ORTHO- Treatment Planning and Management of Class I Malocclusion
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Transcript of ORTHO- Treatment Planning and Management of Class I Malocclusion
8/3/2019 ORTHO- Treatment Planning and Management of Class I Malocclusion
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TREATMENT PLANNING
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Introduction
Treatment planning is the second step in the treatment ofany patient; the first step being diagnosis of the problem.
It entails the formulation of a detailed problem list, setting upof treatment objectives, and finalizing the treatment plan afterdiscussing it with the patient or the patient's guardians.
It also involves, planning space requirements, choice of
appliance and the retention regimen.
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DIAGNOSIS
Orthodontic diagnosis involves three steps - collection ofdata, processing of the collected data and finally drawingconclusions.
Step one involves the taking of case history, intraoral and
extra-oral examination of the patient, making of study modelsand taking the relevant radiographs or other diagnosticrecords.
The second step involves the processing of all this collected
information into understandable and coherent data. This willinvolve undertaking cephalogram and study model analyses.
The resulting information should be able to give a conciseand exact location of the malocclusion.
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A statement of diagnosis should include the exact problem asperceived by the clinician and why and/or what is (etiology)causing the problem.
For example: a 12-year-oldmale patient, suffering from mildcrowding of the upper and lower anterior teeth, with a Class II
skeletal and dental malocclusion due to a short and retro-positioned mandible with proclined upper anteriors and anopen bite of 2mm due to persistent thumb sucking habit.
Another important aspect, which the diagnosis should reflect
upon, is the growth potential.
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PROBLEM LISTSkeletal
Dental
Functional
Soft Tissue
TREATMENT OBJECTIVE
Enlist he problems that have to be attended to in a decreasing orderof priority
Patient’s chief complaint and desires should be given adequateweightage
Must be realistic in setting up objectives and important to remember thegoals of orthodontic treatment - functional efficiency, structural balance andesthetic harmony (Jackson's triad )
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PLANNING SPACE REQUIREMENTS
Corrections required as part of treatment:
1. Retraction of protruded teeth
2. Correction of crowding
3. Alignment of rotated anterior teeth
4. Alignment of rotated posterior teeth
5. Correction of molar relationship
6. Levelling the curve of Spee
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RETRACTION OF PROTRUDED TEETH
For every millimeter of retraction required, 2 mm of space isrequired.
Protruded teeth are the most frequent reason for patients to approach theorthodontist. Unless the retraction required is very less or / and the dentalarches are spaced, extraction of certain teeth might be required to createspace for retraction of proclined teeth.
CORRECTION OF CROWDING
For every millimeter of decrowding, tile same amount of space isrequired for aligning tile teeth.
Crowded teeth are as unsightly as proclined teeth but maybe more harmfulfor the gums. The correction of crowding requires calculating the exactmesiodistal dimensions of the teeth to be aligned and accordingly space canbe created for alignment. Use of Kesling's diagnostic setup can be of
additional help.
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ALIGNMENT OF ROTATED ANTERIOR TEETH
For every millimeter of derotation required, the same amount ofspace is required for aligning the teeth.
The anterior teeth are broader mesiodistally and occupy less space whenthey are rotated. Alignment of such teeth requires additional space in thedental arch.
ALIGNMENT OF ROTATED POSTERIOR TEETH
Space is created when rotated posterior teeth are aligned. The
space created depends upon the tooth and the amount of rotationpresent.
When posterior teeth are rotated, they occupy more space; hence, space isactually created by aligning such teeth.
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CORRECTION OF MOLAR RELATIONSHIP
The space required for mesial or disial movement of the molars is asper the actual movement planned.
To achieve a stable molar relationship, it is essential to have a full Class I orII. End-on relation is not stable and space might be required to bring themaxillary or mandibular molar mesially to achieve stability. The exact spacerequired can be calculated on the study models.
LEVELLlNG THE CURVE OF SPEE
F or every 1mm of levelling, approximately / mm of space is required.
