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OrthodonticOrthodontic
Treatment PlanningTreatment Planning
Clinical AssessmentClinical Assessment
Study Model AnalysisStudy Model Analysis CephalometricCephalometric AnalysisAnalysis
Patients PerceptionPatients Perception
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AETIOLOGY OF MALOCCLUSION:AETIOLOGY OF MALOCCLUSION:GENERAL AND LOCALGENERAL AND LOCAL
FACTORSFACTORS
-
interinter--relationship of factorsrelationship of factors-- genetic v environmental factorsgenetic v environmental factors
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SKELETAL FACTORS AND GROWTHSKELETAL FACTORS AND GROWTH
n SkeletalSkeletal --AA--P (1/ 2/3)P (1/ 2/3)
nn VerticalVertical (high(high -- normalnormal -- low;low;ratios v absolute measurements)ratios v absolute measurements)--
nnTransverseTransverse (relationship to A(relationship to A--P position;P position;
symmetrical and asymmetrical)symmetrical and asymmetrical)
GrowthGrowth -- (especially growth rotations,(especially growth rotations,
also effects of trauma or pathology,also effects of trauma or pathology,
drugs etc.)drugs etc.)
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SOFT TISSUE FACTORSSOFT TISSUE FACTORS
1. Muscles of mastication, muscles ofMuscles of mastication, muscles of
facial expression, zones of balance,facial expression, zones of balance,
effects of trauma / pathologyeffects of trauma / pathology
2. LipsLips -- 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. TongueTongue -- size, position, activity (incl.size, position, activity (incl.
endogenous tongue thrust)endogenous tongue thrust)
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LOCAL FACTORSLOCAL FACTORS
11. Abnormalities of. Abnormalities of
the teeththe teeth
-
-
-
2. Upper labialUpper labial
fraenumfraenum-
-
3. PathologyPathology -
tooth / tissue ratio (Bolton)tooth / tissue ratio (Bolton)
position (position (ectopicectopic / impacted, traumatic/ impacted, traumatic
displacement /displacement / dilacerationdilaceration, transposition), transposition)
form (shape, size,form (shape, size, geminationgemination, fusion), fusion)
number (congenital: absence and supernumerariesnumber (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 diastematadiastemata))
[overlaps with some of (1) above ] also: delayed[overlaps with some of (1) above ] also: delayed
eruptioneruption
of teeth, cysts,of teeth, cysts, odontomesodontomes etc , traumaetc , trauma
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MISCELLANEOUS FACTORSMISCELLANEOUS FACTORS
11.. HabitsHabits
22.. MouthbreathingMouthbreathing
-- (incl. adenoids tonsils etc.)(incl. adenoids tonsils etc.)
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Facial assessment (1)Facial assessment (1)
FrontalFrontal AA--PP
VerticalVertical TransverseTransverse
NasalNasal Cheek contourCheek contour
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Facial assessment (2)Facial assessment (2)
Lips and tooth positionLips and tooth position-- AA--PP-- VerticalVertical
(at rest and smile)(at rest and smile)
Chin projectionChin projection Chin throat lengthChin throat length
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LIP LENGTH AND INCISORLIP LENGTH AND INCISOR
EXPOSUREEXPOSURE
Lip lengthLip length
Lip activityLip activity
Maxillary positionMaxillary position
Crown lengthCrown length
Labial segment inclinationLabial segment inclination
Possibly under correct in in VMEPossibly under correct in in VME
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IDENTIFY THE DISCREPANCYIDENTIFY THE DISCREPANCY
AND TOOTH POSITIONAND TOOTH POSITION
MOLARMOLAR -- VERTICALVERTICAL-- AA--PP
INCISORINCISOR -- VERTICALVERTICAL
-- AA--PP
IN RELATION TO SKELETAL STRUCTURESIN RELATION TO SKELETAL STRUCTURESAND SOFT TISSUESAND SOFT TISSUES
THEREFORE INDIVIDUAL ARCHWIRE SEQUENCETHEREFORE INDIVIDUAL ARCHWIRE SEQUENCEAND DESIGN SPECIFIC TO THE PROBLEMAND DESIGN SPECIFIC TO THE PROBLEM
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CephalometricsCephalometrics
Evaluation of facial proportions andEvaluation of facial proportions and
aestheticsaesthetics
Evaluation ofEvaluation of SkSkand Dental Trans relationsand Dental Trans relations
Evaluation ofEvaluation of SkSkand Dental Aand Dental A--P relationsP relations
Evaluation ofEvaluation of SkSkand Dentaland Dental VertVertrelationsrelations
Growth predictionGrowth prediction
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CephalometricsCephalometrics
Review progress towards a treatmentReview progress towards a treatment
goalgoal
Age / sex / race / growth prognosis /Age / sex / race / growth prognosis /
facial typefacial type
Malocclusion typeMalocclusion type
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SPECIFIC CONSIDERATIONS INSPECIFIC CONSIDERATIONS IN
CEPHALOMETRIC ASSESSMENTCEPHALOMETRIC ASSESSMENT
CephalometricCephalometricpredictionprediction
-- Treatment effectsTreatment effects-- GrowthGrowth
-- soft tissuessoft tissues
-- occlusalocclusal
The borderline patient:The borderline patient:
possibilities and limitationspossibilities and limitations
Extraction patterns in Orthodontic preparationExtraction patterns in Orthodontic preparation
