine or molar
3 mm or less
comprehensive treatment
? Expansion
? Extraction
space regaining
simple appliances
> 3mm
incisor irregularity
with adequate space
Mixed dentition:
defer treatment?
align ?
Older patients: align
Orthodontic Triage
Step 4 : Space problems
Sever problems
moderate problems
Normal Dental Development
Space analysis
Incisor irregularity with
space deficiency
4mm or less
Comprehensive treatment
? Expansion
? Extraction
> 4mm
Midline diastema
2mm or less
Bodily movement, then
frenectomy
space management:
reduce width primary teeth?
selectively extract primary teeth?
arch expansion?
> 2mm
No treatment before
canines erupt.
Tip teeth together in older
patient, Retain
Orthodontic Triage
Step 5 : Other Occlusal Discrepancies
Sever problems
moderate problems
Other Tooth Displacement
Evaluate in light of facial form/
Space analysis results
-Widen midpalatal suture?
- Expand surgically ?
Posterior cross bite: Skeletal
Posterior cross bite: Dental
Include the comprehensive
plan if situation complex
Expand by tipping teeth
(if no vertical/other complications)
Anterior cross bite
Tip teeth with removable
appliance
Excessive overjet
Retract (tip) with removable
appliance
Only if vertical clearance
present
Orthodontic Triage
Step 5 : Other Occlusal Discrepancies
Sever problems
moderate problems
Other Tooth Displacement
Evaluate in light of facial form/
Space analysis results
Anterior open bite
simple
Growth modification?
Jaw surgery ?
Level curve of Spee?
Intrusion ?
Immediate treatment
complex
Deep overbite
Traumatic displacement
primary dentition:
no treatment
mixed dentition:
thumb sucking therapy
Thanks for your attention