Orthodontic treatment planning

1. ORTHODONTIC
TREATMENT PLANNING :
PROBLEM LIST TO
SPECIFIC PLAN
DR. ALI WAQAR HASAN
FCPS – II RESIDENT IN ORTHODONTICS
UCMD UOL

2. TREATMENT PLANNING CONCEPTS
& GOALS
 Comprehensive list of patient’s problems = Orthodontic Diagnosis
 Pathological & Developmental problems separated
 Objective = To design a strategy using best clinical judgement to address
the problems while maximizing benefit and minimizing cost & risk
 Develop treatment plan in collaboration with patient
 “Do not jump to conclusions” !!!!

3. MAJOR ISSUES IN PLANNING
TREATMENT
PATIENT INPUT
 Modern planning = Interactive process
 Doctor cannot decide in a paternalistic way
 Patients & Parents must be involved in decision making process
 Ethically, patients have right to control
 “Treatment is something done for them….Not to them”
 Informed concent

4. DENTAL CROWDING : TO EXPAND or
EXTRACT
 Two controversial aspects of current orthodontic treatment planning
 The extent to which Arch Expansion versus Extraction is indicated as
solution for Crowding in Dental Arches
 The extent to which Growth Modification versus Extraction for Camouflage
or Orthognathic Surgery should be considered as solution for Skeletal
Problems

5.  From beginning of Specialty, Debate on Limits of Expansion of Dental
Arches & advantages of Extraction of some Teeth to provide space for
others outweigh the Disadvantages
 With Extraction, Loss of Tooth/Teeth is Disadvantage
 Greater Stability of result is an Advantage
 Maybe Positive or Negative effects on Facial Esthetics
 Contemporary View : Majority of Orthodontic Patients should be treated
without removal of Teeth
 Extraction to compensate for Crowding, Incisor Protrusion or Jaw
Discrepancy

6. ESTHETIC CONSIDERATIONS
 Major factors in Extraction Decisions = Stability & Esthetics
 Expansion of arches moves the patient in direction of more prominent
teeth, while extraction tends to reduce prominence
 Prominence of Incisors = Excessive Lip separation at rest
 Nose - Chin relationship
 For Best Esthetics = Lower Lip should be as prominent as chin

7. STABILITY CONSIDERATIONS
 For stable results how much arches have to be expanded ?
 Lower arch is more constrained than the upper
 Limitations for stable expansion maybe tighter than the upper
 2mm Limitation for forward movement of Lower Incisors, as Lip pressure
increases 2mm out into space
 Incisors Tipped Lingually away from Lip can be moved farther than Upright
Incisors

9.  More opportunity to expand Transversely than Anteroposteriorly – but
only distal to canines
 Reports show that Expansion across the canines is never maintained,
especially in Lower Arch
 Intercanine Dimensions decrease with age = Lip Pressure at corner of
Mouth
 Expansion across Premolars & Molars is likely to be maintained = Low
Cheek Pressures

10.  One approach to Upper Arch Expansion is by Opening the Midpalatal
Suture, if base is narrow !
 Theory (with no supporting Evidence), upper arch expansion, creating
Temporary Crossbite, Lower Arch follows Lead !!
 Excessive Expansion carries Risk of Fenestration of Premolar & Molar Roots
through the Alveolar Bone
 Increased Risk of Fenestration = Beyond 3mm of Transverse Tooth
movement

11.  Soft Tissue Limitation
 Fenestration of Alveolar Bone & Stripping of Gingiva
 Amount of Attached Gingiva = Critical Variable
 Pre-treatment with Periodontist

12. CONTEMPORARY EXTRACTION
GUIDELINES
Contemporary orthodontic extraction guidelines in Class I Crowding
 LESS THAN 4mm ARCH LENGTH DISCREPANCY:
 Extraction rarely Indicated
 Only if there is severe Incisor Protrusion
 Severe Vertical Discrepancy
 Some cases can be managed without Arch Expansion by slightly reducing
width of selected Teeth

