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  • ORTHODONTIC TREATMENT PLANNING :

    PROBLEM LIST TO SPECIFIC PLAN

    DR M KARANDISH

    WITH REVISES FROM: DR. ALI WAQAR HASAN

    FCPS – II RESIDENT IN ORTHODONTICS

    UCMD UOL

  • In the name of Allah

    • The Compassionate

    • The Merciful

  • اھداف درس  آشنایی با اصول کلی طراحی درمان در بیمارانCl I malocclusion  آشنایی با اصول کلی طراحی درمان در بیمارانCl II malocclusion  آشنایی با اصول کلی طراحی درمان در بیمارانCl III malocclusion  آشنایی با اصول کلی طراحی درمان در بیمارانAsymmetry آشنایی با اصول کلی طراحی درمان در بیماران خاص

    :منبع 17کتاب ملی فصل

  • For the slide presentation you can visit:

    www.drkarandish.ir

  • 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” !!!!

  • 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

  • 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

  •  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

  • 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

  • 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

  •  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

  •  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

  •  Soft Tissue Limitation

     Fenestration of Alveolar Bone & Stripping of Gingiva

     Amount of Attached Gingiva = Critical Variable

     Pre-treatment with Periodontist

  • 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

  •  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

  •  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

  •  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

  •  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

  • 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

  • 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

  •  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

  • 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

  • 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 Mont

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