Deals with timing of orthodontic treatment, Envelop of discrepancy, Setting up goals, Enlisting the treatment objectives, Assessment of growth potential, Assessment of etiological factors, Planning the final interincisal relationship, planning space requirements, planning extractions, planning anchorage, Selection of appliances, planning retention,re-evaluation.

1. Treatment Planning
Dr. Shweta Kolhe
BDS, MDS(Orthodontist)

2. Introduction
• Outline of all the measurement that can be best instituted for
a patient so as to offer maximum, long-term benefits.
• No cook-book approach exists
• At the end of the diagnosis process the following should have
established-
- clinical summary
- comprehensive list of patient’s problems (diagnosis)
• Each case should be assessed & customized treatment plan
formulated to suit the individual patients.

3. Timing of orthodontic treatment
• Many traits of the malocclusion are often seen in early part of
mixed dentition.
• Benefits of starting early treatment:
1. Reduced risk of trauma associated with proclined anterior.
2. Possible to utilize growth
3. May reduce need for extraction in future by expansion
procedures and growth modification.
4. Improve psychological benefits & self esteem
5. Often reduce need for long term future treatment.

4. Disadvantages of early treatment:
• Treatment duration may prolong as most case often need
second phase of treatment in permanent dentition phase.
• By prolonging treatment patients compliance is often
problem.
• Need prolong retention.

5. Ideal time to start treatment:
• Growth modification treatment :
– Late mixed dentition period before the shedding of second
deciduous molars.
• Routing orthodontic treatment :
– Best initiated in the early permanent dentition period.

6. Setting up goals
• From patients point’s of view:
– Basic need is to improve esthetics and functions.
• Orthodontics has additional goals :
– Providing quality treatment that remain relatively intact.
– Achieve aesthetics, functions & stability.

7. Enlisting the treatment objectives
• Enlist the problem in decreasing order of priority.
• Helps to setting up objectives and coming up with possible
solution.
• Patients chief complaints and parental desires should be given
additional importance.
• Orthodontics must be realistic to level of competence, patient
co-operation, etc.,.

8. Assessment of growth potential
• Growth status of an individual is an important factor.
• Patients with growing age has numerous treatment option -
- Orthodontist can modulate growth of dento-facial
structure.
- Orthodontist can guide teeth into more favorable
position.
• In adult -
- treatment options are limited to moving teeth and
surgical correction.

9. Envelope of discrepancy.
• Proffit and Ackerman introduced the concept of the envelop of
discrepancy to graphically illustrate how much change can be
produced by various types of treatment.
• Diagrams helps simplify the relationship of the three basic
treatment possibilities for skeletal discrepancies.
– Inner circle or envelop – limits of camouflage, involving on
orthodontics
– middle envelop – limits of combined orthodontic treatment and
growth modifications.
– Outer envelop – limits of surgical correction.

10. Range of movements in antero-posterior and
vertical direction in incisal region.

11. Range of movements in antero-posterior and
vertical direction in incisal region.

12. Range of movements
in transverse and
vertical direction in
posterior region.

13. Range of movements
in transverse and
vertical direction in
posterior region.

14. Assessment of etiological factors
• Etiological factor responsible for malocclusion should be
determined & adequate steps should be planned for their
elimination.
• Presence of etiological factors limits the corrective procedure
and predispose to relapse.

15. Planning the final interincisal relationship.
• Class I incisor relationship:
– Provision should be made to preserve the integrity of
satisfactory interincisal relationship.
• Class II, division 1 incisor relationship:
• Class II, division 2 incisor relationship:
• Class III incisor relationship:

16. Class I incisor relationship
• In patient presenting with a Class I malocclusion, the
interincisal relation in usually satisfactory.
• Thus provision should be made in the treatment
plan to preserve the integrity of this relationship.

17. Class II, division 1 incisor relationship
• In patient presenting with Class II, div 1 malocclusion, the
severity of presenting skeletal discrepancy usually determines
the choice of treatment and mechanics.
• If patient present with skeletal class I pattern- then
retroclination of maxillary incisors may be sufficient to
produce normal inter-incisor relationship.

18. • In case of a mild Class II skeletal pattern, a
camouflage treatment by retroclination or bodily
lingual movement of the maxillary incisor using fixed
functional appliance may produce satisfactory results
this may often require extraction of teeth to produce
satisfactory results.

19. • Severe Class II skeletal patterns often require
growth modification (in the growing) or surgical
treatment (in case of non-growing adults)
• Growth modification is done by use of myofunctional
appliances such as Activator, Bionator, Herbst
appliance, etc…,.

20. Class II, division 2 incisor relationship
• In class II, division 2 cases that present with a class I
or mid Class II skeletal pattern, uprighting the
maxillary central incisors by application of palatal
root torque may produce desire inter incisal relation.

21. • In case of severe skeletal class II pattern, it may be
advisable to proclined the maxillary central incisor, to
produce class II div 1 pattern, followed by growth
modification. In case of non growing individual
surgery may be required.