13.  ARCH LENGTH DISCREPANCY 5 to 9 mm :
 Non Extraction or Extraction Treatment possible
 Decision depends on both Hard & Soft Tissue Characteristics
 Any of several Teeth can be chosen for Extraction
 Non Extraction Treatment = Transverse Expansion across Premolars &
Molars
 Additional Time if Posterior Teeth are to be moved Distally to increase
Arch Length

14.  ARCH LENGTH DISCREPANCY 10 mm OR more :
 Extraction almost always required
 Amount of Crowding equals the amount of Tooth Mass being Removed =
No effect on Lip support & Facial Appearance
 Extraction choice is Four 1st Premolars or Upper 1st Premolars &
Mandibular Lateral Incisors
 2nd Premolar or Molar Extraction rarely is satisfactory = No space near
crowded Anterior Teeth or Options to correct Midline

15.  Presence of Protrusion along with Crowding complicates the Extraction
decision
 Retracting the Incisors to reduce Lip Prominence requires Space within the
Dental Arch
 General Rule : Lips will move 2/3rd of distance that Incisors are retracted

16.  Retrospective Studies of Ex vs Non Ex cases = Highly variable changes
 The idea that Extraction will lead to narrow Arch and Incisor Retraction & that Non
Extraction leads to Incisor Protrusion and Wider Arches is NOT WELL SUPPORTED
Final Set of Guidelines :
 The more you can expand without moving Incisors forward = Satisfactory Treatment
 The more you can Close Extraction spaces without over Retracting Incisors =
Satisfactory Treatment
 Oral Health = Excessive Expansion increases risk of Mucogingival problems
 Masticatory Function = Expansion or Extraction makes no difference

17. SKELETAL PROBLEMS : GROWTH
MODIFICATION vs CAMOUFLAGE
 If it were possible, Best way to correct Jaw Discrepancy is to get the patient to grow out of
it
 Pattern of Facial Growth is established early in Life and it rarely changes
 Important Q’s = Extent to which Growth can be Modified ?
How advantageous it is to start treatment before Adolescence?
 Data from Randomized Clinical Trials for Class II Treatment outcomes are available
 Skeletal Problems in other Planes of Space remain Controversial

18. TRANSVERSE MAXILLARY
DEFICIENCY
 Close Relationship with Ex vs Non Ex decision
 Child with Crowded teeth, a Diagnosis of Maxillary Deficiency can be a
convenient Rationale for Transverse Expansion to align teeth
 Width of Maxillary Premolar teeth and Width of Palate = Methods to
Diagnose Maxillary Deficiency
 Midpalatal Suture becomes more Tortous and Interdigitated with
increasing Age

19.  In a Child age 9, any Expansion Device (Lingual Arch), will separate the
Midpalatal Suture, also move the molar teeth
 Adolescence, Heavy force from a rigid Jackscrew Device used for separation
(Microfracture
 Maxilla opens like a Hinge superiorly, at base of Nose, also opens more
Anteriorly than Posteriorly
 Heavy forces and Rapid Expansion should not be used in school children =
Risk of producing undesirable changes in nose at that age
 After Adolescence = Bony spicule Interlocked Suture = Surgery

20. In Adolescents, Expansion across the Suture can be done in 3 ways :
I. RAPID EXPANSION with jackscrew attached to Posterior Maxillary
Teeth, at rate of 0.5 to 1 mm/day
II. SLOW EXPANSION with same Device at rate of 1 mm per week
III. EXPANSION with a Device attached to Bone Screws or Implants

