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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       INTRODUCTION EVOLUTION OF TREATMENT PLANNING PRINCIPLES OF TREATMENT PLANNING ORTHODONTIC TRIAGE GROWTH MODULATION DENTAL CAMOUFLAGE MCQ 2

 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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 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 4

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 5

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
diagnosis from the database.
which is the 6

3.
Prioritization
orthodontic of problem the list, items so on that the most important problem receives highest priority for treatment.
4.
Consideration of each problem problems.
possible solutions
list, to the to individual 7

5.
Evaluation of
possible solutions
the
interaction among
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
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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 Jackson’s triad 1.
Esthetic harmony 2.
Functional efficiency 3.
Structural balance 12

This process was used in military and emergency medicine.
Triage was used to separate causalities by the
severity of their injuries.  Medicine  Dentistry  Orthodontics 13


The process to distinguish moderate from severe problems.

Patients are appropriately treated in
dental practice General

or the most appropriately referred to a ( Orthodontist).
specialist
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1.
Syndromes and developmental abnormalities 2.
Facial disproportions and asymmetries 3.
Antero-posterior and vertical problems 15

4.Excessive dental protrusion or retrusion 5.Problems involving dental development 6.Problems involving crowding &malalignment 7.Other tooth displacements 16

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 17

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 18

AGE TREATMENT RECOMMENDED
Primary and Mixed dentition stage Preventive and interceptive procedures Preadolescent patients in mixed dentition Growth modulation procedures Young adolescent patients Adult patients Comprehensive therapy with or without Camouflage
Orthognathic surgeries
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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 21


, provides the ideal results.
if 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 23

Orthopantomogram Lateral Cephalogram PA Cephalogram Upper Occlusogram
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Problem list
• Mesial Step. •Cross-bite of the anteriors.
Etiology Genetic{father midface deficiency} has 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 components.
and Elastics as a removable 25

Midface Deficiency Father Son
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Fabrication of Modified Tandem appliance[Klempner,1999] 27

Installation of the Appliance 28

Less bulky, more esthetic and patient friendly 29

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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
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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A class II malocclusion can be because of: 1.
A prognathic maxilla ( maxillary excess) 2.
A retrognathic mandible 3.
A combination of both 34

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Problem List Treatment objectives
     Protrusion of Class II Molar Upper jaw .
relationships.
  Overjet and overbite correction Class II molars correction.
Increased (8mm); Overbite (3mm).
Overjet  To achieve the aesthetically 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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K-Sir Retraction Spring { Preformed T.P.A.=Molar stabilization } 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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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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 In many cases the three goals of Jackson triad (esthetics ,Function and stability) difficult to achieve.
may be  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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 The treatment plan is a should continuous process be evaluated at regular intervals the active phase of treatment.
and during  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 43

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 44

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 45

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 46

REFERENCES 1.
2.
3.
Graber TM:Principles and Practicce Orthodontics,WB Saunders,1988 Profitt.Contemporary Orthodontics,Elsevier India.3
rd ed.,2000 E Moyers.handbook of Orthodontics,4 th ed. Year Book Medical publishers,inc.,1988 47

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