The document outlines the key components of orthodontic diagnosis and treatment planning, emphasizing the importance of defining patient problems for effective treatment strategies. It distinguishes between psychosocial, developmental, functional, and trauma/disease control indications for orthodontic treatment, highlighting the complexities involved with severe or atypical cases. Additionally, it details criteria for identifying moderate versus complex treatment needs and underscores the significance of multidisciplinary approaches in managing patients with severe skeletal and dental irregularities.

1. TREATMENT
PLANNING

2. Diagnosis
Defining the problem
The purpose of diagnosis is to define and describe in a
definitive manner, the nature of the problem.
Orthodontic diagnosis is complete when a
comprehensive list of the patient’s problems have been
developed and pathologic and developmental problems have
been separated. The more precise and quantitative the
diagnosis, the easier it is to develop treatment planning.
At the end of the diagnosis process the following
should have established-
- clinical summary
- comprehensive list of patient’s problems (diagnosis)

3. Clinical Summary
Skeletal :Skeletal pattern I
Low mandibular plane angle
Denture :Angles class I, molar and Class II canine
on both sides.
Deep overbite.
Moderate crowding at upper and lower
anterior teeth.
Dental :Caries on tooth 31
Oriental premolar with apical abscess on
tooth 34 and 44.
Function :No problem
Soft tissue :No problem

4. History / Interviewing
Clinical Examination
Diagnostic Records
Data Base
Problem List
Developmental / Orthodontic
problem
Pathologic Problem
- crowding at upper and
lower incisors due to large
teeth / small jaw.
- Deep incisor overbite.
- Short lower facial height
and low mandibular plane
angle.
-Caries at tooth 31
-oriental premolar at tooth
34,44 with apical abscess.
Clinical summary

5. PATIENT DATABASE
History
Chief Complaint
Medical hx
Dental hx
Clinical examination
Extraoral exam:
Intraoral exam
Diagnostic Records
Casts
Photographs
Radiographs
DATABASE ANALYSIS
Facial
Dental
Functional
Soft tissue
Habits
PRIORITIZED PROBLEM LIST
DIAGNOSIS
TREATMENT PLAN
TREATMENT
RETENTION
Orthodontic Treatment Flowchart

6. -Aesthetic assessment of face
-Asymmetry of face (Skeletal / Dental)
-Skeletal pattern
-Vertical skeletal relation
-Lateral relation
-Mandible plane angle & mandibular form
-Soft tissue
Extraoral examination

7. Intraoral examination
Intra-arch problems
Alignment problems
Dentitional problems
Space problems
Crowding
Spacing
Inter-arch problems
Molar relation Soft tissue
Canine relation Tongue
Incisor relation
Incisors are proclined / retroclined

9. Radiographs

10. Diagnosis
Define and describe, in a definitive manner, the
nature of problem
PATIENT DATABASE
History
Chief Complaint
Medical hx
Dental hx
Clinical examination
Extraoral exam:
Intraoral exam
Diagnostic Records
Casts
Photographs
Radiographs
DATABASE ANALYSIS
Facial
Dental
Functional
Soft tissue
Habits
PRIORITIZED PROBLEM LIST
DIAGNOSIS

11. Treatment planning
To outline a plan for organizing orthodontic treatments.
The objective of treatment planning is to design the
strategy that a wise and prudent clinician, using his or her best
judgment, would employ to address the problems while
maximizing benefit to the patient and minimizing cost and risk.
How to solve the patient’s problems.

12. Diagnosis to Treatment Plan
Diagnosis
This is the patient’s problem
Treatment Plan
This is how I will fix the patient’s
problem
Treatment Objectives
What I want the patient to
look like at the end of treatment
Treatment Plan
This is how I will fix the patient’s
problem

13. Treatment planning vs Diagnosis
Diagnosis is the truth
Treatment planning is the wisdom.
Treatment planning is continuous and dynamic.

