Module 15 - Treatment Planning SlideShow 080306

8/12/2019 Module 15 - Treatment Planning SlideShow 080306

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OrthodonticOrthodontic

Treatment PlanningTreatment Planning

Clinical AssessmentClinical Assessment

Study Model AnalysisStudy Model Analysis CephalometricCephalometric AnalysisAnalysis

Patients PerceptionPatients Perception


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AETIOLOGY OF MALOCCLUSION:AETIOLOGY OF MALOCCLUSION:GENERAL AND LOCALGENERAL AND LOCAL

FACTORSFACTORS

-

interinter--relationship of factorsrelationship of factors-- genetic v environmental factorsgenetic v environmental factors


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SKELETAL FACTORS AND GROWTHSKELETAL FACTORS AND GROWTH

n SkeletalSkeletal --AA--P (1/ 2/3)P (1/ 2/3)

nn VerticalVertical (high(high -- normalnormal -- low;low;ratios v absolute measurements)ratios v absolute measurements)--

nnTransverseTransverse (relationship to A(relationship to A--P position;P position;

symmetrical and asymmetrical)symmetrical and asymmetrical)

GrowthGrowth -- (especially growth rotations,(especially growth rotations,

also effects of trauma or pathology,also effects of trauma or pathology,

drugs etc.)drugs etc.)


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SOFT TISSUE FACTORSSOFT TISSUE FACTORS

1. Muscles of mastication, muscles ofMuscles of mastication, muscles of

facial expression, zones of balance,facial expression, zones of balance,

effects of trauma / pathologyeffects of trauma / pathology

2. LipsLips -- line, length, activity (competence,line, length, activity (competence,

anterior oral seal and skeletal pattern,anterior oral seal and skeletal pattern,

hyperactive lower lip)hyperactive lower lip)

3. TongueTongue -- size, position, activity (incl.size, position, activity (incl.

endogenous tongue thrust)endogenous tongue thrust)


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LOCAL FACTORSLOCAL FACTORS

11. Abnormalities of. Abnormalities of

the teeththe teeth

-

-

-

2. Upper labialUpper labial

fraenumfraenum-

-

3. PathologyPathology -

tooth / tissue ratio (Bolton)tooth / tissue ratio (Bolton)

position (position (ectopicectopic / impacted, traumatic/ impacted, traumatic

displacement /displacement / dilacerationdilaceration, transposition), transposition)

form (shape, size,form (shape, size, geminationgemination, fusion), fusion)

number (congenital: absence and supernumerariesnumber (congenital: absence and supernumeraries

/ supplemental teeth, extractions: deciduous/ supplemental teeth, extractions: deciduous

and permanent, retained deciduous teeth)and permanent, retained deciduous teeth)

(and other causes of(and other causes of diastematadiastemata))

[overlaps with some of (1) above ] also: delayed[overlaps with some of (1) above ] also: delayed

eruptioneruption

of teeth, cysts,of teeth, cysts, odontomesodontomes etc , traumaetc , trauma


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MISCELLANEOUS FACTORSMISCELLANEOUS FACTORS

11.. HabitsHabits

22.. MouthbreathingMouthbreathing

-- (incl. adenoids tonsils etc.)(incl. adenoids tonsils etc.)


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Facial assessment (1)Facial assessment (1)

FrontalFrontal AA--PP

VerticalVertical TransverseTransverse

NasalNasal Cheek contourCheek contour


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Facial assessment (2)Facial assessment (2)

Lips and tooth positionLips and tooth position-- AA--PP-- VerticalVertical

(at rest and smile)(at rest and smile)

