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Diagnosis & Treatment Planning
- 1. 1 Diagnosis & TreatmentDiagnosis & Treatment PlanningPlanning Dr. KAPIL SAROHA BDS, MDS Orthodontics and dentofacial orthopaedics www.drdentiste.comSaturday, February 11, 2017
- 2. 2 “The first step towards cure is to know what the disease is......” www.drdentiste.com
- 3. 3 A century ago EDWARD. H. ANGLE rightly said: “In studying a case of malocclusion, give no thought to the – methods of treatment or appliances until the case shall be classified with all peculiarities and variations from the normal in – type, occlusion and – facial lines that have been thoroughly comprehended. Then the requirements and proper plan of treatment become apparent”. www.drdentiste.com
- 4. 4 Human head is the mostmost complicatedcomplicated anatomical complex in all creation. The interrelationships are infinite and the causes and effects of these relationships are almost imponderable. www.drdentiste.com
- 5. 5 A thorough understanding of the normal variations in the – Growth and development of dentofacial structures, – Their anatomical fit into each other and – Their reaction to intrinsic and extrinsic factors /stimuli (genetic and environmental) itself is Orthodontic diagnosis. www.drdentiste.com
- 6. 6 Problem OrientedProblem Oriented && Evidence Based DiagnosisEvidence Based Diagnosis www.drdentiste.comSaturday, February 11, 2017
- 7. 7 The goal of the diagnostic process is to produce a complete description of the patient’s problems and make a problem list. To obtain the problem list, a collection of relevant information is required. This collection is called a database. www.drdentiste.com
- 8. 8 Mechano-Mechano- therapytherapy Diagnosis & Treatment Planning - Steps Patient History Clinical Examination Analysis of Diagnostic Records Classification Problem List = Diagnosis Treat pathology (caries, gingivitis etc.) Treat pathology (caries, gingivitis etc.) Problems in priority order A B C D Possible solution to individual problems OptimalOptimal TreatmentTreatment PlanPlan Data Base A B C D
- 9. 9 Patient history, &Patient history, & interview datainterview data 1. Family history 2. Motivation of patient for treatment Internal External 3. Reasons for taking treatment Functional Hygiene Esthetics Speech 4. Pubertal status 5. Prenatal History 1. Health of mother during pregnancy Diseases : Bacterial / Viral Medication Radiation Trauma Patient history, &Patient history, & interview datainterview data 1. Family history 2. Motivation of patient for treatment Internal External 3. Reasons for taking treatment Functional Hygiene Esthetics Speech 4. Pubertal status 5. Prenatal History 1. Health of mother during pregnancy Diseases : Bacterial / Viral Medication Radiation Trauma Clinical Examination:Clinical Examination: 1. General examination 2. Extraoral • Head shape • Frontal symmetry • Profile convexity • Facial divergent • Lip competency • Incisor visibility, 3. Functional • Mastication • Deglutition • Speech • TMJ 4. Intraoral • Hard tissues • Soft tissues Clinical Examination:Clinical Examination: 1. General examination 2. Extraoral • Head shape • Frontal symmetry • Profile convexity • Facial divergent • Lip competency • Incisor visibility, 3. Functional • Mastication • Deglutition • Speech • TMJ 4. Intraoral • Hard tissues • Soft tissues Analysis ofAnalysis of diagnostic records:diagnostic records: 1. Study Models • Upper • Lower 2. Radiographs • Lateral Ceph. • OPG • A-P Ceph. • IOPA • Hand Wrist • Occlusal 3. Photographs • Extra-oral (3 + 2 smiling) • Intra-oral (5) Analysis ofAnalysis of diagnostic records:diagnostic records: 1. Study Models • Upper • Lower 2. Radiographs • Lateral Ceph. • OPG • A-P Ceph. • IOPA • Hand Wrist • Occlusal 3. Photographs • Extra-oral (3 + 2 smiling) • Intra-oral (5) Problem List Problem List Pathology: 1. G ingiva (Attached gingiva) 2. Frenum (Lab. / Ling.) 3. Tonsils / Adenoids 4. Tongue 5. Dental Caries Developm ental Problem s: 1. Profile and Esthetics • Profile (Convex, Straight, Concave) • Frontal ( Sym m etrical, Asym m etry) • Lips 2. Alignm ent • Upper (Crow ding / Spacing) • Low er (Crow ding / Spacing) 3. A-P • Skeleton (Class I, II, III) • Dental ( Class I, II, III) 4. Vertical • Skeleton (VG P /Average / HG P) • Dental (Deep Bite / Norm al / O pen Bite 5. Transverse • Skeleton (W ide / Norm al / Narrow ) • Dental (W ide / Norm al / Narrow ) Problem List Problem List Pathology: 1. G ingiva (Attached gingiva) 2. Frenum (Lab. / Ling.) 3. Tonsils / Adenoids 4. Tongue 5. Dental Caries Developm ental Problem s: 1. Profile and Esthetics • Profile (Convex, Straight, Concave) • Frontal ( Sym m etrical, Asym m etry) • Lips 2. Alignm ent • Upper (Crow ding / Spacing) • Low er (Crow ding / Spacing) 3. A-P • Skeleton (Class I, II, III) • Dental ( Class I, II, III) 4. Vertical • Skeleton (VG P /Average / HG P) • Dental (Deep Bite / Norm al / O pen Bite 5. Transverse • Skeleton (W ide / Norm al / Narrow ) • Dental (W ide / Norm al / Narrow ) www.drdentiste.com
