Borderline cases in Orthodontics

1. 1 Borderline cases Borderline cases In Orthodontics In Orthodontics Prepared by: Prepared by: Dr Mohammed Alruby Dr Mohammed Alruby اكنض هشيعم هل نءاف يركذ نع ضرعا نمو Borderline cases Borderline cases,, Problematic decision for treatment Problematic decision for treatment Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Borderline cases Problematic decision for treatment Types of borderline cases Factors affect decision of extraction and non in borderline cases Skeletal borderline cases Borderline cases Borderline cases,, Problematic decision for treatment Problematic decision for treatment Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 Borderline cases: cases with good facial esthetics but require extraction to reach a stable functional occlusion Classifications: 1-Dental borderline cases: in which extraction or no extraction treatment can occur with normal skeletal relationship 2-Skeletal borderline cases: in which the treatment can done by orthodontic treatment camouflage or orthognathic surgery Dental borderline cases Some cases of orthodontic treatment have clear cut decision for extraction or non-extraction, but other cases in which the space defect is about 5mm so it introduce some problem for decision Factors affecting the decision of extraction or non-extraction in borderline cases: 1-Cephalometric evaluation: In borderline cases the deviation from normal is not much, so the all measurement and more analysis must intermingle with each other to represent the problem and way of treatment. a-Upper and lower incisors inclination: When they are retroclined, they increase the possibility for their proclination and increase the arch length and decrease the need for extraction b-Skeletal measurements: In patients with large lower face height may need to extraction and mesialize the molars that lead to decrease the lower face height c-Soft tissue analysis: Generally, orthodontics affects the soft tissue profile as in some cases the extraction improves the facial profile and in others may lead to dish face, = orthodontic work in both art and science, the facial esthetics is the orthodontic deflection of his art and its improvement is one of his goal so careful attention to soft tissue analysis is very important = most of facial profile changes coming from coming from coming from changes in lip position following retraction or protraction. 2-Treatment timing: The patient in late mixed dentition with crowding 2-4mm, increase the inter-canine width by RME is great benefits in some cases at this age but serial extraction is not useful procedure 3-Third molar consideration: with high incidence of third molar impaction so it requires extraction and distalizing the molars to relieve crowding and create space 4-Patient psychology: Some patients refuse the extraction procedure specially in mild cases 5-Patient cooperation: The cooperative patient is able to treated by anyway, but the uncooperative patient should be treated in short time and by very conservative method We should tell the patient and his or her parents by the way of treatment and reasons to change the type of treatment plane Borderline cases Borderline cases,, Problematic decision for treatment Problematic decision for treatment Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 6-Relapse: When taking the decision of extraction or non-extraction put in consideration: muscular balance and expected relapse 7-The alternative ways for extraction and its limitations: a-Stripping: limited for: -Good aligned posterior teeth and maximum intercuspation -Increase MD/FL index according to Peck and Peck -Optimum enamel thickness to permit stripping -Root width smaller than crown -Fluoride application Disadvantage: -Enamel loss -Disturbed proximal contact that may lead to periodontal problems and increase the incidence of decalcification b-Expansion: Limited for cases with posterior teeth tipped palatally Best applied during active growth period since the muscles is still actively growing as their origin and insertion is changeable and can easily move Disadvantages: tendency of relapse especially if done in adult patient, may require permanent retention c-distalization: may lead to impaction of third molar limited to teeth that their long axis tipped mesially 8-hazards of extraction in borderline cases: a-space reopening b-tendency for re-crowding especially lower incisors c-improper contact point and marginal ridge d-increase the probability for change profile to dish face as the case start with acceptable profile e-Deeping the bite f-Need more time for treatment All these factors make the decision more difficult so, borderline cases need more carful diagnosis and must explain everything for patient and his /her parents 9-Type and patient complain: Dental Profile Skeletal Esthetic 10-Curve of spee: The severity of curve of spee is a factor that can determine the decision because the correction of it need additional space Borderline cases Borderline cases,, Problematic decision for treatment Problematic decision for treatment Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 11-Amount of overjet and overbite: Because correction need spaces 12-Coast of treatment: Longer duration need more coast 13-Social and educational level: Which can affect the type of treatment and can easier to understand the decision is extraction or non N: B: Other factors that effect on decision on border line cases: I- Cephalometric measurements: 1-Low inter incisal angle:----- bimaxillary ---- lower than 127 degree ------- need space 2-L1 to MPA -----if in increased than 90 – 95 ----- need more space to upright 3-U1 to FH ------ if increased than 112 degree ------ need more space 4-U1 to PP ------ if increased than normal 7 degree ----- need more space to correct 5-L1to FHP ------ decreased more than normal 59 degree ------ need space to correct 6-FMP angle ----- increased than normal ------- need more space ----- extraction 7-L1 to NB line ----25 degree and 4mm linear------increased more than normal---need extraction 8-L1—to N Pog --- if it more anterior to this line ----- extraction indicated 9-ANB, or Wits ------- indicate Class II or III so extraction in upper arch or lower arch is indicated to camouflage treatment II- Models: 1-Amount of crowding ----- if increased ----- need extraction 2-Peck and Peck ----- when MD / FL% is more than normal ------ extraction 3-Diagnostic set up ----- explain the amount of space needed 4-Increased overjet: ------- extraction is indicated 5-Increased over bite---- require more space to correct III- Miscellaneous factors: 1-Patient age: in adult patient: growth modification and expansion is not benefit so extraction is more useful 2-Patient cooperation: if patient is more cooperative so extraction is useful to obtain good results 3-Tooth structure: enamel thickness: ---- thicker enamel allow more MD thickness so it can permit reduction during re-approximation Skeletal borderline cases = in which the treatment can done by orthodontic treatment camouflage or orthognathic surgery = the actively growing patient can be treated early with functional appliances in case of mild skeletal discrepancies = management of these cases require collection of all diagnostic data and evaluate it carefully before taking the decision of treatment and determine the advantage and disadvantage of any type of treatment Borderline cases Borderline cases,, Problematic decision for treatment Problematic decision for treatment Dr. Mohammed Alruby Dr. Mohammed Alruby

