Orthodontic

Orthodontic
Treatment Planning
Treatment Planning

Clinical Assessment
Clinical Assessment

Study Model Analysis

Study Model Analysis

Cephalometric
Cephalometric
Analysis
Analysis

Patients Perception
Patients Perception
AETIOLOGY OF MALOCCLUSION:
AETIOLOGY OF MALOCCLUSION:
GENERAL AND LOCAL
GENERAL AND LOCAL
FACTORS
FACTORS
-
inter
inter
-
-
relationship of factors
relationship of factors
-
-
genetic v environmental factors
genetic v environmental factors
SKELETAL FACTORS AND GROWTH
SKELETAL FACTORS AND GROWTH
n
Skeletal
Skeletal
-
-
A
A
-
-
P (1/ 2/3)
P (1/ 2/3)
n
n
Vertical
Vertical
(high
(high
-
-
normal
normal
-
-
low;
low;
ratios v absolute measurements)
ratios v absolute measurements)
-
-
n
n
Transverse
Transverse
(relationship to A
(relationship to A
-
-
P position;
P position;
symmetrical and asymmetrical)
symmetrical and asymmetrical)

Growth
Growth
-
-
(especially growth rotations,
(especially growth rotations,
also effects of trauma or pathology,
also effects of trauma or pathology,
drugs etc.)
drugs etc.)
SOFT TISSUE FACTORS
SOFT TISSUE FACTORS
1.
Muscles of mastication, muscles of
Muscles of mastication, muscles of
facial expression, zones of balance,
facial expression, zones of balance,
effects of trauma / pathology
effects of trauma / pathology
2.
Lips
Lips
-
-
line, length, activity (competence,
line, length, activity (competence,
anterior oral seal and skeletal pattern,
anterior oral seal and skeletal pattern,
hyperactive lower lip)
hyperactive lower lip)
3.
Tongue
Tongue
-
-
size, position, activity (incl.
size, position, activity (incl.
endogenous tongue thrust)
endogenous tongue thrust)
LOCAL FACTORS
LOCAL FACTORS
1 1. Abnormalities of . Abnormalities of
the teeth the teeth
-
-
-
2. Upper labial Upper labial
fraenum fraenum
-
-
3. Pathology Pathology
-
tooth / tissue ratio (Bolton) tooth / tissue ratio (Bolton)
position ( position (ectopic ectopic / impacted, traumatic / impacted, traumatic
displacement / displacement / dilaceration dilaceration, transposition) , transposition)
form (shape, size, form (shape, size, gemination gemination, fusion) , fusion)
number (congenital: absence and supernumeraries number (congenital: absence and supernumeraries
/ supplemental teeth, extractions: deciduous / supplemental teeth, extractions: deciduous
and permanent, retained deciduous teeth) and permanent, retained deciduous teeth)
(and other causes of (and other causes of diastemata diastemata) )
[overlaps with some of (1) above ] also: delayed [overlaps with some of (1) above ] also: delayed
eruption eruption
of teeth, cysts, of teeth, cysts, odontomes odontomes etc , trauma etc , trauma
MISCELLANEOUS FACTORS
MISCELLANEOUS FACTORS
1
1
.
.
Habits
Habits
2
2
.
.
Mouthbreathing
Mouthbreathing
-
-
(incl. adenoids tonsils etc.)
(incl. adenoids tonsils etc.)
Facial assessment (1)
Facial assessment (1)

Frontal
Frontal

A
A
-
-
P
P

Vertical
Vertical

Transverse
Transverse

Nasal
Nasal

Cheek contour
Cheek contour
Facial assessment (2)
Facial assessment (2)

Lips and tooth position

Lips and tooth position
-
-
A
A
-
-
P
P
-
-
Vertical
Vertical
(at rest and smile)
(at rest and smile)

Chin projection
Chin projection

Chin throat length

Chin throat length
LIP LENGTH AND INCISOR
LIP LENGTH AND INCISOR
EXPOSURE
EXPOSURE

Lip length
Lip length

Lip activity
Lip activity

Maxillary position
Maxillary position

Crown length
Crown length

Labial segment inclination

Labial segment inclination
Possibly under correct in in VME
Possibly under correct in in VME
IDENTIFY THE DISCREPANCY
IDENTIFY THE DISCREPANCY
AND TOOTH POSITION
AND TOOTH POSITION

