partonetheroyallondonspaceplanning-200120170455.pptx

SPACE ANALYSIS

1. The Royal London Space Planning: An integration of space analysis and treatment planning Robert H. Kirschen et. al. بسم الله الرحمن الرحيم Mohanad Elsherif BDS (U of K), MFD RCSI, MFDS RCPS( Glasg ), MSc (Orthodontics), M.Orth . RCSEd University of Khartoum Faculty of Dentistry Department of Orthodontics

2. Importance of space in Ortho

3. Why do we need space? Correction of crowding. Retraction of proclined teeth. Reduction of increased overjet and over bite. Leveling of steep curve of S pee . Derotaion of anterior teeth. Correction of unstable molar relations (i.e. Cl II and Cl III molar relations ).

4. Introduction The Royal London Space Planning has evolved since 1985 as part of the postgraduate training program at the Royal London Hospital. The purpose of the Royal London Space Planning is to quantify the space required in each dental arch to attain the treatment objectives in the permanent or late mixed dentition and to quantify the space implications of treatment mechanics .

5. introduction Specifically, the Royal London Space Planning will help the clinician: To ensure a disciplined approach to treatment planning. To define whether the objectives are attainable and modify them if necessary. To anticipate a shortage of anchorage or excess of space. To decide the need for extractions and choice of extractions. To plan the mechanics of anchorage control. To plan the mechanics of correction of arch relationship. To improve pretreatment patient information. To obtain valid informed consent.

6. Assessment of Space Requirement Six specific aspects of the occlusion are considered for which any change has an effect on the space required. These are: Crowding and Spacing. Leveling Occlusal Curves. Arch Expansion and Contraction. Incisor A/P Change. Angulation ( Mesiodistal Tip). Inclination (Torque).

7. Assessment of Space Requirement The measurements are taken and scores recorded to the nearest millimeter or, at times, half millimeter . The measurements are positive when space is present or is created ( eg , by arch expansion) and negative when there is crowding or space is required (e.g. for incisor retraction).

8. Assessment of Space Requirement 1. Crowding and Spacing: The difficulty when quantifying crowding is to decide “ in relation to what .” Clearly, crowding will be quantified as less severe if the archform selected passes through the most prominent incisor and buccally displaced canine , and more severe if it passes through lingually displaced teeth .

9. Assessment of Space Requirement 1. Crowding and Spacing: Crowding and spacing should be quantified in relation to the archform that reflects the majority of teeth , not necessarily the imaginary arch that passes through the incisal edge of the most prominent central incisor in each arch. The line of arch selected does not necessarily represent a treatment objective , as a separate assessment is made for arch width and for the anteroposterior position of the labial segments.

10. Assessment of Space Requirement The method recommended for assessment is to use a clear ruler over the occlusal or labial surface of study models to measure the mesiodistal width of misaligned teeth and available space in the archform selected.

11. Assessment of Space Requirement This technique has been found to be preferable to using calipers to measure all the teeth and a brass wire to assess arch length; that method is less reliable, probably because of cumulative error or bias that arises from the need to measure every tooth rather than just the misaligned ones. The assessment of crowding of 2 adjacent teeth can be undertaken together by measuring the mesiodistal width of each tooth and the combined space available. This method is not recommended for 3 or more teeth as the difference between chord and arc becomes significant.

12. Assessment of Space Requirement Crowding and spacing are assessed anterior to the mesial surface of the first molars . The permanent teeth are considered as they present, regardless of size . When the second primary molars are present, up to 1 mm spacing is allowed for upper E space (the size difference between primary and permanent tooth) and up to 2 mm for lower E space . What If the patient is at an earlier stage in the mixed dentition? Estimations of the size of the permanent unerupted teeth can be made with the aid of radiographs, proportionality tables, or both.

13. Assessment of Space Requirement 2. Leveling Occlusal Curves Space is required to level a curve of Spee , but accurately quantifying this space is very difficult. It is incorrect to assume that the process is equivalent to the 2-dimensional straightening of a curved line, or that the space required is the difference between an arc of a circle and its chord. An increased occlusal curve is due to a series of slipped contact points in the vertical dimension. it is the restoration of the contact point relationships between neighboring teeth that demands increased space within the dental arch. This slippage is usually too slight at any one contact point to be recorded as a form of crowding, but when an arch is taken overall, space is required for leveling. If teeth were parallel-sided (cylindrical), no space would be required when leveling an occlusal curve. Where the teeth are bulbous, the space implications are greater .

14. Assessment of Space Requirement The Royal London Space Planning assesses occlusal curves in relation to a plane from the distal cusps of the first molars to the incisal edges. Two other considerations are relevant: First, the space implication should be recorded only if the premolars have not been assessed as crowded; it would be another example of double counting for premolars to be assessed both as crowded and as needing space from leveling the occlusal curve. Second, clinical judgment is necessary as occlusal curves need not be leveled in all cases. Assess the depth of curve from premolar cusps to a flat plane on distal cusps of first molars and incisors. Only one value is given for the arch, and only if the premolars have not been assessed separately as crowded. Allow 1 mm space for 3 mm depth of curve, 1.5 mm for 4 mm depth, and 2 mm space for a 5 mm curve.

15. Assessment of Space Requirement 3. Arch Expansion and Contraction It seems logical there should be a direct one-to-one relationship between arch expansion and the creation of space. For the purpose of space planning, each millimeter expansion of the intermolar width will create approximately 0.5 mm space within the arch. The space created may be greater when overall arch expansion is achieved by splitting the palatal suture. The buccal or lingual movement of an individual tooth does not constitute a change in arch width, as this would be assessed in the analysis of crowding .

