29/10/2014

GENERAL PRINCIPLES Of
ORTHODONTIC TREATMENT PLANNING
OF DENTAL& SKELETAL
MALOCCLUSION:
Timing of Orthodontic Treatment

DR. GYAN P.SINGH

Associate Professor
Department of Orthodontics & Dentofacial Orthopaedics
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 CONTENTS
 INTRODUCTION
 EVOLUTION OF TREATMENT PLANNING
 PRINCIPLES OF TREATMENT PLANNING
 ORTHODONTIC TRIAGE
 GROWTH MODULATION
 DENTAL CAMOUFLAGE
 MCQ

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 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.

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 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

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 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
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PROBLEM ORIENTED APPROACH

In this approach, diagnosis and Treatment

planning are carried out in a series of
logical steps:-

1. Development of an adequate diagnostic

database.

2. Formulation of problem list which is the

diagnosis from the database. 6
 Treatment planning

3. Prioritization of the items on the

orthodontic problem list, so that most
important problem receives highest priority
for treatment.

4. Consideration of possible solutions to

each problem list, to the individual
problems.

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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.

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 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 Periodontal surgeries and

including cast restorations maintenance therapy 9
 Treatment Planning
• Treatment planning can 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.
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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.
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 Patient’s goals and desires
 Jackson’s triad

1. Esthetic harmony

2. Functional efficiency

3. Structural balance

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 ORTHODONTIC TRIAGE
This process was used in military and emergency
medicine.

Triage was used to separate causalities by the

severity of their injuries.

Medicine
Dentistry
Orthodontics
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 ROLE OF TRIAGE IN DENTISTRY
 The process to distinguish moderate from severe
problems.

 Patients are appropriately treated in General

dental practice

 or the most appropriately referred to a specialist

( Orthodontist).

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 STEPS IN ORTHODONTIC TRIAGE

1. Syndromes and developmental abnormalities

2. Facial disproportions and asymmetries

3. Antero-posterior and vertical problems

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4.Excessive dental protrusion or retrusion

5.Problems involving dental development

6.Problems involving crowding &malalignment

7.Other tooth displacements

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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

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 Timing of Orthodontic Treatment

 Can be carried out at any time.

 Comprehensive treatments -in adolescence as

soon as the second molar erupts.

A. Understand the importance of the treatment

B. Self-motivated
C. Cooperate during appointments
D. Care the appliance and oral hygiene
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 TIMINGS OF THE TREATMENT
AGE TREATMENT RECOMMENDED

Primary and Mixed dentition stage Preventive and interceptive

procedures

Preadolescent patients in mixed Growth modulation procedures

dentition

Young adolescent patients Comprehensive therapy with or

without Camouflage

Adult patients Orthognathic surgeries

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TREATMENT PLANNING IN LATE MIXED
AND EARLY PERMANENT DENTITION
 Alignment Problems

 Transverse Problems

 Antero Posterior Problems

 Vertical Problems

 Eruption problems
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 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 21
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.

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

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 Radiographs (Pre-treatment)

Orthopantomogram

PA Cephalogram

Upper Occlusogram
Lateral Cephalogram 24
 Problem list
• Mesial Step. Etiology
•Cross-bite of the anteriors. Genetic{father has
midface deficiency}
Diagnosis-Developing Angle’s Class III malocclusion
Treatment Plan
{Tandem Appliance( Klempner ,JCO/JUNE
2011)}
(1.)Upper fixed maxillary component.

(2.) Lower fixed component with bite plane.

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(3.)Face bow and Elastics as a removable
 Midface Deficiency

Father Son

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Fabrication of Modified Tandem appliance[Klempner,1999

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Installation
of the
Appliance

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Delaire Petit Tandem

Less bulky, more esthetic and patient friendly

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Protraction of Maxillary Segment

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Correction of Cross-bite{ Harmonious Growth Of Maxilla}

Initial After 1 month After 2 months

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 Pre-Treatment

Facial
Appearance
Of the
Patient

Stage after 3 months.....contd.

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 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.

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 Class II malocclusion
A class II malocclusion can be because of:

1. A prognathic maxilla ( maxillary excess)

2. A retrognathic mandible

3. A combination of both

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

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

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 Enmasse
Retraction of
Upper and
Lower Anterior
Teeth {Preformed T.P.A.=Molar stabilization}

K-Sir Retraction
Spring

NiTi Retraction spring

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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

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P O S T _ T R E A T M E N T
 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
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 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.

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 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.
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MCQ:
1.TRIAGE is the process of
(A) Taking impression in three stages
(B) Planning anchorage
(C) A dental compromise of the skeletal problems
(D) None of the above

2. Camouflage is
(A) A dental compromise of the skeletal problems
(B) Consideration of extraction
(C) Planning anchorage
(D) Disscussion on the records of the patient.

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3.Jackson’s triad is comprises of all except.
(A) Esthetic
(B) Molar relationship
(C) Functional efficiency
(D) Structural balance

4. The commonest tooth is extracted for Orthodontic purpose

(A) Incisor
(B) Molar
(C) Premolar
(D) Canine

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5.Serial extraction procedure should be the best done during
(A) Primary dentition
(B) Mixed dentition
(C)Young adolescent
(D)Adult

6. All the matching statement is true except

(A) Interceptive and preventive procedures-Primary and early
mixed dentition
(B) Growth modification-Mixed or early permanent dentition
(C) Camouflage-Neonatal stage
(D) Orthognathic surgeries-Adult patient

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7.Space is required in Orthodontic management except
(A) Decrowding
(B) Overjet reduction
(C) Derotation of anterior teeth
(D) Derotation of posterior teeth

8. The more complex Orthodontic cases would bereffered to specialist

except
(A) Skeletal posterior cross-bite
(B) Anterior complex open bite
(C) Midline diastemas of more than 2 mm after permanent canine eruption
(D) Midline diastemas of less than 2 mm after permanent canine eruption

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9. Logical steps of diagnosis and treatment planning are comprises
of all except
(A) Treatment objectives and possible solutions
(B) Interview,clinical examination and diagnostic records
(C) Patient-parents consultation
(D) Patient should not be given any role in decision making process

10. Serial extraction procedure involves removal of teeth except

(A) First permanent premolar
(B) Primary first molar
(C) Primary canine
(D) Permanent canine
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 REFERENCES

1. Graber TM:Principles and Practicce Orthodontics,WB

Saunders,1988
2. Profitt.Contemporary Orthodontics,Elsevier India.3rd
ed.,2000
3. E Moyers.handbook of Orthodontics,4th ed. Year Book
Medical publishers,inc.,1988

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