- 10. 10 Timing of Orthodontic Treatment: Pubertal growth spurts Peak Height Velocity (PHV) The importance of the body type www.drdentiste.com
- 11. 11 If all the structures of the craniofacial complex like the skeletal units , the dentition and the soft tissue components grow in harmony , then the result would be a good occlusion with a well balanced face. But the human face like most of our other specialized anatomic parts, certainly has its share of variations. www.drdentiste.com
- 13. 13 Since Class II malocclusion is recognized easily by health professionals as well as by patients and their families, especially in cases of excessive over jet, the correction of class II problems may constitute more than half of the treatmenthalf of the treatment protocolprotocol in a typical orthodontic practice. www.drdentiste.com
- 14. 14 It is interesting to note that the process of evolution in orthodontic diagnosis and treatment planningdiagnosis and treatment planning has been gradual. Now, let us trace through historylet us trace through history, the changing perceptions on the etiology of class II malocclusion. www.drdentiste.com
- 15. 15 For decades together class II was erroneously considered a purely sagittalsagittal problem.problem. Pioneered by Dr. Angle’s classificationDr. Angle’s classification of malocclusion based on anteroposterior relationship of first molarfirst molar, probably thousands of class II of all hues and varities were treated as basically sagittal discrepancies, often with disastrousdisastrous results. www.drdentiste.com
- 16. 16 It was not the orthodontists alone who were guilty of nescience, but even the surgeons jumped onto the bandwagon and restricted themselves to sagittal correction of what was actually a problem involving more than one plane. www.drdentiste.com
- 17. 17 The Angle system of classification still remains at the core of orthodontic diagnosis a century after its development, even though this classification scheme is not sensitive to imbalances in the vertical and transverse dimensions. www.drdentiste.com
- 18. 18 First, let us see, how malocclusions such as Class II develop as sagittal discrepancy. www.drdentiste.com
- 19. 19 SAGITTAL PLANE Prognathic Maxilla Retrognathic Mandible Combination of the two www.drdentiste.com
- 24. 24 Can also be because of decreased cranial flexure, the posterior positioning of glenoid fossa which neutralizes the horizontal growth of mandible ending up in Class II. www.drdentiste.com
- 47. 47 VERTICAL DISCREPANCY With the passage of time, inevitably there was gain of knowledge and wisdom and the focus now began to shift towards other etiologic possibilities of class II malocclusion It was schudy in 1964, who brought into focus the vertical dysplasia causing and affecting the class II malocclusion. Until then, investigators had never explored the vertical dimension of the posterior aspect of the face. But here were the secrets to be found. www.drdentiste.com
- 48. 482 Vertical Discrepancies Discrepancies in the vertical dimension occur in the form of a long facelong face or a short faceshort face syndrome. www.drdentiste.com
- 49. 49 Rotations of Mandible The rotationrotation of the mandible due to vertical growth discrepancies also has to be distinguished. 3 www.drdentiste.com
- 50. 50 Vertical Maxillary Excess Vertical maxillary excess brings about a clockwise rotation of the mandible and a class II situation. www.drdentiste.com
- 51. 51 Decreased Condylar Growth Decreased condylar growth and decreased ramal height swings the mandible backward. www.drdentiste.com
- 52. 52 Excess Condylar Growth Excessive condylar growth causes forward rotation of the mandible leading to a class II deep bite situation. www.drdentiste.com
- 53. 53 Now the concept changed such that when facial morphology indicated that vertical growth had been excessive or that condylar growth had been deficient, the plan was to inhibit the downward growth of the maxillary molars. When it is determined that vertical growth is deficient, the choice is to stimulate the vertical growth of the alveolar processes. www.drdentiste.com