6. 6 1-Orthodontic treatment: Advantages: 1-Prevent risk of surgery 2-More accepted by patient Disadvantages: 1-May require movement of teeth out the area of functional tolerance 2-Need broad basal bone 3-May not improve the facial esthetic to the desired limit as in class III case that after end of treatment the chin is still prominent 4-Require great skill and experience 5-Stability of treatment results 2-Surgical correction: Advantages; -Correction of skeletal discrepancies -Improve facial esthetics Disadvantages: a-Physical will being: -Excessive blood loss -Neurologic injury -Allergic reaction to anesthesia, antibiotic, drugs -Postoperative infection -Bone fracture -Delayed healing or non-healing -Secondary surgery -Respiratory insufficiency -Sinus complication -Relapse of operations -Poor blood supply to the osteomatized jaw segment -Numbness b-Stomatognathic function: -T M J disorder, discomfort, pain -Limitation in range of motion -No gradual changes c-Emotional well- being: -Unexpected facial changes as changes morphology -Unprepared changes, personal relationship d-Oral health sequelae: -Bone loss -Pulpal changes -Tooth damaged or loss = the higher the risk if surgery makes the camouflage treatment more acceptable if case permit, and in some cases the camouflage treatment is difficult disease because the data of the case, SO, Borderline cases Borderline cases,, Problematic decision for treatment Problematic decision for treatment Dr. Mohammed Alruby Dr. Mohammed Alruby

7. 7 these cases need good evaluation of all diagnostic data and good consultation to obtain good results = some cases features are accepted to treated by camouflage alone as: - Case with average short facial height -Case with mild anterior posterior discrepancy -Case with crowding less than 6mm -Case with normal soft tissue features -Case with no transverse skeletal problems Thanks Thanks Borderline cases Borderline cases,, Problematic decision for treatment Problematic decision for treatment Dr. Mohammed Alruby Dr. Mohammed Alruby