21. RAPID PALATAL EXPANSION
 Goal of Growth Modification = Maximize skeletal changes and Minimize the Dental Changes produced by Treatment
 THEORY : Rapid Force application to Posterior Teeth = Not enough Time for Tooth Movement = Force will be
Transferred to Suture = Suture will open while Teeth move Minimally
 RPE at rate of 0.5 to 1 mm/day
 1 cm or more Expansion is obtained in 2 – 3 weeks
 Most of movement being separation of two halves of Maxilla, Midline Diastema
 Expansion device left in pace for 3 – 4 months for Stability
 10 mm of Total Expansion = 8 mm of Skeletal Expansion & 2 mm of Dental Movement
 After 4 Months ( 10 mm Total Expansion ) = 5 mm of Skeletal Expansion & 5 mm Tooth Movement

22. SLOW PALATAL EXPANSION
 0.5 mm per week
 1 quarter turn of screw ( 0.25 mm ) every other day
 Ratio of Dental to Skeletal Expansion is 1:1
 Large Midline Diastema never appears
 10 mm of Expansion over 10 week period = 5 mm of Dental & 5 mm of Skeletal Expansion
 Overall result of Rapid vs Slow Expansion is similar
 With SPE a more Physiologic Response is obtained

23. CLASS II PROBLEMS
 In 1990’s two major projects using clinical randomized trial methodology
were carried out in University of North Carolina & University of Florida,
both were supported by NIDCR
 Data from Trials show 3 important things :
 Children treated prior to Adolescence, had significant improvement in their
Jaw Relationships
 Changes in Skeletal Relationships created during early treatment could be
reversed by Latter Compensatory Growth
 At the end of comprehensive treatment during adolescence, no differences
between early patients and previously untreated controls

24. CAMOUFLAGE BY TOOTH
MOVEMENT
 Tooth Movement alone cannot correct Skeletal Malocclusion
 If malocclusion is corrected and Facial Appearance is acceptable
then treatment outcome can be satisfactory, this is called
ORTHODONTIC CAMOUFLAGE
 Camouflage : Dental Occlusion + Facial Appearance
 Camouflage means that Jaw Discrepancy is no longer apparent

25.  Following 3 patterns of Tooth Movement can be used to correct Class II
malocclusion
 Combination of retraction of Upper teeth and forward movement of Lower
Teeth, without Extractions
 Retraction of Maxillary Incisors into a Premolar Extraction Space
 Distal Movement of Maxillary Molars and eventually the Entire Upper
Dental Arch

26. NON EXTRACTION TREATMENT
WITH CLASS II ELASTICS
 If Forward movement of Lower Arch can be accepted = Class II Malocclusion
can corrected using Class II Elastics
 Almost always, Class II patients have Lower teeth normally positioned on the
mandible or Proclined to some extent
 Result of Class II Elastics = Convex Profile with Protrusive Lower Incisors &
Prominent Lower Lip ==RELAPSE WAITING TO OCCUR
 After Treatment Lip Pressure moves Lower Incisors Lingually = Incisor
Crowding
 Return of Overjet and Overbite

27. RETRACTION OF UPPER INCISORS
INTO PREMOLAR EXTRACTION SPACE
 Straightforward way to correct Excessive Overjet = Retract Protruding Incisors
in to Space created by Maxillary Premolar Extractions
 Without Lower Extractions the patient would have a Class II molar relationship,
but normal Overjet and Canine relationship at the End
 Temporary Skeletal Anchorage
 If Mandibular 1st or 2nd Premolars are also Extracted = Class II Elastics can be
used to bring the Lower Molars Forward & Retract the upper Incisors,
correcting both Molar relationship and Overjet
 Class II Malocclusion due to Mandibular Deficiency ??
 TMJ Dysfunction ?

