In the name of GOD

Orthodontic treatment planning

Presented by:

Dr Somayeh Heidari

Orthodontist
Reference:

Contemporary Orthodontics

Chapter 7

William R. Proffit, Henry W. Fields, David M.Sarver. 2007. Mosby

Collection adequate database

Diagnosis
Problem-oriented approach

Treatment planning
The objective in treatment planning is to design the strategy that a wise clinician,

using his/her best judgment, would employ to address the problem while

maximizing benefit to the patient and minimizing cost and risk.

Avoid both missed opportunities (false negative or undertreatment) and

excessive treatment (false positive or overtreatment) while appropriately

involving the patient in the planning process.

Indications for orthodontic treatment
 Psychosocial indications

Remove, or at least alleviate, the social handicap created by an unacceptable dental

and/or facial appearance.

Enhance dental and facial appearance in individuals who already are socially
acceptable but wish to improve their quality of life.

Although the severity of the malocclusion correlates with its psychosocial effect,
measuring how much the teeth protrude or how irregular they are is not sufficient
to determine individual treatment need.
 Developmental indications

Maintain as normal a developmental process as possible.

Problems related to development of the dentition occur relatively frequently, and often
orthodontic treatment is needed to maintain dental health and continue normal
development.

These problems almost always should be corrected when noticed.

 Functional indications

Improve jaw function and correct problems related to functional impairment.

Sever malocclusion affects normal function, usually not by making it impossible, but
by making it more difficult for the affected individual to breath, incise, chew, swallow
and speak normally.

The reverse also is true: alteration or adaptation in function can be etiologic factors
for malocclusion, by influencing the pattern of growth and development.
 Trauma / Disease control indications

Reduce the impact on the dentition of trauma or disease.

Prevention of periodontal disease almost never is a reason for orthodontic treatment.

Correcting tissue impingement by the teeth can be a benefit from orthodontic treatment at
any age.

Although protruding incisors are more likely to be damage, only in the most accident-prone
child is this a valid reason for reducing overjet.
Adjunctive treatment indications

Facilitate other dental treatment, as an adjunct to restorative, prosthodontic or

periodontal therapy.
Orthodontic treatment almost always is elective,

but it can produce significant benefits in psychosocial well being, normal development,

jaw function, dental/ oral health and improve outcomes in the treatment of dental

disease.

Orthodontics is needed if it would produce these benefits--- and not needed if it would

not.
Type of treatment : Evidence – Based selection

Treatment process should be chosen on the basis of clear evidence that the selected
method is the most successful approach to that particular patient’s problem.

The better the evidence, of course, the easier the decision.

 Problem – oriented approach

Identifying the patient’s problems evaluating the possible solutions

those specific problems

The best way to evaluate alternative treatment methods is with a randomized clinical
trial, with great care is taken to control variables that might affect the outcomes.

A second acceptable way is careful study of treatment outcomes under well-defined

conditions.
 Treatment goals : The soft tissue paradigm

If we accept that both goals and limitations of orthodontic treatment are established
more by soft tissue considerations than skeletal/dental relationships, treatment planning
inevitably is affected.
Primary goal of treatment soft tissue relationships and adaptations

Facial proportions
Teeth – lip and Teeth – face relationships
Soft tissue adaptation to the position of teeth (stability)
Secondary goal of treatment functional occlusion

arrange the occlusion to minimize the chance of injury

 Solving the patient’s problems

Problem oriented diagnosis and treatment planning

 Major issues in planning treatment

Once patient’s orthodontic problems identified and prioritized, three issues

must be faced as treatment planning begins:

 The complexity of the treatment that would be required

 The predictability of success with a given treatment approach

 The patient’s (and parent’s) goals and desires

complexity of treatment

Who should do the treatment?

predictability of treatment

If alternative methods of treatment are available, which one should be chosen?

Based on evidence
Patient input

Most important: treatment planning must be an interactive process.

Both ethically and practically, patient must be involved in the decision making process.
 Orthodontic Triage :

Distinguishing moderate from complex treatment problems

An adequate database and a through problem list are necessary do the triage process.
 Orthodontic Triage
Step1 : Syndromes and Developmental Abnormalities

Sever problems moderate problems

Unusual facial appearance

Analysis of full-face proportions

Craniofacial deformity or syndrome

(cleft lip or palate, hemifacial microsomia,
Crouzon’s syndrome, Treacher- Collin’s syndrome, …)
Complete evaluation by
Special team with
medical consultants
Developmental status
< 3% or > 97%

P.A Ceph, history of trauma?

Excess or deficient growth?
- comprehensive orthodontics True facial asymmetry
- surgery required
 Multidisciplinary treatment approach

Cleft lip and palate

Crouzon’s syndrome

Treacher- Collin’s syndrome Hemifacial microsomia

 Orthodontic Triage
Step2 : Facial Profile Analysis

Sever problems moderate problems

Symmetric face

Facial profile analysis

Antero-Posterior or Vertical jaw discrepancies

Skeletal Class II and Class III
Long face and short face

Cephalometric analysis
- Growth modification or surgery?
- Extraction?