14. The need for treatment and referral
Not all patients with malocclusion need orthodontic
treatment.
Not all patients needing orthodontic treatment
should be treated by orthodontist.
Who need treatment? OR Is treatment indicated?
By whom?

15. Who need treatment?
Is treatment indicated?
Indications for orthodontic treatment

16. Indications for orthodontic treatment
Psychosocial indication
To remove or at least alleviate, the social handicap
created by an unacceptable dental and/or facial
appearance.
Developmental indication
To maintain as normal developmental process as
possible. (Interceptive treatments)
Functional indication
To improve jaw function and correct problems related to
functional impairment.
Trauma/disease control indication
To reduce the impact of trauma or disease on the
dentition.

17. Psychosocial indication
A severe malocclusion is likely to be a social handicap.
Well-aligned teeth and a pleasing smile carry positive
status at all social levels, whereas irregular or protruding teeth
carry negative status.
Social responses conditioned by the appearance of the
teeth can severely affect an individual’s whole adaptation to life.
Appearance can make a difference in student progress in
school, in employability and in competition for a mate
The impact of physical defect on an individual will be
strongly influenced by that individual’s self esteem.
It seems clear that the major reason people need
orthodontic treatment is to minimize psychosocial problems
related to their dental and facial appearance and not just
cosmetic.

22. Developmental indication
Most malocclusions are the result of developmental
variation.
Orthodontic treatment is required for the correction of
abnormal growth of jaws, abnormal development of teeth and
prevention of conditions which would affect the normal
growth.
Extreme variation in the size and position of the maxilla
and mandible
Developmental variation in the size, shape and
position of teeth and local crossbites
Imbalance between the tooth size and jaw size
Early loss of deciduous teeth, pseudo-class III

23. Crowding due to
abnormal tooth size
jaw size discrepancy

24. Abnormal growth of the jaws

25. pseudo-class III

27. Abnormal dental development
Ectopic eruption of first permanent molar

28. Functional indication
A severe malocclusion may compromise all aspects of
oral function.
Adults with severe malocclusion may have difficulty in
chewing (mastication function), adaptive or tongue thrust
swallowing, difficulty in producing certain speech sounds.
Malocclusion with premature occlusal contact with
mandibular deviation may be related with bruxism, increased
oral muscle activity and TMJ problems.
Altered respiratory function such as breathing through
the mouth rather than nose, could change the posture of the
head, jaw, and tongue. This could alter the equilibrium of
pressures on the jaws and teeth and contribute to abnormal jaw
growth and tooth position.

29. Equilibrium of mouth

32. Trauma / disease control indication
Malocclusion, particularly class II malocclusion with
protruding maxillary incisors, can increase the likelihood of an
injury to the teeth.
Excessive overbite so that the lower incisors contact the
palate, can cause significant tissue damage, leading to loss of
the upper incisors, or an extreme wear of incisors.
Severe irregularity of teeth could contribute to both
dental caries and periodontal disease, by making it difficult to
care for the teeth properly or by causing occlusal trauma.
Therefore, orthodontic treatment may be needed on the
basis of preventing trauma to the teeth and periodontal
disease.

33. Severely malaligned central incisors
With potential area for food impaction

35. Gingival recession secondary to incisor crossbite

36. Gingival recession secondary to deep incisal overbite

37. General dentist Diagnosis
Treatment at general practice Treatment at specialist practice
Patient
Need orthodontic treatment?
By whom?
Need referral
Yes
• Psychosocial
• Developmental
• Functional
• Trauma/disease control

38. By Whom?
Who should do treatment?

39. By whom? Or Who should do treatment? Or Does the
patient need referral to a specialist?
“ Enthusiasm is no substitute for experience and
ability, nor does sincerity guarantee correctness. ”
“ One must protect oneself and one’s patients from
well-intentioned but ill-planned therapy. ”
The general principle is that -
“ the less severe problems are handled within the
context of general practice and the more severe
problems are referred. ”

40. Distinguishing moderate from complex treatment problems

41. Distinguishing moderate from complex
treatment problems
Syndromes and Developmental Abnormalies
Patients with syndrome and similarly complex
problems can be recognized by the medical and
dental histories, facial appearance, and evaluation of
developmental status.

