General orthodontics treatment plan from A-Z

how and when to treat ortho cases

1. Treatment Planning 1

2. Treatment Planning In order to formulate an appropriate treatment plan the clinician needs to be competent in history taking , examination of the patient and collection of appropriate records K n o w l e d g e 2

3. General objectives of orthodontic treatment Aesthetics (facially and dentally;) Dental health Function Stability 3

4. 4

5. Orthodontic Problem The patient's concerns Facial and smile aesthetics Alignment and symmetry within each arch Skeletal and dental relationships in the transverse, anteroposterior and vertical planes 5

6. The patient's concerns The patient's role in orthodontic treatment success is vital. The following areas need to be considered: Patient's concerns Patient's expectations (realistic ; unrealistic) Patient motivation (active participation and co-operation) 6

7. Facial and smile aesthetics Affected by personal and cultural factors and also by fashions and trends 7

8. A normal smile should show the following : The whole height of the upper incisors, with only the interproximal gingivae visible The upper incisors do not touch the lower lip The upper incisor edges run parallel to the lower lip The width of the smile displays at least the upper 1 st premolars 8

9. Turning the problem list into a definitive treatment plan. 9

10. Skeletal Problems and Treatment Planning Three Options for Treating Skeletal Malocclusions Orthodontic camouflage Growth modification Combined orthodontic and surgical approach 10

11. Orthodontic Camouflage Means that the skeletal discrepancy is accepted, but the teeth are moved into a Class I relationship. 11

12. Growth Modification Also known as dentofacial orthopaedics Only possible in growing patients. 12

13. Combined Orthodontic and Orthognathic Surgical Treatment Patients who are fully grown. Indicated for patients with severe skeletal,or very severe dento -alveolar problems. 13

14. Basic Principles In Orthodontic Treatment Planning Oral Health Before Establish and maintain good oral health. Fully treat all active disease After Definitive restorations, such as crowns and bridges 14

15. The Lower Arch It is advisable to maintain the current position of the lower labial segment  the lower labial segment is positioned in an area of relative stability between the tongue lingually , and the lips and cheeks labially and buccally . Any excessive movement of the lower labial segment would increase the risk of relapse 15

16. Some examples of when the lower incisors may be proclined. Very mild lower incisor crowding Treatment of Deep overbites A digit-sucking habit The lower incisors can also be retroclined Camouflage Class Ill malocclusion, III Bimaxillary dental proclination 16

17. The upper arch Once the lower arch has been planned, the upper arch position can be planned in order to obtain a Class I incisor relationship. 17

18. Buccal segments Although the aim is usually to obtain a Class I canine and molar relationship, it is not necessary to always have a Class I molar relationship. 18

19. Anchorage Anchorage planning is about resisting unwanted tooth movement it is therefore important to decide how to limit the movement of teeth that do not need to move 19

20. Retention At the end of orthodontic treatment almost every case needs to be retained to prevent relapse back towards the original malocclusion 20

21. Space analysis Space analysis is a process that allows an estimation of the space required in each arch to fulfill the treatment aims 21

22. Space is required to correct the following Crowding Incisor anteroposterior change (usually obtaining a normal overjet of 2 mm) Levelling of occlusal curves Arch contraction Correction of upper incisor angulation ( mesiodistal tip) Correction of upper incisor inclination (torque) Correction of molar relationship Derotation of anterior teeth 22

23. Crowding The amount of crowding present is often classified as: Mild (<4 mm) Moderate (4-8 mm) Severe (>8 mm) 23

24. Incisor anteroposterior change Every millimetre of incisor retraction requires 2 mm of space in the dental arch. Every millimetre of incisor proclination 2 mm of space are created in the arch. 24

25. levelling occlusal curves The depth of curve is assessed from the premolar cusps to a flat plane joining the distal cusps of first permanent molars and incisors 25

26. Methods of gaining space Space can be created by one or more of the following: Extractions Distal movement of molars Enamel stripping Expansion Proclination of incisors Uprighting of tilted teeth Derotation of posterior teeth A combination of any or all of the above 26

27. Extractions The following are factors which affect the choice of teeth for extraction: Prognosis Position Amount of space required and where Incisor relationship Anchorage requirements Appliances to be used . Patient's profile and aims of treatment 27

28. Incisors Extraction Rare due to the risk of compromising aesthetics. Indications of lower incisor Incisor has poor prognosis Buccal segments are Class I. but there is lower incisor crowding Adult patient who has a mild Class III skeletal pattern with well aligned buccal segments 28

29. Canines Canines form the cornerstone of the arch and are important both aesthetically and functionally . Indications severely displaced or ectopic. 29

30. First premolars often the teeth of choice to extract when the space requirement is moderate to severe. 30

31. Second premolars Extraction Indications Mild to moderate space requirement (3-8 mm space required) Space closure by forward movement of the molars. rather than retraction of the labial segments is indicated Severe displacement of the second premolar 31

32. First permanent molars Extraction Makes orthodontic treatment more difficult and prolonged. Indication badly decayed 1 st molar 32

33. Second permanent molars Extraction Indications Facilitation of distal movement of upper buccal segments Relief of mild lower premolar crowding Provision of additional space for the third permanent molars, thus avoiding the likelihood of their impaction (no guarantee) 33

34. Third permanent molars Extraction In the past,early extraction of these teeth has been advocated to prevent lower labial segment crowding. However. it is much more likely that late lower incisor crowding is caused by late mandibular growth. 34

35. Distal movement of molars Can be achieved with headgear or use of implants Produce up to 2-3 mm per side Used when there is a mild space requirement or in addition to extractions when there is a very high space requirement. 35

36. Headgear 36

37. Enamel stripping Enamel interproximal stri pping is the removal of a small amount of enamel on the mesial and distal aspect of teeth and is sometimes known as reproximation . On the anterior teeth approximately 0.5 mm can be removed on each tooth (0.25 mm mesial and distal) without compromising the health of the teeth. Enamel can be carefully removed with an abrasive strip The teeth are treated topically with fluoride following reduction of the enamel . 37

38. Expansion Every 1 mm of posterior arch expansion create approximately 0.5 mm. Any significant expansion in the lower arch, particularly the lower intercanine width, is likely to be unstable 38

39. Proclination of Incisors Each millimetre of incisor advancement creates approximately 2 mm of space within the dental arch 39