Treatment planning in Orthodontics

1. 1 Treatment planning Treatment planning In In Orthodontics Orthodontics Prepared by: Prepared by: Dr Mohammed Alruby Dr Mohammed Alruby كيف سيلام كنع ركذو كلضف ركنا نم اقلخ سانلا ءاوسا Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Early treatment: Is the treatment during the most active growth period Indications: 1-Elimination of bad habits which interfere with normal dento-facial growth 2-Gross mal-relationship of the dental arches (severe class II, III, malocclusion) to utilize growth in treatment of the case, if these deformities remain untreated it is very difficult to be corrected by orthodontic means alone in adults 3-Gross malformation in the dental arches as, cross bite, open bite, and excessive overbite 4-Labioversion or torso-version of permanent incisors especially when crowding is expected because correction of these malposition is followed by great relapse tendency when treated in later age = tooth movement in deciduous dentition and early mixed dentition if necessary should be carried out after complete root formation and before beginning of root resorption Contraindications to early treatment: 1-Minor malocclusion in the deciduous teeth which may be self-corrected by growth and development For example: = Abnormal diastema and spacing of maxillary incisors are corrected with complete eruption of the permanent canines = some rotations of the teeth are self-corrected by complete formation of their roots, protrusion of maxillary incisors without compression of cheeks may be self-corrected by upper lip, also unilateral cross bite, edge to edge bite in deciduous dentition are self-corrected by the action of the tongue 2-Presence of rampant caries and oral sepsis which should be treated before orthodontic treatment is under-taken 3-Nasal obstruction, enlarged tonsils and adenoid which should be surgically removed first 4-Psychologically ill, highly emotional and uncooperative children 5-Disturbances in general health which would interfere with continuity of orthodontic treatment 6-Slight irregularities of individual teeth which would not interferes with normal function, should not be treated in either deciduous or mixed dentition periods Age factor in diagnosis and treatment: = age of the patient is not a primary factor in deciding when corrective treatment should be started, this decision depend on the presence of conditions which if remain would interferes with normal growth and development of dento-facial complex, in such cases treated should be under-taken regardless the age of patient The child has many ages including, chronological age, dental age and developmental or bone age. The various ages may or may not coincide with chronological age of the same patient Therefore, it is important to correlate these ages with standard normal individuals to achieve proper diagnosis = Angle, the 1st who advised treatment as early as possible after appearance of dentofacial deviations = if treatment is started at an early age, the patient should be kept under periodic observations under permanent dentition is completed and growth ceases = early treatment of gross malocclusion gives raise better esthetic, functional and more stable results Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 Eby divided orthodontic treatment into the following developmental age group: 1-Group1: 3-6y: deciduous dentition 2-Group2: 6-9y: early mixed dentition 3-Group3: 9-12y: late mixed dentition 4-Group4: 12-20y: or more: permanent dentition Available space: Mixed and permanent dentition analysis are discussed in regarding the available space, the cases may be classified as: 1-Cases in which there is abundant space as the space is more enough to align the teeth properly as well as to permit proper occlusal adjustment 2-Cases in which there is a sufficient space: the space is enough to align all teeth properly, but no space is left to aids in a chewing class I occlusion (no space for late mesial shift) 3-Cases in which there is deficient space in which there is deficient space: the arch parameter is not enough to accommodate all teeth Lower arch is more critical in the matter of space After careful analysis of the time factor, skeletal pattern and available space, it is easy to locate the treatment protocol of the case Ideal treatment: = the ideal results may be impractical or even harmful to the oral health, the ideal from the esthetic point of view may be not ideal for the periodontal health or occlusal functions = the ideal goal in orthodontic treatment is often rejected because it is very difficult to reach with treatment to the ideal occlusion, because the lack of technical skill = some reasons for rejecting ideal goals in orthodontic treatment: 1-The nature of malocclusion does not always permit ideal results as extraction of the teeth is necessary 2-Dentists do not know how to treat the ideal results 3-The cost of ideal treatment is very expensive Compromised treatment: Is that which approximate the ideal, when the dentist do not know how to treat to the ideal results, there are two alternatives either to refer the case to specialist or to do compromised treatment, the nature of compromised treatment, coast, time and difficulties should be presented clearly and accepted by the patients and his family Symptomatic treatment: Rarely advised and in most cases should be followed by treatment of the basic problem itself, a good example: retraction of proclined maxillary incisors to minimize the incidence of their accidental fracture, this should be followed by treatment of class II if present Specifying the tooth movement: = It is important to specify the direction and distance to which each tooth is to be moved as well as the final angulation and occlusal relationship, diagnostic set up is very important to do this and to determine the expected treatment results = It is better to divides the treatment into stages or phases, write on the patient sheet the aim of each phase and the tooth movement to be achieved in each phase and the best appliance that can produce these movements without adverse effect on the teeth and oral soft tissues Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 = Thus the dentist now has a symptomatic sequence of treatment help him to determine how to complete treatment and difficulties that may be encountered during treatment and to review their solutions = The following list provides in general the sequence of steps in treatment of most malocclusions: a-Removal of all interfering factors to normal function and growth, for example, abnormal pressure habits, premature contact and so forth b-Correction of disharmonies between the dentition including: Anterior posterior disharmonies as: excessive overjet and anterior cross bite Vertical disharmonies as: deep bite and open bite Lateral disharmonies as: posterior cross bites c-Correction of skeletal or osseous disharmonies and fitting the teeth on their osseous bases d-Alignment of the teeth within each dental arch Selection of appliance: = there is an old saying in orthodontics that, it is better to make the appliance fit the patient than make the patient fit the appliance = we must be sure that we doing our best to designing the most efficient appliance that suite the treated case If the goal of treatment has been identified, the stages of treatment have been written and the required tooth movement have been specified Selection of appliance will be easy task; many cases of malocclusion may be finished with in adequate results or even failed because the dentist did not know the best appliance for the case Planning of retention: As the dentist has a good image about the end result of the case under treatment is completed, it is always advisable to write any expected difficulties in retaining the case or any expected tendencies to relapse Diagnosis and treatment planning in deciduous dentition 3 – 6 years 1-Reasons for treatment: To remove any interferences to normal dento-facial growth To maintain or restore normal occlusion 2-Condition that should be treated: Including all conditions that may interfere with normal function or normal dentofacial growth: a-Premature loss of teeth and fear of space closure b-Anterior and posterior cross bite c-Over retained primary teeth that may interfere with normal eruption of permanent incisors d-Premature contact or teeth malposition which might causes functional shifting of the mandible e-Abnormal pressure habits f-Skeletal class III pattern 3-Condition that may be treated: -Positional disto-occlusion -Open bite due to local factors 4-Contraindication to treatment in primary dentition: Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 -Self-corrected malocclusion -When better results can be achieved with less effort by treatment at another time -If poor prognosis is expected -The presence of local or systemic disturbance that cause delayed eruption of permanent teeth -If dilacerations of the permanent teeth roots is expected Occlusal relationship: = two types of occlusion are considered normal: a-Flush terminal plane: the distal aspect of UE and LE are on the same vertical plane (cusp to cusp relationship) b-Intercuspation: the UE and LE follow the same cuspal relationship as seen in permanent dentition = The maxillary and mandibular incisor segment show interdental spacing. = primate space: two distinct space found mesial to the UC and distal to LC, these spaces are important in relief of anterior crowding of permanent incisors and in early mesial shifting of L6 Deciduous dentition as an indicator for normal permanent dentition: = normal alignment of deciduous teeth does not necessarily follow by normal alignment of permanent teeth = the size of deciduous teeth is not an indicator for the size of permanent teeth, permanent dentition occlusion cannot be predicted with high degree of perfection from deciduous dentition occlusion, however the absence of inter-dental spacing in deciduous dentition may indicate crowding of permanent teeth, but there are other growth factors should be considered Effects of deciduous dentition treatment on permanent teeth: = orthodontic treatment of deciduous teeth influences the position of permanent teeth germs = permanent tooth germ follows the direction of movement of the deciduous root, this might causes dilacerations of permanent tooth roots Hazards of orthodontic tooth movement in deciduous dentition: 1-Dilacerations of permanent teeth roots 2-Resorption of primary teeth roots Tipping movement of primary teeth may cause root resorption, so that, light force applied at gingival margin, perpendicular to the long axis of the tooth is advised to prevent tipping of deciduous roots 3-Anchorage problem: The deciduous teeth roots may undergo physiological resorption and the root of the 1st permanent molars may not fully develop, so both may not use as anchor units If deciduous molars are to be used as anchor units, both movement should proceed before advanced root resorption as between 4 – 8 years Premature loss of deciduous teeth: = is not necessary followed by malocclusion, the space may be close or remains stationary or may get wider UA, B rarely followed by space loss of the arch is not crowded U and L C at or after eruption of incisors, the space usually closes interfering with normal eruption of U and L 3 U and L D may or may not followed by space loss Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