42. Examples of such disorders include:
•Cleft lip and palate
•Treacher-Collins’ syndrome (deformities of ears, eyes, Cheekbones,
and chin)
•Hemifacial microstomia (abnormal development of the lower half of
the face, ear, mouth, and mandible)
•Crouzon’s syndrome (skull fuse in abnormal ways and affect the
shape of head and face)
•Down’s syndrome (developmental delay, mild to moderate
intellectual disability)
•Patients with growth disorders, juvenile diabetes etc.
Such patients need multidisciplinary treatment approach to
achieve optimal benefit to the patient.

44. Treacher-Collins’ syndrome

46. Crouzon’s syndrome

47. Down’s syndrome

49. Facial Disproportions and Asymmetries
Facial Asymmetry – Patients with significant skeletal facial
asymmetry is considered as having a severe problem.
Skeletal asymmetry could be the result of growth
disturbances or an injury, which require complete evaluation by
radiographs. Treatment is likely to involve surgery in addition to
comprehensive orthodontics, or growth modification.
For early comprehensive evaluation and treatment, if
necessary, such patients should be referred.
Anteroposterior and Vertical problems – Severe skeletal class II
and class III problems and severe vertical deformities of long
face and short face types may be considered complex
problems.
Early clinical and cephalometric evaluation to plan
appropriate treatment at correct timing is required.

51. Excessive Dental Protrusion and Retrusion
Severe dental protrusion or retrusion is considered as
complex problems because -
These dental problems are usually associated with
skeletal problems and therefore require consideration of
skeletal problem in treatment planning. (skeletal class II or
class III with proclined or retroclined incisors)
Excessive protrusion of incisors in bimaxillary
protrusion usually indicates extraction of four premolars and
retraction of protruding incisors.
Such treatment procedures are complex and require fix
appliance treatment at a correct timing.

53. Excessive protrusion
Excessive retrusion

55. Problems Involving Dental Development
Asymmetric Dental Development
Treatment for asymmetric dental development should be
planned only after careful determination of the underlying cause.
Some patients with asymmetric dental development have
a history of childhood radiation therapy to the head and neck.
Surgical and orthodontic treatment for these patients must be
planned and timed carefully with their medical counterparts.
Missing Permanent Teeth
Several options are available and the correct choice of
treatment requires careful assessment of facial profile, incisor
position, space requirements and the status of the primary teeth.
Early evaluation and planning is essential so that early
referral is indicated.

56. Asymmetric dental development

58. Supernumerary Teeth
The presence of multiple or inverted supernumerary
teeth associated with displacement of permanent teeth are
considered complex problems.
Sometimes, this condition may be associated with
syndromes or congenital abnormality like cleidocranial
dysplasia and treatment becomes more complex.
Usually early removal is indicated followed by
orthodontic correction. Removal of supernumerary teeth
should be done carefully to minimize trauma to adjacent
structure.
Unerupted supernumerary teeth frequently requires
surgical exposure and mechanical traction to bring the teeth
into the arch. Adjunctive periodontal therapy may be needed
after the supernumerary has been moved.

61. Space Problems. (Crowding)
Space discrepancies greater than 4mm, with or
without incisor protrusion or discrepancies less than 4mm
with incisor protrusion constitute complex treatment
problems.
The results of space analysis are essential for
treatment planning and the treatment plan should be taken
into account of other skeletal, soft tissue and functional
problems.

64. Occlusal Discrepancies
Occlusal discrepancies like posterior cross-bites,
anterior cross-bites and anterior open-bite, if the cause is
skeletal and if associated with other vertical and lateral skeletal
abnormalities are considered as complex problems.
Therefore, distinction of dental from skeletal cross-bites
and diagnosis of open-bite secondary to soft tissue and dental
causes are important.

65. Posterior crossbite
Openbite Anterior crossbite

66. Thank you