16. Assessment of Space Requirement 4. Incisor A/P Change It may be desirable to alter the anteroposterior position of the lower incisors, in either direction, depending on the specifics of the malocclusion as assessed clinically and cephalometrically . The upper incisors are then corrected in the analysis to an overjet of 2 to 3 mm in relation to the position selected for the lower incisors. It is essential that the incisors selected for the measurement of overjet and cephalometric tracing correspond to those used to define the archform in relation to which crowding and spacing are assessed. For the purpose of space planning, each millimeter of incisor advancement or retraction will create or consume 2 mm of space within the dental arch.

17. Assessment of Space Requirement 5. Angulation ( Mesiodistal Tip): If upper incisors are too vertical , they take up less space in the arch than if correctly angulated . Very occasionally, teeth are over angulated, and space is gained by correction to normal angulation. Applies only to maxillary incisors. Allow 0.5 mm space for correction of each parallel sided vertical tooth (usually no allowance is necessary).

18. Assessment of Space Requirement 6. Inclination (Torque) Andrews pointed out the importance of the inclination of upper incisors if they are to occupy the correct amount of space, and that failure in this respect would lead either to incorrect buccal occlusion or to spacing. Correct inclination is also important to ensure optimum esthetics. Applies only to maxillary incisors. Allow 1 mm space for every 5° change affecting all 4 incisors, and 0.5 mm space if only 2 teeth are affected.

19. Integration of space requirement component Among the 6 factors considered, only crowding and spacing , arch width change , and incisor anteroposterior change can have substantial space implications. The other factors—occlusal curves, angulation, and inclination of teeth—are associated with only small amounts of space. The difference in the total space required for the upper and lower arches requires clarification: Class I molars are associated with a space requirement that is equal in both upper and lower arches, unless there is a disproportion in the size or number of teeth between the arches ( eg , small or absent maxillary lateral incisors). Assuming 7 mm premolars, bilateral full unit Class II occlusions are associated with an upper space requirement 14 mm greater (more negative) than the lower; a 7 mm discrepancy would imply one half unit Class II molars.

20. Exercise One A 13 years old female patient with a chief complain of sticking-out upper front teeth. Clinically she presented with a class II Div 1 malocclusion on a class II skeletal base and average lower vertical facial proportion. Her malocclusion was complicated by: Moderate upper arch crowding (-7 mm) Mild lower arch crowding (-3 mm) Increased overjet (6 mm) Proclined upper inciosrs (UIMP = 120) Increased lower curve of spee (4 mm)

21. Exercise Two A 15 years old male patient with a chief complain of crooked upper front teeth. Clinically he presented with a class II Div 2 malocclusion on a mild class II skeletal base and decreased lower vertical facial proportion. His malocclusion was complicated by: Upper arch crowding (-8 mm) Palataly displaced upper lateral incisors and are in crossbite Mild lower arch crowding (-3 mm) Overjet (3 mm) Bilateral Scissor bite (4 mm wider maxilla) Retroclined upper incisors (UIMP = 95)

22. Exercise Three A 14 years old female patient with a chief complain of Front to back bite. Clinically she presented with a class III malocclusion on a class I skeletal base and average lower vertical facial proportion. Her malocclusion was complicated by: Moderate upper arch crowding (-5 mm) Lower arch spacing (2 mm) Reversed overjet (-1 mm) Unilateral posterior corssbite ( maxilla in narrow by 3 mm) Proclined upper incisors (UIMP = 130) Mesially angulated upper central incisors (10°) {normal value is 4°}

23. Declaration The author wish to declare that; these presentations are his original work, all materials and pictures collection, typing and slide design has been done by the author. Most of these materials has been done for undergraduate students, although postgraduate students may find some useful basic and advanced information. The universities title at the front page indicate where the lecture was first presented. The author was working as a lecturer of orthodontics at Ibn Sina University, Sudan International University, and as a Master student in Orthodontics at University of Khartoum. The author declare that all materials and photos in these presentations has been collected from different textbooks, papers and online websites. These pictures are presented here for education and demonstration purposes only. The author are not attempting to plagiarize or reproduced unauthorized material, and the intellectual properties of these photos belong to their original authors.

24. Declaration As the authors reviews several textbooks, papers and other references during preparation of these materials, it was impossible to cite every textbook and journal article, the main textbooks that has been reviewed during preparation of these presentations were: Contemporary Orthodontics 5 th edition; Proffit , William R, Henry W. Fields, and David M. Sarver. Handbook of Orthodontics. 1 st edition; Cobourne , Martyn T, and Andrew T. DiBiase . Clinical cases in orthodontics; Martyn T. Cobourne , Padhraig S. Fleming, Andrew T. DiBiase , Sofia Ahmad Essentials of orthodontics: Diagnosis and Treatment; Robert N. Staley, Neil T. Reske Orthodontics: Current Principles & Techniques 5 th edition; Graber, Lee W, Robert L. Vanarsdall , and Katherine W. L. Vig Evidence based Orthodontics; Greg J. Huang, Stephen Richmond, Katherine W.L. Vig .

25. Declaration For the purposes of dissemination and sharing of knowledge, these lectures were given to several colleagues and students. It were also uploaded to SlideShare website by the author. Colleagues and students may download, use, and modify these materials as they see fit for non-profit purposes. The author retain the copyright of the original work. The author wish to thank his family, teachers, colleagues and students for their love and support throughout his career. I also wish to express my sincere gratitude to all orthodontic pillars for their tremendous contribution to our specialty. Finally, the author welcome any advices and enquires through his email address: [email protected]

26. Thank You