28. DISTAL MOVEMENT OF UPPER
TEETH
 If Upper Molars moved Posteriorly = correct a Class II Molar Relationship and
provide space into which other Maxillary Teeth could be Retracted
 More Often Maxillary 1st Molars are Rotated Mesiolingually when a Class II
Molar relationship exists
 Tipping the crowns Distally to gain space is difficult, and Bodily Movement is
Difficult Still
 Until recently the Anchorage by Transpalatal Lingual Arch is accepted as the
Best way to undertake Distalization
 Can be done Theoretically with a HEAD GEAR = Time Consuming & Excellent
patient compliance

29.  Palatal Anchorage for Molar Movement can be created by
Splinting the Maxillary Premolars & including an Acrylic
Pad in splint so it contacts the Palatal Mucosa
 2/3rd of space which opens between Molar & Premolars is
from Distal movement of Molars
 Tend to come forward again as rest of Maxillary Teeth are
Retracted so more than a half – cusp Molar correction
cannot be expected
 Ideal Patient = Minimum Growth potential + Good Jaw
Relationship

30.  Temporary Skeletal Anchorage = Greatly improves Distal movement of
Maxillary Dentition
 Space in Tuberosity region = Remove 3rd Molars
 Bone Anchors placed Bilaterally in base of Zygomatic Arch or in the Palate,
Nickel Titanium spring generates force needed for Distalization
 Bone Screws between Teeth prevent Distal Movement of Roots Mesial to
the screw
 In some patients = 6 mm of Distal Movement of 1st & 2nd Molars
 In addition the Premolars move back along with Molars ( Due to
SUPRACRESTAL FIBERS )

31. THE CAVEAT : (warning, Limitation)
 If Class II Malocclusion is due to Maxillary Dental Protrusion,
moving upper teeth back is logical approach
 But if there is Mandibular Deficiency, Retraction of Maxillary
Incisors after Distal movement of Molars & Premolars have same
Potential Problem as that with 1st Premolar Extraction

32. SUMMARY
 In the Absence of Favorable Growth, treating Class II is Difficult
 Compromises have to be accepted in order to correct occlusion
 Fortunately, even though Growth Modification cannot be expected to totally
correct an Adolescent Class II problem
 Some Forward Movement of Mandible relative to Maxilla does contribute to
successful treatment
 Rest of correction = Combination of Upper Incisor Retraction + Forward
movement of lower arch
 When No Growth expected = Orthognathic Surgery

33. CLASS III PROBLEMS
 Growth Modification is just reverse of Class II
 Differential growth of maxilla relative to Mandible
 Edward Angle’s concept = Class III exclusively due to Excess Mandibular
growth
 Any combination of Maxillary deficiency or Mandibular Excess
 Maxillary Deficiency frequent occurrence = Promotion of Maxillary growth

34. HORIZONTAL – VERTICAL
MAXILLARY DEFICIENCY
 If Headgear force = compressing Maxillary Sutures = Inhibition of Growth
 Reverse Pull Headgear = separating the sutures = Stimulate Growth
 Delaire & coworkers in France showed effects of reverse head gear
 RESULTS = Successful Forward repositioning of Maxilla can be
accomplished before age 8, afterwards the Orthodontic Tooth movement
overwhelms the skeletal change

35. Even in young patients, 2 side effects are almost inevitable :
 Forward movement of Maxillary Teeth relative to Maxilla
 Downward & Backward Rotation of Mandible
IDEAL PATIENTS FOR THIS TREATMENT :
 Normally positioned or Retrussive, but not Protrussive Maxillary Teeth
 Normal or Short, but not Long, Anterior Facial Vertical Dimensions

36. MANDIBULAR EXCESS
 Condylar Growth in response to Translation as surrounding Tissues grow
 Results from CHIN CUP THERAPY are discouraging (Lower Incisors Tipped
Lingually )
 DeClerk : Light but Full Time force from Class III elastics is used from
Skeletal Anchors in Maxilla to Skeletal Anchors in Mandible, effects on
both the jaws are observed

37. CLASS III CAMOUFLAGE
 Moderately Severe Class III = Proclining the Upper Incisors & Retracting
the Lower Incisors into Extraction space
 Unfortunately this illustrates as Camouflage Failure
 Failure especially likely = Large & Prominent Mandible
 Retracting the Mandibular Teeth = makes the chin more Prominent
 Improving Dental Occlusion while making Jaw Discrepency more Obvious
is not successful teatment