Chin projectionChin projection Chin throat lengthChin throat length


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LIP LENGTH AND INCISORLIP LENGTH AND INCISOR

EXPOSUREEXPOSURE

Lip lengthLip length

Lip activityLip activity

Maxillary positionMaxillary position

Crown lengthCrown length

Labial segment inclinationLabial segment inclination

Possibly under correct in in VMEPossibly under correct in in VME


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IDENTIFY THE DISCREPANCYIDENTIFY THE DISCREPANCY

AND TOOTH POSITIONAND TOOTH POSITION

MOLARMOLAR -- VERTICALVERTICAL-- AA--PP

INCISORINCISOR -- VERTICALVERTICAL

-- AA--PP

IN RELATION TO SKELETAL STRUCTURESIN RELATION TO SKELETAL STRUCTURESAND SOFT TISSUESAND SOFT TISSUES

THEREFORE INDIVIDUAL ARCHWIRE SEQUENCETHEREFORE INDIVIDUAL ARCHWIRE SEQUENCEAND DESIGN SPECIFIC TO THE PROBLEMAND DESIGN SPECIFIC TO THE PROBLEM


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CephalometricsCephalometrics

Evaluation of facial proportions andEvaluation of facial proportions and

aestheticsaesthetics

Evaluation ofEvaluation of SkSkand Dental Trans relationsand Dental Trans relations

Evaluation ofEvaluation of SkSkand Dental Aand Dental A--P relationsP relations

Evaluation ofEvaluation of SkSkand Dentaland Dental VertVertrelationsrelations

Growth predictionGrowth prediction


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Review progress towards a treatmentReview progress towards a treatment

goalgoal

Age / sex / race / growth prognosis /Age / sex / race / growth prognosis /

facial typefacial type

Malocclusion typeMalocclusion type


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SPECIFIC CONSIDERATIONS INSPECIFIC CONSIDERATIONS IN

CEPHALOMETRIC ASSESSMENTCEPHALOMETRIC ASSESSMENT

CephalometricCephalometricpredictionprediction

-- Treatment effectsTreatment effects-- GrowthGrowth

-- soft tissuessoft tissues

-- occlusalocclusal

The borderline patient:The borderline patient:

possibilities and limitationspossibilities and limitations

Extraction patterns in Orthodontic preparationExtraction patterns in Orthodontic preparation

h d i


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CephalometricCephalometricAnalysis:Analysis:

comparison to average valuescomparison to average values

comparison to graphical normscomparison to graphical norms


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Eight Methods of Analysing aEight Methods of Analysing a CephalogramCephalogram

to Establishto EstablishAnteroposteriorAnteroposteriorSkeletalSkeletalDiscrepancyDiscrepancy

Moira BrownMoira Brown

BJO 1981 8: 139BJO 1981 8: 139 -- 146146

O h d iO h d i


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CephalometricCephalometricAnalysis:Analysis:

comparison to average valuescomparison to average values

comparison to graphical normscomparison to graphical norms


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GROWTHGROWTH

andand

GROWTH PREDICTIONGROWTH PREDICTION


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Growth evaluationGrowth evaluation

Growth SpurtGrowth Spurt

DurationDuration

AmountAmount

DirectionDirection

Age / SexAge / Sex


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BJORK ANALYSIS


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JARABAK ANALYSIS:

PFH / AFH


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BASIC ASPECTSBASIC ASPECTS OFOF

PATIENT EVALUATIONPATIENT EVALUATION

Orthodontics is extrusive and may resultOrthodontics is extrusive and may resultin a downward and backwardin a downward and backward mandibularmandibular

rotationrotation

A skeletal problem is truly camouflagedA skeletal problem is truly camouflaged

when satisfactory facial aesthetics arewhen satisfactory facial aesthetics areproduced in addition to a good occlusionproduced in addition to a good occlusion


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Orthodontic MechanicsOrthodontic Mechanics

Incisor positionIncisor position

Arch correlationArch correlation

Arch formArch form

Fixed appliance system SWA / TipFixed appliance system SWA / Tip--edgeedge Bracket prescriptionBracket prescription

MechanicsMechanics -- method of levellingmethod of levelling

-- full archfull arch

-- segmentalsegmental

-- COSCOS

-- archwirearchwire sequencesequence

S f CS f C t


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Summary of ContemporarySummary of Contemporary