MOLAR
MOLAR
-
-
VERTICAL
VERTICAL
-
-
A
A
-
-
P
P

INCISOR
INCISOR
-
-
VERTICAL
VERTICAL
-
-
A
A
-
-
P
P

IN RELATION TO SKELETAL STRUCTURES

IN RELATION TO SKELETAL STRUCTURES
AND SOFT TISSUES
AND SOFT TISSUES

THEREFORE INDIVIDUAL ARCHWIRE SEQUENCE

THEREFORE INDIVIDUAL ARCHWIRE SEQUENCE
AND DESIGN SPECIFIC TO THE PROBLEM
AND DESIGN SPECIFIC TO THE PROBLEM
Cephalometrics
Cephalometrics

Evaluation of facial proportions and

Evaluation of facial proportions and
aesthetics
aesthetics

Evaluation of
Evaluation of
Sk
Sk
and Dental Trans relations
and Dental Trans relations

Evaluation of
Evaluation of
Sk
Sk
and Dental A
and Dental A
-
-
P relations
P relations

Evaluation of
Evaluation of
Sk
Sk
and Dental
and Dental
Vert
Vert
relations
relations

Growth prediction
Growth prediction
Cephalometrics
Cephalometrics

Review progress towards a treatment

Review progress towards a treatment
goal
goal

Age / sex / race / growth prognosis /

Age / sex / race / growth prognosis /
facial type
facial type

Malocclusion type
Malocclusion type
SPECIFIC CONSIDERATIONS IN
SPECIFIC CONSIDERATIONS IN
CEPHALOMETRIC ASSESSMENT
CEPHALOMETRIC ASSESSMENT

Cephalometric
Cephalometric
prediction
prediction
-
-
Treatment effects
Treatment effects
-
-
Growth
Growth
-
-
soft tissues
soft tissues
-
-
occlusal
occlusal

The borderline patient:
The borderline patient:
possibilities and limitations
possibilities and limitations

Extraction patterns in Orthodontic preparation
Extraction patterns in Orthodontic preparation
Orthodontic
Orthodontic
Treatment Planning
Treatment Planning
Cephalometric
Cephalometric
Analysis:
Analysis:

comparison to average values

comparison to average values

comparison to graphical norms

comparison to graphical norms
Eight Methods of Analysing a
Eight Methods of Analysing a
Cephalogram
Cephalogram
to Establish
to Establish
Anteroposterior
Anteroposterior
Skeletal
Skeletal
Discrepancy
Discrepancy
Moira Brown
Moira Brown
BJ O 1981 8: 139
BJ O 1981 8: 139
-
-
146
146
Orthodontic
Orthodontic
Treatment Planning
Treatment Planning
Cephalometric
Cephalometric
Analysis:
Analysis:

comparison to average values

comparison to average values

comparison to graphical norms

comparison to graphical norms
GROWTH
GROWTH
and
and
GROWTH PREDICTION
GROWTH PREDICTION
Growth evaluation
Growth evaluation

Growth Spurt
Growth Spurt

Duration
Duration

Amount
Amount

Direction
Direction

Age / Sex
Age / Sex
BJ ORK ANALYSIS
J ARABAK ANALYSIS:
PFH / AFH
BASIC ASPECTS
BASIC ASPECTS
OF
OF
PATIENT EVALUATION
PATIENT EVALUATION

Orthodontics is extrusive and may result

Orthodontics is extrusive and may result
in a downward and backward
in a downward and backward
mandibular
mandibular
rotation
rotation

A skeletal problem is truly camouflaged

A skeletal problem is truly camouflaged
when satisfactory facial aesthetics are
when satisfactory facial aesthetics are
produced in addition to a good occlusion
produced in addition to a good occlusion
Orthodontic Mechanics
Orthodontic Mechanics

Incisor position
Incisor position

Arch correlation
Arch correlation

Arch form
Arch form

Fixed appliance system SWA / Tip
Fixed appliance system SWA / Tip
-
-
edge
edge

Bracket prescription
Bracket prescription

Mechanics
Mechanics
-
-
method of levelling
method of levelling
-
-
full arch
full arch
-
-
segmental
segmental
-
-
COS
COS
-
-
archwire
archwire
sequence
sequence
Summary of Contemporary
Summary of Contemporary
Extraction Guidelines
Extraction Guidelines