- 54. 54 This quantum shift in knowledge about the causative factors of class II malocclusion brought into light an entirely new gamut of treatment possibilities. www.drdentiste.com
- 55. 55 Now let us look at some class II cases with predominant verticalvertical discrepancydiscrepancy and their treatment options. www.drdentiste.com
- 68. 68 Lefort I Osteotomy Premaxillary setback Genioplasty www.drdentiste.com
- 69. 69
- 70. 70
- 78. 78 TRANSVERSE DISCREPANCY It has only been during the last two decades or so that the role of transverse dimensiontransverse dimension has been a topic of interest to the typical practicing orthodontist. Until then it was a classical illustration of, “the eyes cannot see what the mind does not know.” www.drdentiste.com
- 79. 79 Many class II malocclusions, when evaluated clinically have no obvious maxillary constriction. www.drdentiste.com
- 80. 80 When a set of study models of the patient are “hand articulated", how-ever, it becomes obvious that when the dental casts are placed with the posterior dentition in a Class I relationship, a unilateral or a bilateral cross bitecross bite is produced. This indicates the presence of maxillarymaxillary constrictionconstriction as a component of class II malocclusion. www.drdentiste.com
- 81. 81 FOOT AND SHOE MECHANISM Richen Bach and Taatz in 1971 used the example of a foot and a shoe, with the foot representing the mandible and the shoe representing the maxilla. If the shoe is too narrow, it is impossible for the foot to slide fully into the shoe. By widening the shoe, the foot slides forward into its usual position. www.drdentiste.com
- 82. 82 When treating in the mixed dentition, the first step in the treatment of mild to moderate Class II malocclusions characterized, by mild mandibular skeletal retraction and maxillary constriction may be expansion of maxilla. www.drdentiste.com
- 83. 83 The patients can be left in a over expanded position with contacts still being maintained between the upper lingual cusps and lower buccal cusps of the posterior teeth. www.drdentiste.com
- 84. 84 Widening the maxilla often leads to a spontaneous forward posturing of the mandible during the retention period. After 6 to 12 months, the spontaneous correction of the class II relationship can be seen in many mild to moderate class II patients. www.drdentiste.com
- 85. 85 The net result of this change in outlook has been a reduction in the number of functional jaw orthopedic appliances that now are used in the treatment of mild to moderate class II malocclusion. www.drdentiste.com
- 94. 94 Class III malocclusionClass III malocclusion www.drdentiste.comSaturday, February 11, 2017
- 95. 95 SAGITTAL PLANE Retrognathic maxilla Prognathic mandible Combination of the two www.drdentiste.com
- 100. 100 During the1940’s and 50’s mandibular prognathism was believed to be the sole etiological cause for Class III malocclusions. www.drdentiste.com
- 101. 101 All clinical efforts were concentrated in correcting the mandibular prognathism using Chin cup therapy or surgical correction by mandibular set back was the only alternative practiced. www.drdentiste.com
- 102. 102 A lack of a clear understanding of the underlying etiology often compounded by adressal of wrong treatment objectives resulting in disastrous treatment results often accentuating the problem rather than solving it. www.drdentiste.com
- 103. 103 With the advent of newer diagnostic aids such as cephalometrics identification of the role of maxilla in the development class III malocclusion came into picture completely revolutionizing the present treatment philosophy. www.drdentiste.com
- 110. 110
- 115. 115
- 116. 116
- 117. 117 BSSO-Setback
- 118. 118 Genioplasty
- 119. 119
- 120. 120
- 121. 121
- 122. 122
- 123. 123
- 124. 124
- 129. 129 8 mm.Downward & 6.5mm. Advancement of Maxilla www.drdentiste.com
- 136. 136 Conclusion But as the philosopher Fredrick Jensen has said, “What we think we know today shatter the errors and blunders of yesterday and is tomorrow discarded as worthless. So we go from larger mistakes to small mistakes so long as we do not loose courage. This is true of all therapy, no method is final”.
- 137. 137 Thus even with tremendous progress in basic research and mind boggling improvement in appliance systems, class II & III malocclusion has still remained an enigma www.drdentiste.com
- 138. 138 ORTHODONTICS AS OF TODAY CreatesCreates WONDERSWONDERS www.drdentiste.com