diagnosis & treatment planning

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Diagnosis & Diagnosis & Treatment PlanningTreatment Planning

Dr. KAPIL SAROHABDS, MDS

Orthodontics and dentofacial orthopaedics

www.drdentiste.comMonday, May 1, 2023

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“The first step towards cure is to know what the

disease is......”www.drdentiste.com

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A century ago EDWARD. H. ANGLE rightly said:“In studying a case of malocclusion, give no

thought to the – methods of treatment or appliances

until the case shall be classified with all peculiarities and variations from the normal in – type, occlusion and – facial lines that have been

thoroughly comprehended. Then the requirements and proper plan of

treatment become apparent”. www.drdentiste.com

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Human head is the most most complicatedcomplicated anatomical complex in all creation.

The interrelationships are infinite and the causes and effects of these relationships are almost imponderable.

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A thorough understanding of the normal variations in the – Growth and development of

dentofacial structures,– Their anatomical fit into each other

and – Their reaction to intrinsic and

extrinsic factors /stimuli (genetic and environmental) itself is

Orthodontic diagnosis.

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Problem Oriented Problem Oriented &&

Evidence Based DiagnosisEvidence Based Diagnosis


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The goal of the diagnostic process is to produce a complete description of the patient’s problems and make a problem list.

To obtain the problem list, a collection of relevant information is required. This collection is called a database.

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Mechano-Mechano-therapytherapy

Diagnosis & Treatment Planning - StepsPatient History

Clinical Examination

Analysis of Diagnostic Records

Classification Problem List = Diagnosis

Treat pathology(caries, gingivitis etc.)

Problems in

priorityorder

ABCD

Possiblesolution toindividualproblems

Optimal Optimal Treatment Treatment

PlanPlan

DataBase

ABCD

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Patient history, & Patient history, & interview datainterview data1. Family history2. Motivation of patient for treatment

Internal External

3. Reasons for taking treatment Functional Hygiene Esthetics Speech

4. Pubertal status5. Prenatal History

1. Health of mother during pregnancy Diseases : Bacterial / Viral Medication Radiation Trauma

Clinical Examination:Clinical Examination:1. General examination2. Extraoral

• Head shape• Frontal symmetry• Profile convexity• Facial divergent• Lip competency• Incisor visibility,

3. Functional • Mastication • Deglutition• Speech• TMJ

4. Intraoral• Hard tissues• Soft tissues

Analysis of Analysis of diagnostic records:diagnostic records:

1. Study Models • Upper• Lower

2. Radiographs • Lateral Ceph.• OPG• A-P Ceph.• IOPA• Hand Wrist• Occlusal

3. Photographs • Extra-oral (3 + 2 smiling)• Intra-oral (5)

Problem List

Problem List

Pathology:

1.Ging

iva (A

ttach

ed gi

ngiva

)

2.Fren

um (L

ab. /

Ling.)

3.Ton

sils / A

deno

ids

4.Ton

gue

5.Den

tal C

aries

Develo

pmental

Problems:

1.Profile

and Esth

etics

•Profile

(Conve

x, Stra

ight, Conca

ve)

•Frontal

( Sym

metrica

l, Asy

mmetry)

•Lips

2.Alig

nment

•Upper

(Crowding / S

pacing)

•Lower

(Crowding / S

pacing)

3.A-P

•Ske

leton (C

lass I

, II, II

I)

•Den

tal ( C

lass I

, II, II

I)

4.Vert

ical

•Ske

leton (V

GP /Ave

rage /

HGP)

•Den

tal (D

eep Bite

/ Norm

al / O

pen Bite

5.Tran

svers

e

•Ske

leton (W

ide / Norm

al / N

arrow)

•Den

tal (W

ide / Norm

al / N

arrow)

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Timing of Orthodontic Treatment: Pubertal growth spurts Peak Height Velocity (PHV) The importance of the body type

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If all the structures of the craniofacial complex like the skeletal units , the dentition and the soft tissue components grow in harmony , then the result would be a good occlusion with a well balanced face.

But the human face like most of our other specialized anatomic parts, certainly has its share of variations.

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Class II Malocclusion

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Since Class II malocclusion is recognized easily by health professionals as well as by patients and their families, especially in cases of excessive over jet, the correction of class II problems may constitute more than half of the treatment protocolhalf of the treatment protocol in a typical orthodontic practice.

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It is interesting to note that the process of evolution in orthodontic diagnosis and diagnosis and treatment planningtreatment planning has been gradual.

Now, let us trace through let us trace through historyhistory, the changing perceptions on the etiology of class II malocclusion.

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For decades together class II was erroneously considered a purely sagittal problem. sagittal problem.

Pioneered by Dr. Angle’s classificationDr. Angle’s classification of malocclusion based on anteroposterior relationship of first first molarmolar, probably thousands of class II of all hues and varities were treated as basically sagittal discrepancies, often with disastrousdisastrous results.

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It was not the orthodontists alone who were guilty of nescience, but even the surgeons jumped onto the bandwagon and restricted themselves to sagittal correction of what was actually a problem involving more than one plane.

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The Angle system of classification still remains at the core of orthodontic diagnosis a century after its development, even though this classification scheme is not sensitive to imbalances in the vertical and transverse dimensions.