h d i
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OrthodonticOrthodontic
Treatment PlanningTreatment Planning
CephalometricCephalometricAnalysis:Analysis:
comparison to average valuescomparison to average values
comparison to graphical normscomparison to graphical norms
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Eight Methods of Analysing aEight Methods of Analysing a CephalogramCephalogram
to Establishto EstablishAnteroposteriorAnteroposteriorSkeletalSkeletalDiscrepancyDiscrepancy
Moira BrownMoira Brown
BJO 1981 8: 139BJO 1981 8: 139 -- 146146
O h d iO h d i
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OrthodonticOrthodontic
Treatment PlanningTreatment Planning
CephalometricCephalometricAnalysis:Analysis:
comparison to average valuescomparison to average values
comparison to graphical normscomparison to graphical norms
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GROWTHGROWTH
andand
GROWTH PREDICTIONGROWTH PREDICTION
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Growth evaluationGrowth evaluation
Growth SpurtGrowth Spurt
DurationDuration
AmountAmount
DirectionDirection
Age / SexAge / Sex
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BJORK ANALYSIS
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JARABAK ANALYSIS:
PFH / AFH
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BASIC ASPECTSBASIC ASPECTS OFOF
PATIENT EVALUATIONPATIENT EVALUATION
Orthodontics is extrusive and may resultOrthodontics is extrusive and may resultin a downward and backwardin a downward and backward mandibularmandibular
rotationrotation
A skeletal problem is truly camouflagedA skeletal problem is truly camouflaged
when satisfactory facial aesthetics arewhen satisfactory facial aesthetics areproduced in addition to a good occlusionproduced in addition to a good occlusion
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Orthodontic MechanicsOrthodontic Mechanics
Incisor positionIncisor position
Arch correlationArch correlation
Arch formArch form
Fixed appliance system SWA / TipFixed appliance system SWA / Tip--edgeedge Bracket prescriptionBracket prescription
MechanicsMechanics -- method of levellingmethod of levelling
-- full archfull arch
-- segmentalsegmental
-- COSCOS
-- archwirearchwire sequencesequence
S f CS f C t
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Summary of ContemporarySummary of Contemporary
Extraction GuidelinesExtraction Guidelines < 4mm rarely indicated unless incisor< 4mm rarely indicated unless incisor
protrusion or vertical discrepancyprotrusion or vertical discrepancy
55 -- 9 mm non X or X possible. Depends upon9 mm non X or X possible. Depends uponsoft tissue aesthetics and stability. Non Xsoft tissue aesthetics and stability. Non X
will require arch inter premolar expansionwill require arch inter premolar expansion
when appropriatewhen appropriate
> 10mm X indicated> 10mm X indicated
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Orthodontic CamouflageOrthodontic Camouflage
A skeletal problem is truly camouflagedA skeletal problem is truly camouflaged
when satisfactory facial aesthetics arewhen satisfactory facial aesthetics are
achieved in addition to a good occlusionachieved in addition to a good occlusion
Orthodontic treatment is extrusive inOrthodontic treatment is extrusive in
nature and may produce a downwardnature and may produce a downwardand backwardand backward mandibularmandibularrotationrotation
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THE BORDERLINE PATIENTTHE BORDERLINE PATIENT
CAMOUFLAGE OR SURGERY ?CAMOUFLAGE OR SURGERY ?
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CephalometricsCephalometrics
The Borderline Surgical Case:The Borderline Surgical Case: OJ > 10mmOJ > 10mm
Age > 12 for girls 14 for boysAge > 12 for girls 14 for boys PgPg --NperpNperp > 18mm> 18mm
MandMandbody length (Gobody length (Go--Pg)< 70mmPg)< 70mmand / or TFH >125mmand / or TFH >125mm
Di i d T t tDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanning
The DevelopmentThe Development
of aof a
Problem ListProblem List
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Orthodontic ConsiderationsOrthodontic Considerations
Incisor and molar positionIncisor and molar position -- AA--PP-- VerticalVertical-- TransverseTransverse
Treatment planTreatment plan -- X ?X ?
Arch formArch form
Bracket prescription NB 3s and 2sBracket prescription NB 3s and 2s
ArchwireArchwire sequence and levelling phasesequence and levelling phase
Continuous V. segmental mechanicsContinuous V. segmental mechanics Rectangular and round wireRectangular and round wire
Class 11 and class 111 elasticsClass 11 and class 111 elastics
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningIntroduction:Introduction:
what are the patients concerns ?what are the patients concerns ?
where do we wish to place thewhere do we wish to place the
occlusion horizontally and verticallyocclusion horizontally and verticallywithin the face ?within the face ?
what are the diagnostic features towhat are the diagnostic features toobserve to decide how best satisfyobserve to decide how best satisfythese requirements ?these requirements ?
