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ORTHODONTIC TREATMENT PLANNING : PROBLEM LIST TO SPECIFIC PLAN DR. ALI WAQAR HASAN FCPS – II RESIDENT IN ORTHODONTICS UCMD UOL

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Page 1: Orthodontic treatment planning

ORTHODONTIC TREATMENT PLANNING :

PROBLEM LIST TO SPECIFIC PLAN

DR. ALI WAQAR HASANFCPS – II RESIDENT IN ORTHODONTICS

UCMD UOL

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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

“Do not jump to conclusions” !!!!

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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

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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

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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

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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

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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

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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

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One approach to Upper Arch Expansion is by Opening the Midpalatal Suture, 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

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Soft Tissue Limitation

Fenestration of Alveolar Bone & Stripping of Gingiva

Amount of Attached Gingiva = Critical Variable

Pre-treatment with Periodontist

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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

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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

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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

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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

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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

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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 ? How advantageous it is to start treatment before Adolescence?

Data from Randomized Clinical Trials for Class II Treatment outcomes are available

Skeletal Problems in other Planes of Space remain Controversial

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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

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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

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In Adolescents, Expansion across the Suture can be done in 3 ways :

I. RAPID EXPANSION with jackscrew attached to Posterior Maxillary Teeth, at rate of 0.5 to 1 mm/day

II. SLOW EXPANSION with same Device at rate of 1 mm per week

III. EXPANSION with a Device attached to Bone Screws or Implants

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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

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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

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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

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CAMOUFLAGE BY TOOTH MOVEMENT

Tooth Movement alone cannot correct Skeletal Malocclusion

If malocclusion is corrected and Facial Appearance is acceptable then treatment outcome can be satisfactory, this is called ORTHODONTIC CAMOUFLAGE

Camouflage : Dental Occlusion + Facial Appearance

Camouflage means that Jaw Discrepancy is no longer apparent

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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

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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

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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 ?

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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

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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

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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 )

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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