Extraction GuidelinesExtraction Guidelines < 4mm rarely indicated unless incisor< 4mm rarely indicated unless incisor

protrusion or vertical discrepancyprotrusion or vertical discrepancy

55 -- 9 mm non X or X possible. Depends upon9 mm non X or X possible. Depends uponsoft tissue aesthetics and stability. Non Xsoft tissue aesthetics and stability. Non X

will require arch inter premolar expansionwill require arch inter premolar expansion

when appropriatewhen appropriate

> 10mm X indicated> 10mm X indicated


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Orthodontic CamouflageOrthodontic Camouflage

A skeletal problem is truly camouflagedA skeletal problem is truly camouflaged

when satisfactory facial aesthetics arewhen satisfactory facial aesthetics are

achieved in addition to a good occlusionachieved in addition to a good occlusion

Orthodontic treatment is extrusive inOrthodontic treatment is extrusive in

nature and may produce a downwardnature and may produce a downwardand backwardand backward mandibularmandibularrotationrotation


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THE BORDERLINE PATIENTTHE BORDERLINE PATIENT

CAMOUFLAGE OR SURGERY ?CAMOUFLAGE OR SURGERY ?


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The Borderline Surgical Case:The Borderline Surgical Case: OJ > 10mmOJ > 10mm

Age > 12 for girls 14 for boysAge > 12 for girls 14 for boys PgPg --NperpNperp > 18mm> 18mm

MandMandbody length (Gobody length (Go--Pg)< 70mmPg)< 70mmand / or TFH >125mmand / or TFH >125mm

Di i d T t tDiagnosis and Treatment


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Diagnosis and TreatmentDiagnosis and Treatment

PlanningPlanning

The DevelopmentThe Development

of aof a

Problem ListProblem List


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Orthodontic ConsiderationsOrthodontic Considerations

Incisor and molar positionIncisor and molar position -- AA--PP-- VerticalVertical-- TransverseTransverse

Treatment planTreatment plan -- X ?X ?

Arch formArch form

Bracket prescription NB 3s and 2sBracket prescription NB 3s and 2s

ArchwireArchwire sequence and levelling phasesequence and levelling phase

Continuous V. segmental mechanicsContinuous V. segmental mechanics Rectangular and round wireRectangular and round wire

Class 11 and class 111 elasticsClass 11 and class 111 elastics



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PlanningPlanningIntroduction:Introduction:

what are the patients concerns ?what are the patients concerns ?

where do we wish to place thewhere do we wish to place the

occlusion horizontally and verticallyocclusion horizontally and verticallywithin the face ?within the face ?

what are the diagnostic features towhat are the diagnostic features toobserve to decide how best satisfyobserve to decide how best satisfythese requirements ?these requirements ?



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PlanningPlanning occlusionocclusion

facial soft tissue profilefacial soft tissue profile

lip morphology and activitylip morphology and activity

AA--P, vertical and transverseP, vertical and transverse SkSk

TMDTMD patients complaints and compliancepatients complaints and compliance

age and sexage and sex



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PlanningPlanningAnteroAntero--posterior incisor position to aposterior incisor position to a

givengiven cephalometriccephalometric goal:goal:

does it produce more aestheticdoes it produce more aestheticresults than otherresults than other cephceph analyses ?analyses ?

are the results more stable ?are the results more stable ?

can the position be achieved ?can the position be achieved ?

is it quick easy and accurate to use ?is it quick easy and accurate to use ?



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PlanningPlanning

stability and lower incisor positionstability and lower incisor position aesthetics and incisor positionaesthetics and incisor position



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PlanningPlanningA suggested lower incisor position (1):A suggested lower incisor position (1):

leave them where you find themleave them where you find themunless:unless:

severe class 11/1 casessevere class 11/1 cases

some class 111 casessome class 111 cases

some class 11/2 casessome class 11/2 cases

correction ofcorrection of bimaxillarybimaxillaryproclinationproclination



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PlanningPlanningA suggested lower incisor position (2):A suggested lower incisor position (2):

leave them where you find themleave them where you find themunless:unless:

well aligned lower arch and mildwell aligned lower arch and mildcurve ofcurve of speespee

mildly crowded aches < 3mildly crowded aches < 3mmmm

deliberate anchorage compromisesdeliberate anchorage compromises



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PlanningPlanningExtraction v. non extraction:Extraction v. non extraction:

Why the need for space ?Why the need for space ?