Skeletal malocclusions are very commonly associated with an increase in thecurve of Spee. An excessive curve will not only limit the amount of retractionof the maxillary anteriors but can also aid in the relapse of the condition.
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PLANNING ANCHORAGE
Anchorage consideration forms an important part of thetreatment planning exercise
All efforts should be taken to minimize unwanted tooth
movements
Failure to plan anchorage invariably results in failure oftreatment mechanics
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Anchorage demand for an individual patient depends on:
1. Number of teeth being moved – the greater the number ofteeth being moved, the greater would be the demand onanchorage
2. Type of teeth – tooth movement involving multi-rootedposteriors offer greater strain on anchorage that movingsmaller teeth
3. Type of tooth movement – tipping movement are less
demanding on anchorage than bodily
4. Duration or treatment – Complicated treatments ofprolonged duration strains the anchor teeth
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SELECTION OF APPLIANCE
Based on a number of Factors
1. The type of tooth movements required
2. Patient's expectations
3. Growth potential of the patient
4. Patient's ability to maintain oral hygiene
5. The cost of the treatment
6. The skills of the treating clinician.
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THE TYPE OF TOOTH MOVEMENTS REQUIRED
Simple tipping movements can be achieved using removable appliances.
If multiple, complex tooth movements are desired, it is advisable to use oneof the available fixed orthodontic appliances.
PATIENT'S EXPECTATIONS
Patients who have high expectations are expecting ideal finishes which mightnot be possible using removable appliances.
Such patients are concerned about their esthetics to such an extent that thelabial appliances might not be an option. They might desire the use of lingual
appliances.
A compromise might need to be arrived at regarding treatment results andthe patient's expectations, it is advised to inform the patient exactly what isachievable with which appliance, to the best of the clinician's ability beforecommencing the treatment.
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GROWTH POTENTIAL OF THE PATIENT
Growing patients who exhibit skeletal malocclusion should be treated withappliances that modulate the growth.
Results achieved during growth are more stable yet sometimes the return ofan aberrant growth pattern following completion of treatment can result inrelapse of the treatment results.
PATIENT'S ABILITY TO MAINTAIN ORAL HYGIENE
Certain age groups or patients with compromised motor functions might notbe able to maintain adequate oral hygiene with fixed appliance therapy. Suchpatients can be treated using removable appliances with compromisedtreatment results.
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THE COST OF THE TREATMENT
Fixed orthodontic treatment is more costly as compared to removableappliance therapy. Sometimes the patient might not be able to afford costlyyet ideal treatment plans.
The financial implications of the treatment should be considered andexplained to the patient at the time of deciding upon a particular treatment
plan.
THE SKILLS OF THE TREATING CLINICIAN
It is the duty of the clinician to choose an appliance that is appropriate for the
particular case and not just appropriate for the clinician.
It is always better to work within your means and to present treatment plansthat can be achieved.
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PLANNING RETENTION
It is now accepted that teeth once moved, tend to go back to their initialposition. The potential for relapse is increased by the presence of certainfactors, which are
Stretched periodontal ligament – the stretched gingival fibers are a frequent
cause of relapse in case of rotated teeth, since these fibers take a long timeto reorganize around their new position
Unstable occlusion – teeth placed in unstable position at the end oforthodontic therapy tend to relapse
Continuation of growth pattern – Continuation of the growth pattern that hascaused a skeletal malocclusion after orthodontic therapy results inresurfacing of the malocclusion after treatment
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DISCUSSION WITH THE PATIENT AND PATIENT
CONSENT
Patient today act as co-decision makers. Hence, it is the orthodontist legaland moral duty to discuss the risk/benefit of the treatment and alternatives aswell as the risks of no treatment at all.
Informed consent can and should be taken after providing the patient with
enough information to have an understanding of the condition (malocclusion),its severity and the proposed treatment-its goals and objectives.
Patient should be made to understand the commitment required on his/herpart-both regards to the time and financial.