6. 6 U and L E show high percentage of space loss, if lost before eruption of 6, space retaining appliance should be preserved until the 1st permanent molars begin to erupt, because the insertion of spurs against the unerupted 6 in mucous membrane may actually interfere with its eruption Over retained deciduous teeth should be extracted in the following condition: 1-If the root is completely resorbed while crown still attached to alveolar mucosa 2-If the permanent tooth is ready to erupt as indicated by the completely formed root while the deciduous tooth root shows no resorption 3-When the permanent canine is erupting through the alveolar mucosa while deciduous canine still retained 4-When the premolars are ready to erupt by full root formation and their proximity to alveolar crest, deciduous molar should extracted 5-When premolars are erupting bucally or lingually under the deciduous molars, the deciduous molars should be removed 6-When the 1st permanent molars are above the 2nd deciduous molars occlusally, there is danger of wedging the 2nd deciduous molars in the alveolar process, so they should be extracted and space maintainer is inserted 7-In the congenital absence of premolars, if there is crowding, the deciduous molar should be extracted and space allowed to close under supervision to prevent forward shifting of 6 if undesired Diagnosis and treatment planning in mixed dentition 6 – 9 years: Treatment is indicated when the deciduous roots are not respond to the degree that interfere with anchorage or make the tooth movement is effective 9 -12 years: Treatment in this phase should not interfere with: -Normal growth -Rapid occlusal adjustment -Eruption of permanent teeth == extensive movement of newly erupted teeth should be avoided Purpose of treatment in mixed dentition: Treatment may be preventive, interceptive, or corrective: 1-Correction of abnormalities of growth 2-Elimination of functional interference 3-Elimination of abnormal pressure habits 4-Interception of the early symptoms of malocclusion 5-Correction of gross malocclusion which if left, may cause facial a symmetry and cannot be treated well in permanent dentition Condition that should be treated: 1-Mal-relationship of the dental arches, class I, II, III angle especially functional or dental types 2-Premature loss of primary teeth and space closure 3-Malposition of individual teeth that may interfere with normal development 4-Premature contact and functional interferences 5-Supernumerary teeth Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