< 4mm rarely indicated unless incisor
< 4mm rarely indicated unless incisor
protrusion or vertical discrepancy
protrusion or vertical discrepancy

5
5
-
-
9 mm non X or X possible. Depends upon
9 mm non X or X possible. Depends upon
soft tissue aesthetics and stability. Non X
soft tissue aesthetics and stability. Non X
will require arch inter premolar expansion
will require arch inter premolar expansion
when appropriate
when appropriate

> 10mm X indicated

> 10mm X indicated
Orthodontic Camouflage
Orthodontic Camouflage

A skeletal problem is truly camouflaged

A skeletal problem is truly camouflaged
when satisfactory facial aesthetics are
when satisfactory facial aesthetics are
achieved in addition to a good occlusion
achieved in addition to a good occlusion

Orthodontic treatment is extrusive in

Orthodontic treatment is extrusive in
nature and may produce a downward
nature and may produce a downward
and backward
and backward
mandibular
mandibular
rotation
rotation
THE BORDERLINE PATIENT
THE BORDERLINE PATIENT
CAMOUFLAGE OR SURGERY ?
CAMOUFLAGE OR SURGERY ?
Cephalometrics
Cephalometrics
The Borderline Surgical Case:
The Borderline Surgical Case:

OJ > 10mm
OJ > 10mm

Age > 12 for girls 14 for boys

Age > 12 for girls 14 for boys

Pg
Pg
-
-
Nperp
Nperp
> 18mm
> 18mm

Mand
Mand
body length (Go
body length (Go
-
-
Pg)< 70mm
Pg)< 70mm
and / or TFH >125mm
and / or TFH >125mm
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
The Development
The Development
of a
of a
Problem List
Problem List
Orthodontic Considerations
Orthodontic Considerations

Incisor and molar position
Incisor and molar position
-
-
A
A
-
-
P
P
-
-
Vertical
Vertical
-
-
Transverse
Transverse

Treatment plan
Treatment plan
-
-
X ?
X ?

Arch form
Arch form

Bracket prescription NB 3s and 2s
Bracket prescription NB 3s and 2s

Archwire
Archwire
sequence and levelling phase
sequence and levelling phase

Continuous V. segmental mechanics
Continuous V. segmental mechanics

Rectangular and round wire
Rectangular and round wire

Class 11 and class 111 elastics
Class 11 and class 111 elastics
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
Introduction:
Introduction:

what are the patients concerns ?

what are the patients concerns ?

where do we wish to place the

where do we wish to place the
occlusion horizontally and vertically
occlusion horizontally and vertically
within the face ?
within the face ?

what are the diagnostic features to

what are the diagnostic features to
observe to decide how best satisfy
observe to decide how best satisfy
these requirements ?
these requirements ?
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning

occlusion
occlusion

facial soft tissue profile

facial soft tissue profile

lip morphology and activity

lip morphology and activity

A
A
-
-
P, vertical and transverse
P, vertical and transverse
Sk
Sk

TMD
TMD

patients complaints and compliance

patients complaints and compliance

age and sex

age and sex
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
Antero
Antero
-
-
posterior incisor position to a
posterior incisor position to a
given
given
cephalometric
cephalometric
goal:
goal:

does it produce more aesthetic

does it produce more aesthetic
results than other
results than other
ceph
ceph
analyses ?
analyses ?

are the results more stable ?

are the results more stable ?

can the position be achieved ?

can the position be achieved ?

is it quick easy and accurate to use ?

is it quick easy and accurate to use ?
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning

stability and lower incisor position

stability and lower incisor position

aesthetics and incisor position

aesthetics and incisor position
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
A suggested lower incisor position (1):
A suggested lower incisor position (1):
leave them where you find them
leave them where you find them
unless:
unless:

severe class 11/1 cases

severe class 11/1 cases

some class 111 cases

some class 111 cases

some class 11/2 cases

some class 11/2 cases

correction of
correction of
bimaxillary
bimaxillary
proclination
proclination
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
A suggested lower incisor position (2):
A suggested lower incisor position (2):
leave them where you find them
leave them where you find them
unless:
unless:

well aligned lower arch and mild

well aligned lower arch and mild
curve of
curve of
spee
spee

mildly crowded aches < 3

mildly crowded aches < 3mm mm

deliberate anchorage compromises

deliberate anchorage compromises
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
Extraction v. non extraction:
Extraction v. non extraction:

Why the need for space ?

