DR. GYAN P.SINGH Associate Professor Department of Orthodontics & Dentofacial O rthopaedics

1. 29/10/2014GENERAL PRINCIPLES Of ORTHODONTIC TREATMENT PLANNING OF DENTAL& SKELETAL MALOCCLUSION:Timing of Orthodontic Treatment DR. GYAN P.SINGH Associate Professor Department of Orthodontics & DentofacialOrthopaedics

2. CONTENTS • INTRODUCTION • EVOLUTION OF TREATMENT PLANNING • PRINCIPLES OF TREATMENT PLANNING • ORTHODONTIC TRIAGE • GROWTH MODULATION • DENTAL CAMOUFLAGE • MCQ

3. INTRODUCTION • 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.

4. Diagnosis • 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

5. DIAGNOSIS INTERVIEW CLINICAL EXAMINATION DATA BASE ANALYSIS OF DIAGNOSTIC RECORDS CLASSIFCATION PROBLEM LIST PATHOLOGY( CARIES, PERIO) CONTROL BEFORE ORTHO TREATMENT OPTIMAL INTERACTION ORTHODONTIC PROBLEMS TREATMENT COMPROMISE ( IN PRIORITY ORDER) AND PLAN COST-RISK / BENEFIT THE POSSIBLE SOLUTIONS TO INDIVIDUAL PROBLEMS MECHANOTHERAPY

6. PROBLEM ORIENTED APPROACH In this approach, diagnosis and Treatment planning are carried out in a series of logical steps:- • Development of an adequate diagnostic database. • Formulation of problem list which is the diagnosis from the database.

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

8. 5. Evaluation of the interaction among possible solutions 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.

9. 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

10. Treatment Planning • Treatment planningcan 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.

11. 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.

12. Patient’s goals and desires • Jackson’s triad • Esthetic harmony • Functional efficiency • Structural balance

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

14. ROLE OF TRIAGE IN DENTISTRY • The process to distinguish moderate from severeproblems. • Patients are appropriately treated in General dental practice • or the most appropriately referred to a specialist ( Orthodontist).

15. STEPS IN ORTHODONTIC TRIAGE • Syndromes and developmental abnormalities • Facial disproportions and asymmetries • Antero-posterior and vertical problems

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

17. 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

18. Timing of Orthodontic Treatment • Can be carried out at any time. • Comprehensive treatments -in adolescence as soon as the second molar erupts. • Understand the importance of the treatment • Self-motivated • Cooperate during appointments • Care the appliance and oral hygiene

19. TIMINGS OF THE TREATMENT

20. TREATMENT PLANNING IN LATE MIXED AND EARLY PERMANENT DENTITION Alignment Problems Transverse Problems Antero Posterior Problems Vertical Problems Eruption problems

21. 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

22. Growth modification, if possible, provides the ideal results. • 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.

23. Case[Developing Class III] S. Y.; 7.5 yrs /M

24. Radiographs (Pre-treatment) Orthopantomogram PACephalogram UpperOcclusogram LateralCephalogram

25. Problem list • Mesial Step. • Cross-bite of the anteriors. • Diagnosis-Developing Angle’s Class III malocclusion Etiology Genetic{father has midface deficiency} Treatment Plan {Tandem Appliance( Klempner ,JCO/JUNE 2011)} (1.)Upper fixed maxillary component. (2.) Lower fixed component with bite plane. (3.)Face bow and Elastics as a removable components.

26. Midface Deficiency Son Father

27. Fabrication of Modified Tandem appliance[Klempner,1999]

28. Installation of the Appliance

29. Delaire Petit Tandem Less bulky, more esthetic and patient friendly

30. Protraction of Maxillary Segment

31. Correction of Cross-bite{ Harmonious Growth Of Maxilla} Initial After 1 month After 2 months

32. Facial Appearance Of the Patient Pre-Treatment Stage after 3 months.....contd.

33. 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.

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

35. Case[Angle’s Class II Div.1H.A. 14 Yrs/Male

36. Problem List Treatment objectives Overjet and overbite correction Class II molars correction. To achieve the aesthetically and normal functional occlusion. • Protrusion of Upper jaw . • Class II Molar relationships. • Increased Overjet (8mm);Overbite(3mm). • 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 .

37. Enmasse Retraction of Upper and Lower Anterior Teeth {PreformedT.P.A.=Molarstabilization} K-SirRetractionSpring NiTi Retraction spring

38. 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

39. 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

40. Compromise • In many cases the three goals of Jackson triad (esthetics ,Function and stability) may be difficult to achieve. • The Orthodontist should strike a balance in fulfilling the major esthetic desires of the patient within the bounds of keys that stand for stability.

41. Re-Evaluation • The treatment plan is a continuous process and should be evaluated at regular intervals during the active phase of treatment. • 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.

42. MCQ: 1.TRIAGE is the process of • Taking impression in three stages • Planning anchorage • A dental compromise of the skeletal problems • None of the above 2. Camouflage is • A dental compromise of the skeletal problems • Consideration of extraction (C) Planning anchorage (D) Disscussion on the records of the patient.

43. 3.Jackson’s triad is comprises of all except. • Esthetic • Molar relationship • Functional efficiency • Structural balance 4. The commonest tooth is extracted for Orthodontic purpose • Incisor • Molar (C) Premolar (D) Canine

44. 5.Serial extraction procedure should be the best done during • Primary dentition • Mixed dentition (C)Young adolescent (D)Adult 6. All the matching statement is true except • Interceptive and preventive procedures-Primary and early mixed dentition • Growth modification-Mixed or early permanent dentition • Camouflage-Neonatal stage • Orthognathic surgeries-Adult patient

45. 7.Space is required in Orthodontic management except • Decrowding • Overjet reduction • Derotation of anterior teeth • Derotation of posterior teeth 8. The more complex Orthodontic cases would bereffered to specialist except • Skeletal posterior cross-bite • Anterior complex open bite • Midline diastemas of more than 2 mm after permanent canine eruption • Midline diastemas of less than 2 mm after permanent canine eruption

46. 9. Logical steps of diagnosis and treatment planning are comprises of all except • Treatment objectives and possible solutions • Interview,clinical examination and diagnostic records • Patient-parents consultation • Patient should not be given any role in decision making process 10. Serial extraction procedure involves removal of teeth except • First permanent premolar • Primary first molar • Primary canine • Permanent canine

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

48. Thank You