22. Class III incisor relationship
• Class III patients - present with a forward path of closure
usually present a better prognosis.
• In patients, referred to as postural or pseudo class III
reationship, removal of the occlusal interference by
proclination of the maxillary incisors produce a satisfactory
inter-incisal reation
• Very sever Class III pattern, a stable inter-incisal relation is
often achieved by proclination of maxillary incisors and
retroclination of the mandibular incisors.
• In severe Class III csaes - surgical correction.

23. Planning space reqirments
• Most malocclusions require space to move teeth to more ideal
positions.
• Following are some of the conditions that require space for
correction:
1. Correction of crowding
2. Rotations
3. Leveling the curve of spee
4. Correction of proclination
5. Molar correction
6. Space for anchorage loss

24. Correction of crowding
• For correction of crowding space is required.
• The rule of thumb is that for every mm of crowding,
a mm of arch length (space) is required.

25. Rotations
• Rotated anterior teeth occupy lesser arch length.
• Hence space is required for derotating these teeth =
The total mesio-distal width of rotated teeth
distance between the proximal surface of adjacent
teeth .

26. Leveling the curve of spee
• Common features associated with skeletal
malocclusion is increased curve of spee.
• A flat arch occupies more space than one with an
excessive curve of spee.
• Provision should be made in treatment plan to
provide space for leveling.
• Failure to correct curve spee result in proclination
that is unstable.

27. Correction of proclination
• retraction of proclined teeth required space.
• In space dentition, existing spaces can be use.
• If dentition is not spaced, alternate way of gaining space
should be planned.
• For every one mm of reduction to proclination two mm
of space is required.

28. Molar correction
• Presence of an unstable molar relation at the end of
treatment is a cause of instability.
• The molars should be moved to achieve good
intercuspation.

29. Space for anchorage loss
• Some amount of movement of the anchor teeth
should be expected.
• While retracting anterior teeth, molars also invariably
move forward to certain extent called anchorage
loss.
• In extraction case, almost 40% of space is lost by
mesial movement of posterior anchor teeth.

30. • The orthodontist should sum up the space required to correct
malocclusion.
• Once space required is known, different avenues to needed
space then explored.-
• Methods of gaining space:
1. Use of existing space
2. Proximal stripping
3. Expansion
4. Extraction
5. Distalization
6. Uprighting of molar.

31. Planning extractions
• Extraction of teeth – part of comprehensive procedure.
• Arch length tooth material discrepancy result in
crowding and proclination need extraction.
• Also to correct inter-arch relationship.

32. Class I skeletal / Dental pattern
• It is vitally important that extractions are done in
both the upper and lower arches so as to maintain
the buccal occlusal relationship.

33. Class II cases
• The upper dental arch is forwardly placed or the
lower arch placed back.
• By extracting only in upper arch – possible to reduce
the abnormal upper proclination & discourage the
forward development of the upper arch.
• Whenever extraction done in only upper arch – The
end of the treatment a Class II molar relation & a
Class I Canine relation.

34. • In case of lower arch crowding or when the molars
are not in full Class II occlusion (extract in both the
upper as well as the lower arches) – end of
treatment with Class I molar and canine relation.

35. Class III
• It is beneficial to avoid extraction in the upper arch as it
may retard the forward development of the maxilla.
• Preferred extraction in lower arch / in both arches
• In case of lower teeth extraction – end of treatment a
class III molar relation & class I canine relation.
• Extraction in both arches – end of treatment Class I
molar & canine relation.

36. Planning Anchorage
• Important part of treatment planning
• Efforts should be taken to minimize unwanted tooth
movements.
• Failure to plan anchorage invariably results in failure
of treatment mechanics.

37. Anchorage demand depends on following factor:
• Number of teeth being moved:
greater the number of teeth being moved, greater would be the
demand on anchorage.
• Type of teeth:
Multi-rooted posteriors offer greater strain on anchorage than
smaller teeth.
• Type of tooth movement:
Tipping less demanding on anchorage than bodily tooth movement.
• Duration of treatment :
Complicated orthodontic treatment of rolong duration result in anchorage
loss.

38. Selection of appliance
• Growth potential: appliance that modulate the growth used so
existing skeletal problem is solved or at least not worsened.
• Type of tooth movement:
Simple tipping tooth movement – removable appliance
Bodily, rotation, torque, axial tooth movement – fixed appliance
• Oral hygiene: essential factor.
Fixed apliance – risk of caries, decalcification, plaque, accumulation.
• Cost:
Removable appliance is far less expensive than fixed appliance.

39. Planning Retention
• Stretched periodontal ligament:
frequent cause of relapse in rotated teeth, as take long
time to reorganized so long retention period required.
• Unstable occlusion:
Unstable position at the end of orthodontic
treatment tend to relapse.
• Continuation of growth pattern:
Result in resurfacing of malocclusion.

40. Re-evaluation
• Treatment pan should be re-evaluated during active
phase of treatment so as to confirm objective are
fulfilled.
• Changes might be made if desired changes are not
taking place or if unforeseen problem arise.

41. Thank you