7. 7 6-Cross bite in permanent dentition 7-Abnormal pressure habits 8-Correction of proclined maxillary incisors 9-Ectopic eruption of the teeth 10-Space opening for erupting teeth 11-Closing median diastema 12-Expansion of excessively narrow dental arch 13-Alignment of crowded, rotated permanent teeth 14-Correction of deep bite, open bite and excessive overjet Condition that may be treated: -Skeletal class II -Gross inadequacy of apical base, serial extraction must be undertaken Diagnostic principles: In the absence of gross abnormalities, diagnosis should be based on more than one examination (at regular interval) because the dentition is in highly dynamic state of growth and development Disproportion between sizes of dental and basal arches: Basal arch inadequacy can be diagnosed by: 1-Uneven resorption of deciduous roots 2-Rotation of the teeth 3-Absence of interdental spacing between primary teeth 4-Abnormal eruption pattern 5-Rapid closure of spaces due to premature loss of deciduous teeth 6-Crowding of permanent incisors Many cases of apparent malocclusion in mixed dentition may actually normal stage in growth and development For example: Broadbent ugly duckling phenomena and crowding or linguversion of mandibular incisors and some labioversion of maxillary incisors, these cases would be corrected by latter development Treatment in mixed dentition: = light force and extreme care should be applied in the mixed dentition treatment = the use of 1st permanent molars as an anchorage unit may interfere with early and late mesial shifting required for occlusal adjustment, if this occurs, the 2nd premolars may erupt axially inclined and rotated = when there is slight crowding, sufficient space to align the teeth can usually obtain by distal tipping of 1st permanent molars. Care must be exercised not to minimize the space required for eruption of 2nd molars, otherwise the 2nd molar may be impacted along the distal root of 1st molars = if the space was critical, upper and lower space maintainer should be inserted to prevent forward shifting of 1st permanent molars The two stage of treatment: Many appliances may interfere with normal growth and development, for this reasons the treatment in mixed dentition period is better carried out in two stages: 1st stage: should concerned with correction of gross abnormalities and interfering factors, then the treatment discontinued to allow for normal growth and development Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

8. 8 2nd stage: should be carried after eruption of permanent teeth if being necessary Diagnosis and treatment planning in permanent dentition: 12 -20 years or more Diagnosis is more certain and treatment is more definite The pubertal growth spurt is favorable time for initiating orthodontic treatment, early adolescent treatment can frequently obviate the need for extended later treatment Prognosis in orthodontic therapy Favorable prognosis depends on: 1-Proper selection of the patient 2-Accurate diagnosis 3-Proper timing of treatment 4-Proper treatment planning 5-Proper selection and designing of the appliance 6-Adequate tissue response 7-Proper planning of retention 8-Proper growth prediction Causes of poor prognosis: A-Faults of operator: 1-Improper selection of the patient 2-Wrong diagnosis and lack of proper knowledge about dentofacial growth 3-Lack of experience and technical skills 4-Selection of the wrong time for treatment 5-Improper selection of the appliance or refusal to use other appliance rather than his favorite 6-Improper sequential treatment planning and lack of good control on the case 7-Extraction of the teeth when contraindicated 8-Overexpansion of the dental arch 9-Forced tooth movement or appliance of heavy force 10-Failure to remove the cause as; abnormal habits 11-Failure to consider the psychological factor in choosing the appliance 12-Lack of final occlusal equilibration after treatment is finished 13-Neglecting the muscle factor in planning of retention 14-Improper retention of the case 15-Improper growth prediction B-Faults lie at the patient’s side: 1-Patients un-cooperation: = lack of attitude to treatment, do not wear removable appliance or always distort or break fixed appliance = lack of attitude to oral health, improper oral hygiene, caries, periodontal disease = patient did not wear retainer = patient do not keep his appointment Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

9. 9 C-Faults lies beyond the control of patient or operator: 1-Unexpected illness or accident 2-Psychological illness, epilepsy 3-Persistent dentofacial habits 4-Uncontrolled caries or infections 5-Large tongue size, and abnormal musculature 6-Genetic factors 7-Poor physical state 8-Resorption of the roots 9-Sever osseous deformities Treatment planning in Orthodontics Treatment planning in Orthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby