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ORTHODONTIC TREATMENT PLANNING SECRETS
- 2. TREATMENT PLANNING CONCEPTS & GOALS Comprehensive list of patient’s problems = Orthodontic Diagnosis Pathological & Developmental problems separated Objective = To design a strategy using best clinical judgement to address the problems while maximizing benefit and minimizing cost & risk Develop treatment plan in collaboration with patient ~~Hasanin alkendi~~
- 3. MAJOR ISSUES IN PLANNING TREATMENT PATIENT INPUT Modern planning = Interactive process Doctor cannot decide in a paternalistic way Patients & Parents must be involved in decision making process Ethically, patients have right to control “Treatment is something done for them….Not to them” Informed concent~~Hasanin alkendi~~
- 4. DENTAL CROWDING : TO EXPAND or EXTRACT Two controversial aspects of current orthodontic treatment planning The extent to which Arch Expansion versus Extraction is indicated as solution for Crowding in Dental Arches The extent to which Growth Modification versus Extraction for Camouflage or Orthognathic Surgery should be considered as solution for Skeletal Problems ~~Hasanin alkendi~~
- 5. From beginning of Specialty, Debate on Limits of Expansion of Dental Arches & advantages of Extraction of some Teeth to provide space for others outweigh the Disadvantages With Extraction, Loss of Tooth/Teeth is Disadvantage Greater Stability of result is an Advantage Maybe Positive or Negative effects on Facial Esthetics Contemporary View : Majority of Orthodontic Patients should be treated without removal of Teeth Extraction to compensate for Crowding, Incisor Protrusion or Jaw Discrepancy ~~Hasanin alkendi~~
- 6. ESTHETIC CONSIDERATIONS Major factors in Extraction Decisions = Stability & Esthetics Expansion of arches moves the patient in direction of more prominent teeth, while extraction tends to reduce prominence Prominence of Incisors = Excessive Lip separation at rest Nose - Chin relationship For Best Esthetics = Lower Lip should be as prominent as chin ~~Hasanin alkendi~~
- 7. STABILITY CONSIDERATIONS For stable results how much arches have to be expanded Lower arch is more constrained than the upper Limitations for stable expansion maybe tighter than the upper 2mm Limitation for forward movement of Lower Incisors, as Lip pressure increases 2mm out into space Incisors Tipped Lingually away from Lip can be moved farther than Upright Incisors ~~Hasanin alkendi~~
- 9. More opportunity to expand Transversely than Anteroposteriorly – but only distal to canines Reports show that Expansion across the canines is never maintained, especially in Lower Arch Intercanine Dimensions decrease with age = Lip Pressure at corner of Mouth Expansion across Premolars & Molars is likely to be maintained = Low Cheek Pressures ~~Hasanin alkendi~~
- 10. One approach to Upper Arch Expansion is by Opening the SMidpalataluture, if base is narrow ! Theory (with no supporting Evidence), upper arch expansion, creating temporary Crossbite, Lower Arch follows Lead !! Excessive Expansion carries Risk of Fenestration of Premolar & Molar Roots through the Alveolar Bone Increased Risk of Fenestration = Beyond 3mm of Transverse Tooth movement ~~Hasanin alkendi~~
- 11. Soft Tissue Limitation Fenestration of Alveolar Bone & Stripping of Gingiva Amount of Attached Gingiva = Critical Variable Pre-treatment with Periodontist ~~Hasanin alkendi~~
- 12. CONTEMPORARY EXTRACTION GUIDELINES Contemporary orthodontic extraction guidelines in Class I Crowding LESS THAN 4mm ARCH LENGTH DISCREPANCY: Extraction rarely Indicated Only if there is severe Incisor Protrusion Severe Vertical Discrepancy Some cases can be managed without Arch Expansion by slightly reducing width of selected Teeth~~Hasanin alkendi~~
- 13. ARCH LENGTH DISCREPANCY 5 to 9 mm : Non Extraction or Extraction Treatment possible Decision depends on both Hard & Soft Tissue Characteristics Any of several Teeth can be chosen for Extraction Non Extraction Treatment = Transverse Expansion across Premolars & Molars Additional Time if Posterior Teeth are to be moved Distally to increase Arch Length ~~Hasanin alkendi~~
- 14. ARCH LENGTH DISCREPANCY 10 mm OR more : Extraction almost always required Amount of Crowding equals the amount of Tooth Mass being Removed = No effect on Lip support & Facial Appearance Extraction choice is Four 1st Premolars or Upper 1st Premolars & Mandibular Lateral Incisors 2nd Premolar or Molar Extraction rarely is satisfactory = No space near crowded Anterior Teeth or Options to correct Midline ~~Hasanin alkendi~~
- 15. Presence of Protrusion along with Crowding complicates the Extraction decision Retracting the Incisors to reduce Lip Prominence requires Space within the Dental Arch General Rule : Lips will move 2/3rd of distance that Incisors are retracted ~~Hasanin alkendi~~
- 16. Retrospective Studies of Ex vs Non Ex cases = Highly variable changes The idea that Extraction will lead to narrow Arch and Incisor Retraction & that Non Extraction leads to Incisor Protrusion and Wider Arches is NOT WELL SUPPORTED Final Set of Guidelines : The more you can expand without moving Incisors forward = Satisfactory Treatment The more you can Close Extraction spaces without over Retracting Incisors = Satisfactory Treatment Oral Health = Excessive Expansion increases risk of Mucogingival problems Masticatory Function = Expansion or Extraction makes no difference ~~Hasanin alkendi~~
- 17. SKELETAL PROBLEMS : GROWTH MODIFICATION vs CAMOUFLAGE If it were possible, Best way to correct Jaw Discrepancy is to get the patient to grow out of it Pattern of Facial Growth is established early in Life and it rarely changes Important Q’s = Extent to which Growth can be Modified Data from Randomized Clinical Trials for Class II Treatment outcomes are available Skeletal Problems in other Planes of Space remain Controversial~~Hasanin alkendi~~
- 18. TRANSVERSE MAXILLARY DEFICIENCY Close Relationship with Ex vs Non Ex decision Child with Crowded teeth, a Diagnosis of Maxillary Deficiency can be a convenient Rationale for Transverse Expansion to align teeth Width of Maxillary Premolar teeth and Width of Palate = Methods to Diagnose Maxillary Deficiency Midpalatal Suture becomes more Tortous and Interdigitated with increasing Age ~~Hasanin alkendi~~
- 19. In a Child age 9, any Expansion Device (Lingual Arch), will separate the Midpalatal Suture, also move the molar teeth Adolescence, Heavy force from a rigid Jackscrew Device used for separation (Microfracture Maxilla opens like a Hinge superiorly, at base of Nose, also opens more Anteriorly than Posteriorly Heavy forces and Rapid Expansion should not be used in school children = Risk of producing undesirable changes in nose at that age After Adolescence = Bony spicule Interlocked Suture = Surgery ~~Hasanin alkendi~~
- 20. In Adolescents, Expansion across the Suture can be done in 3 ways : I. II. III. RAPID EXPANSION with jackscrew attached to Posterior Maxillary Teeth, at rate of 0.5 to 1 mm/day SLOW EXPANSION with same Device at rate of 1 mm per week EXPANSION with a Device attached to Bone Screws or Implants ~~Hasanin alkendi~~
- 21. RAPID PALATAL EXPANSION Goal of Growth Modification = Maximize skeletal changes and Minimize the Dental Changes produced by Treatment THEORY : Rapid Force application to Posterior Teeth = Not enough Time for Tooth Movement = Force will be Transferred to Suture = Suture will open while Teeth move Minimally RPE at rate of 0.5 to 1 mm/day 1 cm or more Expansion is obtained in 2 – 3 weeks Most of movement being separation of two halves of Maxilla, Midline Diastema Expansion device left in pace for 3 – 4 months for Stability 10 mm of Total Expansion = 8 mm of Skeletal Expansion & 2 mm of Dental Movement After 4 Months ( 10 mm Total Expansion ) = 5 mm of Skeletal Expansion & 5 mm Tooth Movement ~~Hasanin alkendi~~
- 22. SLOW PALATAL EXPANSION 0.5 mm per week 1 quarter turn of screw ( 0.25 mm ) every other day Ratio of Dental to Skeletal Expansion is 1:1 Large Midline Diastema never appears 10 mm of Expansion over 10 week period = 5 mm of Dental & 5 mm of Skeletal Expansion Overall result of Rapid vs Slow Expansion is similar With SPE a more Physiologic Response is obtained ~~Hasanin alkendi~~
- 23. CLASS II PROBLEMS In 1990’s two major projects using clinical randomized trial methodology were carried out in University of North Carolina & University of Florida, both were supported by NIDCR Data from Trials show 3 important things : Children treated prior to Adolescence, had significant improvement in their Jaw Relationships Changes in Skeletal Relationships created during early treatment could be reversed by Latter Compensatory Growth At the end of comprehensive treatment during adolescence, no differences between early patients and previously untreated controls ~~Hasanin alkendi~~
- 24. CAMOUFLAGE BYTOOTH MOVEMENT Tooth Movement alone cannot correct Skeletal Malocclusion If malocclusion is corrected and Facial Appearance is Tacceptable then treatment outcomecan be satisfactory, this is calledORTHODONTIC CAMOUFLAGE Camouflage : Dental Occlusion + Facial Appearance Camouflage means that Jaw Discrepancy is no longer apparent ~~Hasanin alkendi~~
- 25. Following 3 patterns of Tooth Movement can be used to correct Class II malocclusion Combination of retraction of Upper teeth and forward movement of Lower Teeth, without Extractions Retraction of Maxillary Incisors into a Premolar Extraction Space Distal Movement of Maxillary Molars and eventually the Entire Upper Dental Arch ~~Hasanin alkendi~~
- 26. NON EXTRACTION TREATMENT WITH CLASS II ELASTICS If Forward movement of Lower Arch can be accepted = Class II Malocclusion can corrected using Class II Elastics Almost always, Class II patients have Lower teeth normally positioned on the mandible or Proclined to some extent Result of Class II Elastics = Convex Profile with Protrusive Lower Incisors & Prominent Lower Lip ==RELAPSE WAITING TO OCCUR After Treatment Lip Pressure moves Lower Incisors Lingually = Incisor Crowding Return of Overjet and Overbite ~~Hasanin alkendi~~
- 27. RETRACTION OF UPPER INCISORS INTO PREMOLAR EXTRACTION SPACE Straightforward way to correct Excessive Overjet = Retract Protruding Incisors in to Space created by Maxillary Premolar Extractions Without Lower Extractions the patient would have a Class II molar relationship, but normal Overjet and Canine relationship at the End Temporary Skeletal Anchorage If Mandibular 1st or 2nd Premolars are also Extracted = Class II Elastics can be used to bring the Lower Molars Forward & Retract the upper Incisors, correcting both Molar relationship and Overjet Class II Malocclusion due to Mandibular Deficiency ?? TMJ Dysfunction ? ~~Hasanin alkendi~~
- 28. DISTAL MOVEMENT OF UPPER TEETH If Upper Molars moved Posteriorly = correct a Class II Molar Relationship and provide space into which other Maxillary Teeth could be Retracted More Often Maxillary 1st Molars are Rotated Mesiolingually when a Class II Molar relationship exists Tipping the crowns Distally to gain space is difficult, and Bodily Movement is Difficult Still Until recently the Anchorage by Transpalatal Lingual Arch is accepted as the Best way to undertake Distalization Can be done Theoretically with a HEAD GEAR = Time Consuming & Excellent patient compliance ~~Hasanin alkendi~~