Excessive protrusion or
retrusion of incisors
Excessive protrusion or retrusion of incisor teeth often accompanies skeletal jaw
discrepancies (skeletal problem)

It is possible for an individual with good skeletal proportions to have protrusion of

incisors teeth rather than crowding.

Bimaxillary protrusion ( excessive protrusion of incisors without excessive overjet)

usually is an indication for premolar extraction and retraction of protruding incisors:
complex and prolonged treatment
Because of the profile changes produced by adolescent growth, it is better for most
children to defer extraction until late mixed dentition or early permanent dentition.

It is definitely an error to begin extraction early and then allow the permanent molars
to drift forward, because this will make effective incisor retraction impossible.
 Orthodontic Triage
Step3 : dental development

Sever problems
Good facial proportions

Review intra-oral radiographs for abnormalities

of dental development

Monitor: selective extraction? Asymmetric dental development

Retain primary? Prosthetic replacement? Missing permanent teeth

Extract, allow permanent teeth to drift?
Extract, orthodontic space closure?
Ankylosed permanent teeth
Combined surgical-orthodontic treatment

Primary failure of eruption

Extract supernumerary, reposition other teeth Supernumerary teeth

complicated by position or number
Problems involving dental development usually need treatment as soon as they are
discovered, typically during the early mixed dentition, and often can be handled in
family practice.
Asymmetric dental development

 if the difference is 6 months or more

 careful monitoring of the situation is needed
 often requires selective extraction
 can prevent a sever asymmetry problem at a later time
 few patients have a history of childhood radiation therapy to head and neck
Missing permanent teeth

 is an actual (primary predecessor is missing or lost) or potential (primary tooth is

still present)
 most likely: mandibular second premolars and maxillary lateral incisors
 making the correct decision requires a careful assessment of facial profile, incisor
position, space requirements and the status of the primary teeth
 ankylosed permanent teeth fall into the same
category as missing teeth
Supernumerary teeth

 in the anterior segment of the maxilla: 90%

 multiple, inverted or malformed supernumerary teeth: often displaced adjacent
teeth
 multiple supernumerary: complex problem, perhaps syndrome or congenital
abnormality
 early removal: carefully to minimize damage to adjacent teeth
 if causes displacement: surgical exposure, adjunctive periodontal surgery, and
possibly mechanical traction
 Orthodontic Triage
Step3 : dental development

Moderate problems
Good facial proportions

Review intra-oral radiographs for abnormalities

of dental development

Single supernumerary
with uncomplicated position extract supernumerary

Retained or ankylosed Monitor:

primary teeth Extract and maintain space if
space loss or vertical displacement

Ectopic eruption Monitor:

Reposition?
Extract, space regain?
 Orthodontic Triage
Step 4 : Space problems

Sever problems moderate problems

Normal Dental Development

Space analysis

Prematurely missing primary canine space maintenance

or molar, adequate space

Localized space deficiency due to early

Loss of primary canine or molar
space regaining
3 mm or less simple appliances
comprehensive treatment
? Expansion > 3mm
? Extraction
incisor irregularity Mixed dentition:
with adequate space defer treatment?
align ?
Older patients: align
 Orthodontic Triage
Step 4 : Space problems

Sever problems moderate problems

Normal Dental Development

Space analysis

Incisor irregularity with

space deficiency space management:
reduce width primary teeth?
4mm or less selectively extract primary teeth?
arch expansion?
Comprehensive treatment
? Expansion > 4mm
? Extraction

Midline diastema No treatment before

canines erupt.
2mm or less Tip teeth together in older
Bodily movement, then patient, Retain
frenectomy > 2mm
 Orthodontic Triage
Step 5 : Other Occlusal Discrepancies

Sever problems moderate problems

Other Tooth Displacement

Evaluate in light of facial form/

Space analysis results

-Widen midpalatal suture? Posterior cross bite: Skeletal

- Expand surgically ?

Posterior cross bite: Dental Expand by tipping teeth

(if no vertical/other complications)

Include the comprehensive Anterior cross bite Tip teeth with removable
plan if situation complex appliance

Excessive overjet Retract (tip) with removable

appliance
Only if vertical clearance
present
 Orthodontic Triage
Step 5 : Other Occlusal Discrepancies

Sever problems moderate problems

Other Tooth Displacement

Evaluate in light of facial form/

Space analysis results

Anterior open bite primary dentition:

simple no treatment
mixed dentition:
Growth modification? complex thumb sucking therapy
Jaw surgery ?

Level curve of Spee? Deep overbite

Intrusion ?

Immediate treatment Traumatic displacement

Thanks for your attention