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First, let us see, how malocclusions such as Class II develop as sagittal discrepancy.

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SAGITTAL PLANE

Prognathic MaxillaRetrognathic Mandible Combination of the two

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Normal Mandible, Prognathic Maxilla

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Prognathic Maxillary Dentition

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Normal Maxilla, Retrognathic Mandible.

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Prognathic maxilla, Retrognathic mandible.

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Can also be because of decreased cranial flexure, the posterior positioning of glenoid fossa which neutralizes the horizontal growth of mandible ending up in Class II.

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VERTICAL DISCREPANCY With the passage of time, inevitably

there was gain of knowledge and wisdom and the focus now began to shift towards other etiologic possibilities of class II malocclusion

It was schudy in 1964, who brought into focus the vertical dysplasia causing and affecting the class II malocclusion.

Until then, investigators had never explored the vertical dimension of the posterior aspect of the face. But here were the secrets to be found.

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Vertical Discrepancies Discrepancies in the vertical dimension occur in the

form of a long facelong face or a short faceshort face syndrome.

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Rotations of Mandible

The rotationrotation of the mandible due to vertical growth discrepancies also has to be distinguished.


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Vertical Maxillary Excess Vertical maxillary excess brings about a clockwise

rotation of the mandible and a class II situation.

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Decreased Condylar Growth Decreased condylar growth and decreased ramal

height swings the mandible backward.

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Excess Condylar Growth

Excessive condylar growth causes forward rotation of the mandible leading to a class II deep bite situation.

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Now the concept changed such that when facial morphology indicated that vertical growth had been excessive or that condylar growth had been deficient, the plan was to inhibit the downward growth of the maxillary molars.

When it is determined that vertical growth is deficient, the choice is to stimulate the vertical growth of the alveolar processes.

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This quantum shift in knowledge about the causative factors of class II malocclusion brought into light an entirely new gamut of treatment possibilities.

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Now let us look at some class II cases with predominant vertical vertical discrepancydiscrepancy and their treatment options.

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Pre-expansion Post-expansion

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PretreatmentA.T.www.drdentiste.com

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Pre-surgicalA.T.

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Lefort I Osteotomy Premaxillary setback

Genioplasty www.drdentiste.com

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A.T. Post-Treatment

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TRANSVERSE DISCREPANCY It has only been during the last

two decades or so that the role of transverse dimensiontransverse dimension has been a topic of interest to the typical practicing orthodontist.

Until then it was a classical illustration of, “the eyes cannot see what the mind does not know.”

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Many class II malocclusions, when evaluated clinically have no obvious maxillary constriction.

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When a set of study models of the patient are “hand articulated", how-ever, it becomes obvious that when the dental casts are placed with the posterior dentition in a Class I relationship, a unilateral or a bilateral cross bitecross bite is produced.

This indicates the presence of maxillary constrictionmaxillary constriction as a component of class II malocclusion.

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FOOT AND SHOE MECHANISM

Richen Bach and Taatz in 1971 used the example of a foot and a shoe, with the foot representing the mandible and the shoe representing the maxilla.

If the shoe is too narrow, it is impossible for the foot to slide fully into the shoe. By widening the shoe, the foot slides forward into its usual position.

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When treating in the mixed dentition, the first step in the treatment of mild to moderate Class II malocclusions characterized, by mild mandibular skeletal retraction and maxillary constriction may be expansion of maxilla.

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The patients can be left in a over expanded position with contacts still being maintained between the upper lingual cusps and lower buccal cusps of the posterior teeth.

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Widening the maxilla often leads to a spontaneous forward posturing of the mandible during the retention period.

After 6 to 12 months, the spontaneous correction of the class II relationship can be seen in many mild to moderate class II patients.

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The net result of this change in outlook has been a reduction in the number of functional jaw orthopedic appliances that now are used in the treatment of mild to moderate class II malocclusion.

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Class III malocclusionClass III malocclusion


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SAGITTAL PLANE

Retrognathic maxilla Prognathic mandible Combination of the two

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Retrognathic Maxillary Dentition

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Retrognathic Maxilla

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Prognathic Mandible

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Combination

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During the1940’s and 50’s mandibular prognathism was believed to be the sole etiological cause for Class III malocclusions.

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All clinical efforts were concentrated in correcting the mandibular prognathism using Chin cup therapy or surgical correction by mandibular set back was the only alternative practiced.

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A lack of a clear understanding of the underlying etiology often compounded by adressal of wrong treatment objectives resulting in disastrous treatment results often accentuating the problem rather than solving it.

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With the advent of newer diagnostic aids such as cephalometrics identification of the role of maxilla in the development class III malocclusion came into picture completely revolutionizing the present treatment philosophy.

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117 BSSO-Setback

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Genioplasty

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1298 mm.Downward & 6.5mm. Advancement of Maxilla

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Conclusion

But as the philosopher Fredrick Jensen has said, “What we think we know today shatter the errors and blunders of yesterday and is tomorrow discarded as worthless. So we go from larger mistakes to small mistakes so long as we do not loose courage. This is true of all therapy, no method is final”.

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Thus even with tremendous progress in basic research and mind boggling improvement in appliance systems, class II & III malocclusion has still remained an enigma

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ORTHODONTICS AS OF TODAY

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