- 29. Palatal Anchorage for Molar Movement can be created by Splinting the Maxillary Premolars & including an Acrylic Pad in splint so it contacts the Palatal Mucosa 2/3rd of space which opens between Molar & Premolars is from Distal movement of Molars Tend to come forward again as rest of Maxillary Teeth are Retracted so more than a half – cusp Molar correction cannot be expected Ideal Patient = Minimum Growth potential + Good Jaw Relationship ~~Hasanin alkendi~~
- 30. Temporary Skeletal Anchorage = Greatly improves Distal movement of Maxillary Dentition Space in Tuberosity region = Remove 3rd Molars Bone Anchors placed Bilaterally in base of Zygomatic Arch or in the Palate, Nickel Titanium spring generates force needed for Distalization Bone Screws between Teeth prevent Distal Movement of Roots Mesial to the screw In some patients = 6 mm of Distal Movement of 1st & 2nd Molars In addition the Premolars move back along with Molars ( Due to SUPRACRESTAL FIBERS ) ~~Hasanin alkendi~~
- 31. THE CAVEAT : (warning, Limitation) If Class II Malocclusion is due to Maxillary Dental Protrusion, moving upper teeth back is logical approach But if there is Mandibular Deficiency, Retraction of Maxillary Incisors after Distal movement of Molars & Premolars have same Potential Problem as that with 1st Premolar Extraction ~~Hasanin alkendi~~
- 32. SUMMARY In the Absence of Favorable Growth, treating Class II is Difficult Compromises have to be accepted in order to correct occlusion Fortunately, even though Growth Modification cannot be expected to totally correct an Adolescent Class II problem Some Forward Movement of Mandible relative to Maxilla does contribute to successful treatment Rest of correction = Combination of Upper Incisor Retraction + Forward movement of lower arch When No Growth expected = Orthognathic Surgery ~~Hasanin alkendi~~
- 33. CLASS III PROBLEMS Growth Modification is just reverse of Class II Differential growth of maxilla relative to Mandible Edward Angle’s concept = Class III exclusively due to Excess Mandibular growth Any combination of Maxillary deficiency or Mandibular Excess Maxillary Deficiency frequent occurrence = Promotion of Maxillary growth ~~Hasanin alkendi~~
- 34. HORIZONTAL – VERTICAL MAXILLARY DEFICIENCY If Headgear force = compressing Maxillary Sutures = Inhibition of Growth Reverse Pull Headgear = separating the sutures = Stimulate Growth Delaire & coworkers in France showed effects of reverse head gear RESULTS = Successful Forward repositioning of Maxilla can be accomplished before age 8, afterwards the Orthodontic Tooth movement overwhelms the skeletal change ~~Hasanin alkendi~~
- 35. Even in young patients, 2 side effects are almost inevitable : Forward movement of Maxillary Teeth relative to Maxilla Downward & Backward Rotation of Mandible IDEAL PATIENTS FOR THIS TREATMENT : Normally positioned or Retrussive, but not Protrussive Maxillary Teeth Normal or Short, but not Long, Anterior Facial Vertical Dimensions ~~Hasanin alkendi~~
- 36. MANDIBULAR EXCESS Condylar Growth in response to Translation as surrounding Tissues grow Results from CHIN CUP THERAPY are discouraging (Lower Incisors Tipped Lingually ) DeClerk : Light but Full Time force from Class III elastics is used from Skeletal Anchors in Maxilla to Skeletal Anchors in Mandible, effects on both the jaws are observed ~~Hasanin alkendi~~
- 37. CLASS III CAMOUFLAGE Moderately Severe Class III = Proclining the Upper Incisors & Retracting the Lower Incisors into Extraction space Unfortunately this illustrates as Camouflage Failure Failure especially likely = Large & Prominent Mandible Retracting the Mandibular Teeth = makes the chin more Prominent Improving Dental Occlusion while making Jaw Discrepency more Obvious is not successful teatment ~~Hasanin alkendi~~
