TREATMENT PLANNING

Introduction

Treatment planning is the second step in the treatment of any patient; the first step being diagnosis of the problem. It entails the formulation of a detailed problem list, setting up of treatment objectives, and finalizing the treatment plan after discussing it with the patient or the patient's guardians. It also involves, planning space requirements, choice of appliance and the retention regimen.

DIAGNOSIS

Orthodontic diagnosis involves three steps - collection of data, processing of the collected data and finally drawing conclusions. Step one involves the taking of case history, intraoral and extra-oral examination of the patient, making of study models and taking the relevant radiographs or other diagnostic records. The second step involves the processing of all this collected information into understandable and coherent data. This will involve undertaking cephalogram and study model analyses. The resulting information should be able to give a concise and exact location of the malocclusion.

A statement of diagnosis should include the exact problem as perceived by the clinician and why and/or what is (etiology) causing the problem. For example: a 12-year-oldmale patient, suffering from mild crowding of the upper and lower anterior teeth, with a Class II skeletal and dental malocclusion due to a short and retropositioned mandible with proclined upper anteriors and an open bite of 2mm due to persistent thumb sucking habit. Another important aspect, which the diagnosis should reflect upon, is the growth potential.

PROBLEM LIST
Skeletal Dental Functional Soft Tissue

TREATMENT OBJECTIVE

Enlist he problems that have to be attended to in a decreasing order of priority Patients chief complaint and desires should be given adequate weightage Must be realistic in setting up objectives and important to remember the
goals of orthodontic treatment - functional efficiency, structural balance and esthetic harmony (Jackson's triad )

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

RETRACTION OF PROTRUDED TEETH

For every millimeter of retraction required, 2 mm of space is required.

Protruded teeth are the most frequent reason for patients to approach the orthodontist. Unless the retraction required is very less or / and the dental arches are spaced, extraction of certain teeth might be required to create space for retraction of proclined teeth.

CORRECTION OF CROWDING

For every millimeter of decrowding, tile same amount of space is required for aligning tile teeth.
Crowded teeth are as unsightly as proclined teeth but maybe more harmful for the gums. The correction of crowding requires calculating the exact mesiodistal dimensions of the teeth to be aligned and accordingly space can be created for alignment. Use of Kesling's diagnostic setup can be of additional help.

ALIGNMENT OF ROTATED ANTERIOR TEETH

For every millimeter of derotation required, the same amount of space is required for aligning the teeth.
The anterior teeth are broader mesiodistally and occupy less space when they are rotated. Alignment of such teeth requires additional space in the dental 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 rotation present.
When posterior teeth are rotated, they occupy more space; hence, space is actually created by aligning such teeth.

CORRECTION OF MOLAR RELATIONSHIP

The space required for mesial or disial movement of the molars is as per the actual movement planned.
To achieve a stable molar relationship, it is essential to have a full Class I or II. End-on relation is not stable and space might be required to bring the maxillary or mandibular molar mesially to achieve stability. The exact space required can be calculated on the study models.

LEVELLlNG THE CURVE OF SPEE

For every 1mm of levelling, approximately / mm of space is required.

Skeletal malocclusions are very commonly associated with an increase in the curve of Spee. An excessive curve will not only limit the amount of retraction of the maxillary anteriors but can also aid in the relapse of the condition.

PLANNING ANCHORAGE

Anchorage consideration forms an important part of the treatment planning exercise All efforts should be taken to minimize unwanted tooth movements Failure to plan anchorage invariably results in failure of treatment mechanics

Anchorage demand for an individual patient depends on: Number of teeth being moved the greater the number of teeth being moved, the greater would be the demand on anchorage Type of teeth tooth movement involving multi-rooted posteriors offer greater strain on anchorage that moving smaller teeth Type of tooth movement tipping movement are less demanding on anchorage than bodily Duration or treatment Complicated treatments of prolonged duration strains the anchor teeth

1.

2.

3.

4.

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.

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 one of the available fixed orthodontic appliances.

PATIENT'S EXPECTATIONS

Patients who have high expectations are expecting ideal finishes which might not be possible using removable appliances.
Such patients are concerned about their esthetics to such an extent that the labial 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 and the patient's expectations, it is advised to inform the patient exactly what is achievable with which appliance, to the best of the clinician's ability before commencing the treatment.