Why the need for space ?
-
-
relief of crowding
relief of crowding
-
-
correction of incisor relationship
correction of incisor relationship
-
-
provision of anchorage
provision of anchorage
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
Extraction v. non extraction:
Extraction v. non extraction:

Proposed
Proposed
diadvantages
diadvantages
of
of
extracions
extracions
-
-
mandibular
mandibular
dysfunction
dysfunction
-
-
a less attractive facial appearance
a less attractive facial appearance
-
-
longer and more difficult treatment
longer and more difficult treatment
-
-
pain and anxiety etc of extractions
pain and anxiety etc of extractions
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning

plan the lower arch first

plan the lower arch first

aim for minimum class 11 traction

aim for minimum class 11 traction

assess the lower arch crowding and

assess the lower arch crowding and
COS
COS

the effect on available space of

the effect on available space of
antero
antero
-
-
posterior expansion / retraction
posterior expansion / retraction
or transverse expansion
or transverse expansion
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
Assessing the lower arch crowding:
Assessing the lower arch crowding:

Mild (1
Mild (1
-
-
4
4
mm
mm
) = non X or 5s
) = non X or 5s

Moderate (5
Moderate (5
-
-
8
8
mm
mm
) = 4s or 5s
) = 4s or 5s

Marked ( 9+
Marked ( 9+
mm
mm
) = 4s
) = 4s

canine
canine
angulation
angulation
and target lower
and target lower
incisor position will
incisor position will
inluence
inluence
these
these
choices
choices
Diagnosis and Treatment
Diagnosis and Treatment
Planning
Planning
Factors which influence the choice of
Factors which influence the choice of
extraction in each category:
extraction in each category:

at which end of range is crowding

at which end of range is crowding

COS
COS

age and sex

age and sex

profile and pragmatism

profile and pragmatism

crowded second and third molars

crowded second and third molars
Treatment goals
Treatment goals
Intercuspal
Intercuspal
goals
goals
Andrews 6 keys
Andrews 6 keys
1. Correct
1. Correct
interarch
interarch
relationships
relationships
2. Correct crown
2. Correct crown
angulation
angulation
(tip)
(tip)
3. Correct crown inclination (torque)
3. Correct crown inclination (torque)
4. No rotations
4. No rotations
5. Tight contact points
5. Tight contact points
6. Flat curve of
6. Flat curve of
Spee
Spee
(0
(0
-
-
2.5
2.5mm mm
)
)
Treatment goals
Treatment goals
Functional
Functional
Occlusal
Occlusal
goals
goals

Correct
Correct
condylar
condylar
position
position

Correct disk position

Correct disk position
Treatment goals
Treatment goals
Andrews LF (1972)
Andrews LF (1972)
The 6 keys to normal occlusion
The 6 keys to normal occlusion
AJO 62: 296
AJO 62: 296
-
-
309
309
Treatment goals
Treatment goals
Intercuspal
Intercuspal
goals
goals
Andrews 6 keys
Andrews 6 keys
1. Correct
1. Correct
interarch
interarch
relationships
relationships
2. Correct crown
2. Correct crown
angulation
angulation
(tip)
(tip)
3. Correct crown inclination (torque)
3. Correct crown inclination (torque)
4. No rotations
4. No rotations
5. Tight contact points
5. Tight contact points
6. Flat curve of
6. Flat curve of
Spee
Spee
(0
(0
-
-
2.5
2.5mm mm
)
)
Treatment goals
Treatment goals
Functional
Functional
Occlusal
Occlusal
goals
goals

Achieve a 6 keys
Achieve a 6 keys
intercuspal
intercuspal
occlusion
occlusion

Choose appropriate bracket

Choose appropriate bracket
prescription
prescription

Check functional occlusion during

Check functional occlusion during
treatment
treatment

ICP within 1mm of RCP

ICP within 1mm of RCP
Treatment goals
Treatment goals
Functional
Functional
Occlusal
Occlusal
goals
goals
ICP WITHIN 1
ICP WITHIN 1MM MM
OF RCP
OF RCP