- 38. Candidate for Class III camouflage : Reverse Overjet due to Protrussive mandibular incisors & Retrussive Maxillary Incisors Short Anterior Face Height so that a downward – Backward rotation of Mandible would improve both anterior and posterior Vertical Facial Proportions ~~Hasanin alkendi~~
- 39. VERTICAL PROBLEMS Skeletal vertical problems do not lend themselves to camouflage by tooth movement For Short Face Patients = Growth modification involves down and back rotation of mandible without creating anteroposterior mandibular deficiency Which is why a short face Class III problem is more treatable than a long face one Long Face pattern of growth is difficult to modify & elongating anterior teeth to close off accompanying open bite is Antithesis of camouflage Makes Facial appearance worse Orthognathic Surgery : Vertically Reposition the Maxilla Bone Anchors = Intrude Posterior Teeth ~~Hasanin alkendi~~
- 40. TREATMENT PLANNING IN SPECIAL CIRCUMSTANCES DENTAL DISEASE PROBLEMS Concern that Endodontically treated teeth cannot be moved As long as PDL is normal Endo treated teeth respond in same manner Hemisection !! In General, Prior Endo treatment does not Contraindicate Orthodontic Tooth Movement Pre Ortho Periodontal Procedures Free Gingival Grafts ~~Hasanin alkendi~~
- 41. SYSTEMIC DISEASE PROBLEMS Systemic Diseases = Greater risk for complications Successful Orthodontic Treatment = Systemic Disease under control Most common is Diabetes Mellitus (DM) Diabetes under control = Good Periodontal response to Orthodontic Force Alveolar Bone Loss !! Diabetes not controlled = Real risk of Periodontal Breakdown and Bone Loss Prolonged Orthodontic treatment should be avoided~~Hasanin alkendi~~
- 42. Juvenile Rheumatoid Arthritis (JRA) = Severe Mandibular Deficiency Adult onset Rheumatoid Arthritis destroys condylar process Reduced mandibular growth reported in cases with steroid injections into TM Joint for JRA treatment Long Term Steroid use = Periodontal Problems during Orthodontics Children on steroids also take BISPHONATES = Ortho impossible Prolonged Treatment avoided ~~Hasanin alkendi~~
- 43. Orthodontic Treatment can be carried out in PREGNANCY, but there are risks involved Gingival Hyperplasia, Hormonal Fluctuations Bone Turn Over issues = Alveolar bone loss & Root Resorption Radiographs to check status of bone = not permissible during pregnancy Treatment should be deferred until completion of pregnancy If patients becomes Pregnant during Treatment = Place her treatment in a Holding Pattern during Last Trimester ~~Hasanin alkendi~~
- 44. ANOMALIES & JAW INJURIES MAXILLARY INJURIES Fortunately, Injuries to maxilla in children are rare If displaced by Trauma = Immediately repositioned Protraction force from a face mask before Fractures have completely Healed can Reposition it ~~Hasanin alkendi~~
- 45. ASYMMETRIC MANDIBULAR DEFICIENCY In planning treatment, its important to evaluate the condyle to see if its translating properly Functional Appliance should be tried first Asymmetry with deficient growth on one side and normal on other side HYBRID FUNCTIONAL APPLIANCE Requirements will be different for both sides Restriction of condyle = reduced growth on affected side Oral & Maxillofacial Surgery = Goal ~~Hasanin alkendi~~
- 46. HEMIMANDIBULAR HYPERTROPHY Facial asymmetry can also be caused by excessive growth at one condyle Escape of growing tissues on one side from normal regulatory control Never Symmetric, Late Teens, Frequently in Girls Body of mandible affected = Bowing downward Old name = Condylar Hyperplasia Treatment = Ramal Osteotomy or Condylectomy ~~Hasanin alkendi~~