STEPS FOR DEVELOPING TREATMENT

PLAN
FORMING A PROBLEM LIST
After thorough history taking, examination and analysis of records. A clear list of
problems must be formulated.
Problem list doesn't only include the orthodontic problems.
Take a step back and look at the bigger picture.
Be a dentist before being an orthodontists.
FORMING A PROBLEM LIST
Problem list is divided to
1. Pathological problems (diseases) from caries and periodontal diseases to cysts
and suspicious ulcers and lesions.
2. Developmental problems: those problems relating to malocclusion.
FORMING A PROBLEM LIST
6 sections to consider when forming a problem list:
1. Patient’s concerns
2. Facial and smile aesthetics
3. Alignment and symmetry within each arch
4. Skeletal and dental relationships in the transverse plane
5. Skeletal and dental relationships in the AP plane
6. Skeletal and dental relationships in vertical plane

Why do we need to do a list of problems for each patient?

AIMS OF TREATMENT
To achieve and maintain excellent oral and dental health
Achieve class I incisors and canine relationships with good buccal interdigitation.
Achieve Andrew’s six keys (static occlusion)
Achieve mutually protected occlusion (dynamic occlusion)
Achieve stable results
AIMS OF TREATMENT
Systematic approach to develop a treatment plan (do it for all cases)
1. Achieve optimal oral health with no pathologies.
2. If skeletal problem present consider:
A. Camouflage
B. Growth modification
C. Surgery
D. Compromise
AIMS OF TREATMENT
3. Plan lower arch FIRST
4. Quantify space needs in the lower arch to reach the set objectives
5. Plan your anchorage in lower arch
6. Plan your upper arch BASED ON LOWER ARCH
7. Quantify space needs in upper arch
8. Plan anchorage in upper arch
9. Type of appliance and mechanics
10. Type of retention
FACTORS TO CONSIDER IN BORDERLINE CASES
(ALMUZIAN)
General factors
Patient concern and expectation
Cooperation
Age
Medical condition
FACTORS TO CONSIDER IN BORDERLINE CASES
(ALMUZIAN)
Malocclusion factors
Profile
Jaw relation
Soft tissue feature
Type of malocclusion
Presence and severity of crowding
Biological limit of alveolar and PD apparatus
A lack of palatal bone into which to retract the upper incisors.
Proclination of the lower incisors may result in the loss of labial bony support and
labial gingival recession.
METHODS OF CREATING SPACE
what are the methods of creating space?
INTERPROXIMAL STRIPPING
Removing enamel on the mesial and distal surfaces
Creates space
Provide better stability in lower incisors (widening contact point)
Reduce/abolish black triangles
0.25mm on each side
Can cause damage to teeth and periodontium
Carried out when teeth are reasonably aligned
CONTRADICTIONS (ALMUZIAN)
1. Poor OH
2. High caries rate index
3. Big space required
4. Rectangular shape teeth
5. Broad contact points
6. Small teeth
7. Large pulp chamber
8. Teeth with restoration or hypoplasia
9. Severely rotated teeth
PROCLINATION
Each 1mm advancement creates 2mm space within the arch
Depends on aims of treatment
Avoid excessive proclination of incisors
EXPANSION
Each 1mm expansion = 0.5mm space within the arch
Ideally carried out when there is crossbite
EXTRACTION
Factors to consider:
1. Prognosis
2. Position
3. Amount of space required
4. Incisor relationship
5. Anchorage requirements
6. Appliances to be used (if any)
7. Patient’s profile and the aims of treatment.
INCISORS EXTRACTION
Rarely the first choice due to compromise of aesthetics
Indications:
1. Incisor has poor prognosis or compromised periodontal support.
2. Buccal segments are Class I, but there is moderate lower incisor
crowding.
3. Adult patient who has a mild Class III skeletal pattern with well aligned buccal
segments

Use fixed retainer.

CANINES
In cases it is severely displaced
There is good contact between premolar and lateral incisor.
Refer to RCS-England guidelines.
If canine is missing check if there is protected occlusion
FIRST PREMOLAR
Most extracted.
Allows for spontaneous alignment of canines.
Rule of thumb: 40-60% of space is available using fixed appliances alone without
reinforcing anchorage
SECOND PREMOLAR
Indications:
1. mild to moderate space requirement (3–8 mm space required)
2. space closure by forward movement of the molars, rather than retraction of the
labial segments is indicated
3. severe displacement of the second premolar of a poor prognosis
second molar.

25-50% of space available

Space closure mostly by forward movement of posterior teeth
FIRST PERMANENT MOLAR
RCS-England guidelines for extraction of permanent first molars (Cobourne 2010)

For four sixes (Sandler et al 2000 and revisited version by DiBiase et al 2021)
SECOND MOLAR EXTRACTION
Indication:
1. To facilitate distal movement of upper buccal segments.
2. Relief of mild lower premolar crowding.
3. Provision of additional space for the third permanent molars, thus
avoiding the likelihood of their impaction
Chances of eruption of third molar is improved when:
1. Angle between the third permanent molar tooth germ and the long
axis of the second molar is 10–30°.
2. Crypt of developing third molar overlaps the root of the second
molar.
3. The third permanent molar is developed to the bifurcation
THIRD MOLARS
Should they be extracted to prevent lower incisor crowding?
NICE guidelines for extraction of wisdom teeth
Some clinicians advocate removal of third molars to facilitate distalisation.
DISTALISATION
Different appliances. (intra/extra oral. Dental/skeletal appliances)
Conventional methods can achieve up to half unit distalisation.
TAD may be able to achieve more.
Examples of clinical situations when it may be used include:
1. class I incisor relationship with mild crowding in the upper arch
2. class II division 1 incisor relationship with minimally increased overjet
and molar relationship of less than half a unit Class II
3. where extraction of first premolars does not give sufficient space to
complete alignment
4. where unilateral loss of a deciduous molar has resulted in mesial drift
of the first permanent molar
THANK YOU…