-- relief of crowdingrelief of crowding-- correction of incisor relationshipcorrection of incisor relationship

--provision of anchorageprovision of anchorage



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PlanningPlanningExtraction v. non extraction:Extraction v. non extraction:

ProposedProposed diadvantagesdiadvantages ofof extracionsextracions

-- mandibularmandibulardysfunctiondysfunction-- a less attractive facial appearancea less attractive facial appearance

-- longer and more difficult treatmentlonger and more difficult treatment--pain and anxiety etc of extractionspain and anxiety etc of extractions



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PlanningPlanning

plan the lower arch firstplan the lower arch first

aim for minimum class 11 tractionaim for minimum class 11 traction

assess the lower arch crowding andassess the lower arch crowding andCOSCOS

the effect on available space ofthe effect on available space of

anteroantero--posterior expansion / retractionposterior expansion / retractionor transverse expansionor transverse expansion



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PlanningPlanningAssessing the lower arch crowding:Assessing the lower arch crowding:

Mild (1Mild (1--44mmmm) = non X or 5s) = non X or 5s

Moderate (5Moderate (5--88mmmm) = 4s or 5s) = 4s or 5s

Marked ( 9+Marked ( 9+mmmm) = 4s) = 4s

caninecanine angulationangulation and target lowerand target lowerincisor position willincisor position will inluenceinluence thesethesechoiceschoices



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PlanningPlanningFactors which influence the choice ofFactors which influence the choice of

extraction in each category:extraction in each category:

at which end of range is crowdingat which end of range is crowding COSCOS

age and sexage and sex

profile and pragmatismprofile and pragmatism

crowded second and third molarscrowded second and third molars

Treatment goalsTreatment goals


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IntercuspalIntercuspal goalsgoals

Andrews 6 keysAndrews 6 keys

1. Correct1. Correct interarchinterarch relationshipsrelationships

2. Correct crown2. Correct crown angulationangulation (tip)(tip)3. Correct crown inclination (torque)3. Correct crown inclination (torque)

4. No rotations4. No rotations5. Tight contact points5. Tight contact points

6. Flat curve of6. Flat curve of SpeeSpee (0(0 -- 2.52.5mmmm))


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Treatment goalsg

Andrews LF (1972)Andrews LF (1972)

The 6 keys to normal occlusionThe 6 keys to normal occlusion

AJO 62: 296AJO 62: 296 -- 309309



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ea e goa sg

IntercuspalIntercuspal goalsgoalsAndrews 6 keysAndrews 6 keys

1. Correct1. Correct interarchinterarch relationshipsrelationships

2. Correct crown2. Correct crown angulationangulation (tip)(tip)3. Correct crown inclination (torque)3. Correct crown inclination (torque)

4. No rotations4. No rotations5. Tight contact points5. Tight contact points

6. Flat curve of6. Flat curve of SpeeSpee (0(0 -- 2.52.5mmmm))



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gg

FunctionalFunctional OcclusalOcclusal goalsgoals Achieve a 6 keysAchieve a 6 keys intercuspalintercuspal occlusionocclusion

Choose appropriate bracketChoose appropriate bracket

prescriptionprescription

Check functional occlusion duringCheck functional occlusion duringtreatmenttreatment

ICP within 1mm of RCPICP within 1mm of RCP



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gg

FunctionalFunctional OcclusalOcclusal goalsgoals

ICP WITHIN 1ICP WITHIN 1MMMM OF RCPOF RCP

Module 15 - Treatment Planning SlideShow 080306

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