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanning occlusionocclusion
facial soft tissue profilefacial soft tissue profile
lip morphology and activitylip morphology and activity
AA--P, vertical and transverseP, vertical and transverse SkSk
TMDTMD patients complaints and compliancepatients complaints and compliance
age and sexage and sex
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningAnteroAntero--posterior incisor position to aposterior incisor position to a
givengiven cephalometriccephalometric goal:goal:
does it produce more aestheticdoes it produce more aestheticresults than otherresults than other cephceph 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 TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanning
stability and lower incisor positionstability and lower incisor position aesthetics and incisor positionaesthetics and incisor position
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningA suggested lower incisor position (1):A suggested lower incisor position (1):
leave them where you find themleave them where you find themunless:unless:
severe class 11/1 casessevere class 11/1 cases
some class 111 casessome class 111 cases
some class 11/2 casessome class 11/2 cases
correction ofcorrection of bimaxillarybimaxillaryproclinationproclination
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningA suggested lower incisor position (2):A suggested lower incisor position (2):
leave them where you find themleave them where you find themunless:unless:
well aligned lower arch and mildwell aligned lower arch and mildcurve ofcurve of speespee
mildly crowded aches < 3mildly crowded aches < 3mmmm
deliberate anchorage compromisesdeliberate anchorage compromises
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningExtraction v. non extraction:Extraction v. non extraction:
Why the need for space ?Why the need for space ?
-- relief of crowdingrelief of crowding-- correction of incisor relationshipcorrection of incisor relationship
--provision of anchorageprovision of anchorage
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningExtraction v. non extraction:Extraction v. non extraction:
ProposedProposed diadvantagesdiadvantages ofof extracionsextracions
-- mandibularmandibulardysfunctiondysfunction-- a less attractive facial appearancea less attractive facial appearance
-- longer and more difficult treatmentlonger and more difficult treatment--pain and anxiety etc of extractionspain and anxiety etc of extractions
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanning
plan the lower arch firstplan the lower arch first
aim for minimum class 11 tractionaim for minimum class 11 traction
assess the lower arch crowding andassess the lower arch crowding andCOSCOS
the effect on available space ofthe effect on available space of
anteroantero--posterior expansion / retractionposterior expansion / retractionor transverse expansionor transverse expansion
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningAssessing the lower arch crowding:Assessing the lower arch crowding:
Mild (1Mild (1--44mmmm) = non X or 5s) = non X or 5s
Moderate (5Moderate (5--88mmmm) = 4s or 5s) = 4s or 5s
Marked ( 9+Marked ( 9+mmmm) = 4s) = 4s
caninecanine angulationangulation and target lowerand target lowerincisor position willincisor position will inluenceinluence thesethesechoiceschoices
Diagnosis and TreatmentDiagnosis and Treatment
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Diagnosis and TreatmentDiagnosis and Treatment
PlanningPlanningFactors which influence the choice ofFactors which influence the choice of
extraction in each category:extraction in each category:
at which end of range is crowdingat which end of range is crowding COSCOS
age and sexage and sex
profile and pragmatismprofile and pragmatism
crowded second and third molarscrowded second and third molars
Treatment goalsTreatment goals
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Treatment goalsTreatment goals
IntercuspalIntercuspal goalsgoals
Andrews 6 keysAndrews 6 keys
1. Correct1. Correct interarchinterarch relationshipsrelationships
2. Correct crown2. Correct crown angulationangulation (tip)(tip)3. Correct crown inclination (torque)3. Correct crown inclination (torque)
4. No rotations4. No rotations5. Tight contact points5. Tight contact points
6. Flat curve of6. Flat curve of SpeeSpee (0(0 -- 2.52.5mmmm))
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Treatment goalsTreatment goals
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Treatment goalsg
Andrews LF (1972)Andrews LF (1972)
The 6 keys to normal occlusionThe 6 keys to normal occlusion
AJO 62: 296AJO 62: 296 -- 309309
Treatment goalsTreatment goals
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ea e goa sg
IntercuspalIntercuspal goalsgoalsAndrews 6 keysAndrews 6 keys
1. Correct1. Correct interarchinterarch relationshipsrelationships
2. Correct crown2. Correct crown angulationangulation (tip)(tip)3. Correct crown inclination (torque)3. Correct crown inclination (torque)
4. No rotations4. No rotations5. Tight contact points5. Tight contact points
6. Flat curve of6. Flat curve of SpeeSpee (0(0 -- 2.52.5mmmm))
Treatment goalsTreatment goals
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gg
FunctionalFunctional OcclusalOcclusal goalsgoals Achieve a 6 keysAchieve a 6 keys intercuspalintercuspal occlusionocclusion
Choose appropriate bracketChoose appropriate bracket
prescriptionprescription
Check functional occlusion duringCheck functional occlusion duringtreatmenttreatment
ICP within 1mm of RCPICP within 1mm of RCP
Treatment goalsTreatment goals
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gg
FunctionalFunctional OcclusalOcclusal goalsgoals
ICP WITHIN 1ICP WITHIN 1MMMM OF RCPOF RCP
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