GROWTH POTENTIAL OF THE PATIENT

Growing patients who exhibit skeletal malocclusion should be treated with appliances that modulate the growth. Results achieved during growth are more stable yet sometimes the return of an aberrant growth pattern following completion of treatment can result in relapse of the treatment results.

PATIENT'S ABILITY TO MAINTAIN ORAL HYGIENE

Certain age groups or patients with compromised motor functions might not be able to maintain adequate oral hygiene with fixed appliance therapy. Such patients can be treated using removable appliances with compromised treatment results.

THE COST OF THE TREATMENT

Fixed orthodontic treatment is more costly as compared to removable appliance therapy. Sometimes the patient might not be able to afford costly yet ideal treatment plans. The financial implications of the treatment should be considered and explained 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 plans that can be achieved.

PLANNING RETENTION

It is now accepted that teeth once moved, tend to go back to their initial position. The potential for relapse is increased by the presence of certain factors, 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 time to reorganize around their new position

Unstable occlusion teeth placed in unstable position at the end of orthodontic therapy tend to relapse

Continuation of growth pattern Continuation of the growth pattern that has caused a skeletal malocclusion after orthodontic therapy results in resurfacing of the malocclusion after treatment

DISCUSSION WITH THE PATIENT AND PATIENT CONSENT

Patient today act as co-decision makers. Hence, it is the orthodontist legal and moral duty to discuss the risk/benefit of the treatment and alternatives as well 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/her part-both regards to the time and financial. Risks involved, of the treatment and of not getting treatment, should also be explained.

MANAGEMENT OF CLASS I MALOCCLUSIONS

MIDLINE DIASTEMA

Midline diastema refers to anterior midline spacing between the two maxillary central incisors It is one of the most frequently seen malocclusions that is considered easy to treat 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

Supernumerar y

Iatrogenic

Peg laterals

Spacing

Proclination

Missing Laterals

Habits

High Frenum

MANAGEMENT

Removal of Cause Active treatment Retention Cosmetic restorations

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. 2. 3.

Arch length tooth size discrepancy Habits Abnormally large tongue tongue thrusting

Diagnosis
1. 2.

Model analysis

Radiographic examination any impacted, supernumerary tooth

Management
Removal of cause Use removable or fixed appliance Active appliances incorporating labial bows can be used to close spaces short labial bow, long labial bow

Crowns and prosthesis

Spacing that occurs due to microdontia Absence / missing teeth

CROWDING

Crowding is another common manifestation of a Class I malocclusion Occurs usually as a result of disproportion between tooth size and arch length relative increase in tooth size or decrease in arch length

Etiology
1. 2. 3. 4. 5.

Arch length- tooth size discrepancy Presence of supernumerary teeth Prolonged retention of deciduous teeth Abnormalities of tooth shape and size Premature loss of deciduous teeth Eg: early loss of 2nd deciduous molar, drifting of permanent 1st molar and resulting in 2nd premolar having less space to erupt lingually placed. Similarly upper canines Late lower labial segment crowing noticed in mid to late teens. Seen in patient who had well aligned teeth. Factors causing it:

6.

1.

Late mandibular growth

Believed that mandible may grow further forward after maxillary growth has stopped. As mandible grows forwards, mandibular dentition is pushed lingually, reducing arch length and resulting in crowding
2.

Reduction in intercanine width

Reduction in intercanine width noticed after age of 9. this continues into teenage and into 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. 5.

Lack of approximal attrition 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 mandibular growth But lower anterior crowding seen even when 3rd molars have not developed or have

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 leeway space. 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 and patients profile.
Gain space by proximal stripping, extractions, expansion, proclination, derotating and uprighting posterior teeth

ROTATIONS

Rotations are tooth movements that occur around their long axes Two types: Mesio-lingual / disto-buccal Disto-ligual / mesio-buccal

Anterior teeth occupy less space when rotated, so require space to derotate them Posterior teeth occupy more space when rotated, so gain space when derotated

Management Space management Removable appliances Z spring

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