Risks involved, of the treatment and of not getting treatment, should also beexplained.
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MANAGEMENT
OFCLASS I MALOCCLUSIONS
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MIDLINE DIASTEMA
Midline diastema refers to anterior midline spacing between the twomaxillary central incisors
It is one of the most frequently seen malocclusions that is considered easy totreat but difficult to retain
Causes for midline diastema:
◦ Transient malocclusion
◦ Tooth material – arch length discrepancy (peg laterals, microdontic laterals)
◦ Unerputed mesiodens
◦ Abnormal frenal attachment
◦ Proclination
◦ Midline pathology
◦ Iatrogenic
◦ Pressure habits
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Supernumerary
Iatrogenic
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Peg laterals
Spacing
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Proclination
MissingLaterals
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Habits
High Frenum
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MANAGEMENT
Removal of Cause
Active treatment
Retention
Cosmetic restorations
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SPACING The presence of spacing between teeth is one of the commonly seen
manifestations of a Class I malocclusion.
Spaces can be in localized area or the entire arch can exhibit spacing
Etiology
1. Arch length – tooth size discrepancy2. Habits
3. Abnormally large tongue – tongue thrusting
Diagnosis
1. Model analysis2. Radiographic examination – any impacted, supernumerary tooth
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Management
Removal of cause
Use removable or fixed appliance
Active appliances incorporating labial bows can be used to close spaces – shortlabial bow, long labial bow
Crowns and prosthesis
Spacing that occurs due to microdontia
Absence / missing teeth
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CROWDING
Crowding is another common manifestation of a Class I malocclusion
Occurs usually as a result of disproportion between tooth size and archlength – relative increase in tooth size or decrease in arch length
Etiology
1. Arch length- tooth size discrepancy2. Presence of supernumerary teeth
3. Prolonged retention of deciduous teeth
4. Abnormalities of tooth shape and size
5. Premature loss of deciduous teeth – Eg: early loss of 2nd deciduous molar,drifting of permanent 1st molar and resulting in 2nd premolar having lessspace to erupt – lingually placed. Similarly upper canines
6. Late lower labial segment crowing – noticed in mid to late teens. Seen inpatient who had well aligned teeth. Factors causing it:
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1. Late mandibular growth
Believed that mandible may grow further forward after maxillary growth hasstopped.
As mandible grows forwards, mandibular dentition is pushed lingually, reducingarch
length and resulting in crowding
2. Reduction in intercanine width
Reduction in intercanine width noticed after age of 9. this continues into teenage
andinto adulthood at a recued rate. This responsible for late lower anterior crowding
3. Gingival fibers and occlusal forces
Pressure from transeptal fibers along with anteriorly directed occlusal forces are
believed to encourage mesial movement of posterior teeth and result in
crowding
4. Lack of approximal attrition
5. Role of 3r molars
One theory - Erupting molars produce mesial force causing crowding
The other – 3rd molar prevent dentition from moving distally in response to late mandibulargrowth
But lower anterior crowdin seen even when 3rd molars have not develo ed or have
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Diagnosis
Model analysis –
Careys analysis
Arch perimeter analysis
Boltons analysis
Treatment
Most minor crowding in mixed dentition resolves spontaneously during
transition to permanent dentition
Early loss of deciduous teeth – use space maintainers
Moderate crowding in mixed dentition can be corrected by using leewayspace. Hold molars from moving forward by using lip bumper, etc
Severe crowing in mixed dentition may need Serial Extraction
Permanent dentition – Assess space required, location of crowding andpatient’s profile.
Gain space by proximal stripping, extractions, expansion, proclination,derotating and uprighting posterior teeth
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ROTATIONS
Rotations are tooth movements that occur around their long axes
Two types: Mesio-lingual / disto-buccalDisto-ligual / mesio-buccal
Anterior teeth occupy less space when rotated, so require space to derotatethem
Posterior teeth occupy more space when rotated, so gain space when
derotated
Management
Space management
Removable appliances – Z spring
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Thank You