38. Candidate for Class III camouflage :
 Reverse Overjet due to Protrussive mandibular incisors & Retrussive
Maxillary Incisors
 Short Anterior Face Height so that a downward – Backward rotation of
Mandible would improve both anterior and posterior Vertical Facial
Proportions

39. VERTICAL PROBLEMS
 Skeletal vertical problems do not lend themselves to camouflage by tooth movement
 For Short Face Patients = Growth modification involves down and back rotation of mandible
without creating anteroposterior mandibular deficiency
 Which is why a short face Class III problem is more treatable than a long face one
 Long Face pattern of growth is difficult to modify & elongating anterior teeth to close off
accompanying open bite is Antithesis of camouflage
 Makes Facial appearance worse
 Orthognathic Surgery : Vertically Reposition the Maxilla
 Bone Anchors = Intrude Posterior Teeth

40. TREATMENT PLANNING IN SPECIAL
CIRCUMSTANCES
DENTAL DISEASE PROBLEMS
 Concern that Endodontically treated teeth cannot be moved
 As long as PDL is normal Endo treated teeth respond in same manner
 Hemisection !!
 In General, Prior Endo treatment does not Contraindicate Orthodontic Tooth
Movement
 Pre Ortho Periodontal Procedures
 Free Gingival Grafts

41. SYSTEMIC DISEASE PROBLEMS
 Systemic Diseases = Greater risk for complications
 Successful Orthodontic Treatment = Systemic Disease under control
 Most common is Diabetes Mellitus (DM)
 Diabetes under control = Good Periodontal response to Orthodontic Force
 Alveolar Bone Loss !!
 Diabetes not controlled = Real risk of Periodontal Breakdown and Bone Loss
 Prolonged Orthodontic treatment should be avoided

42.  Juvenile Rheumatoid Arthritis (JRA) = Severe Mandibular Deficiency
 Adult onset Rheumatoid Arthritis destroys condylar process
 Reduced mandibular growth reported in cases with steroid injections into TM
Joint for JRA treatment
 Long Term Steroid use = Periodontal Problems during Orthodontics
 Children on steroids also take BISPHONATES = Ortho impossible
 Prolonged Treatment avoided

43.  Orthodontic Treatment can be carried out in PREGNANCY, but there are risks
involved
 Gingival Hyperplasia, Hormonal Fluctuations
 Bone Turn Over issues = Alveolar bone loss & Root Resorption
 Radiographs to check status of bone = not permissible during pregnancy
 Treatment should be deferred until completion of pregnancy
 If patients becomes Pregnant during Treatment = Place her treatment in a
Holding Pattern during Last Trimester

44. ANOMALIES & JAW INJURIES
MAXILLARY INJURIES
 Fortunately, Injuries to maxilla in children are rare
 If displaced by Trauma = Immediately repositioned
 Protraction force from a face mask before Fractures have
completely Healed can Reposition it

45. ASYMMETRIC MANDIBULAR DEFICIENCY
 In planning treatment, its important to evaluate the condyle to see if its
translating properly
 Functional Appliance should be tried first
 Asymmetry with deficient growth on one side and normal on other side
HYBRID FUNCTIONAL APPLIANCE
 Requirements will be different for both sides
 Restriction of condyle = reduced growth on affected side
 Oral & Maxillofacial Surgery = Goal

46. HEMIMANDIBULAR HYPERTROPHY
 Facial asymmetry can also be caused by excessive growth at one
condyle
 Escape of growing tissues on one side from normal regulatory control
 Never Symmetric, Late Teens, Frequently in Girls
 Body of mandible affected = Bowing downward
 Old name = Condylar Hyperplasia
 Treatment = Ramal Osteotomy or Condylectomy