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Saturday, July 30, 2011

Orthodontic Treatment Planning

  • The treatment planning approach advocated here is specifically designed to avoid both missed opportunities (the false negatives or under-treatment side of treatment planning) and excessive treatment (the false positive or over-treatment side), while appropriately involving the patient in the planning.

1.  The sequence of steps in planning orthodontic treatment
- Diagnosis results in a comprehensive list of the patients problems.
  1. Separate orthodontic (developmental) problems from pathological ones.
  2. Put the orthodontic problems in priority order.
  3. Note the treatment possibilities, being sure to be complete.
  4. Evaluate the possible solutions, considering factors that can affect the probable result.
  5. Establish the treatment plan concept in an interactive session with the patient and parents.
  6. Develop the detailed plan of clinical steps and procedures.

  • Control all disease states first
  • Setting priorities for orthodontic treatment
  • Balance between patient’s wishes and the severity of the problem
  • Above all do no harm

a) Creating the Problem List:  Pathologic vs. Developmental Problems
An important principle is that a patient does not have to be in perfect health to have orthodontic treatment, but any problems related to disease and pathology must be under control.  Developmental problems should be identified.
b)  Setting Priorities for the Orthodontic Problem List
Putting the patient’s orthodontic (developmental) problems in priority order is the most important step in the entire treatment planning process.  In order to maximize benefit to the patient, the most important problems must be identified, and the treatment plan must focus on what is important for that particular patient.  Sequence the 5 components of the Ackerman-Proffit scheme based on severity

2.  Treatment Possibilities
At this stage each problem is considered individually, and for the moment the possible solutions are examined as if this problem were the only one the patient had.  Broad possibilities, not details of treatment procedures, are what is sought.  The objective is to be sure that no reasonable possibilities are overlooked.
Factors in evaluating treatment possibilities
a)  Interaction among possible solutions – example: relation between horizontal and vertical dimensions
b)  Compromise:  In a broad sense, the major goals of orthodontic treatment are ideal occlusion, ideal facial esthetics, and ideal stability of result.  Often it is impossible to maximize all three. An example of compromise is extraction of teeth for orthodontics
c)  Cost-risk/ Benefit analysis:  Often Cost-Risks of procedures are overlooked in the light of benefits.  “Is it worth it?”  Benefits need to outweigh the cost-risks.  Costs include “burden of care”.  Risks include negative consequences, side effects, and unexpected events.

3.  Informed Consent
·           Paternalistic approach:  the doctor should analyze the pts  situation and should prescribe what he or she had determined to be the best treatment – the doctor, as a father figure, knows best and makes decisions (No longer used)
·           Patient centered approach:  pts have a right to determine what is done to them in treatment. Pts must be told what their problems are, what the treatment alternatives are, and what the possible outcomes of treatment or no treatment are likely to be.

4.  Indication for Orthodontic Treatment
a)  Psychosocial (treat only if severe malocclusion)
b)  Developmental (ankylosis, or congenitally missing teeth)
c)  Functional (respiration, TMD, Mastication, Speech)
d)  Trauma/Disease control (tx for prevention of trauma to protruding incisors, tx not indicated for disease control in kids)

5.  Timing of Orthodontic Treatment
a)  Traditional timing during adolescent growth spurt and permanent dentition
b)  Treatment in the mixed dentition

6.  Treatment in the primary dentition – summary
·           Malposed, crowded, and irregular incisors are uncommon, but the absence of spaces between primary incisors often indicates that there will be crowding when permanent incisors erupt.  No treatment is indicated until the mixed dentition.
·           Space should be mnaintained for missing primary molars, but not anterior teeth.
·           Posterior crossbites, particularly those with a lateral shift of the mandible upon closure, should be treated in the primary dentition, either by occlusal adjustment or by maxillary expansion.
·           Anterior crossbites caused by forward mandibular shift should also be treated early
·           Although skeletal anteroposterior and vertical problems can be detected in the primary dentition, treatment is indicated only for the most severe problems.

7.  Treatment in the early mixed dentition
a)  Moderate problems
Space problems (missing teeth, localized space, generalized moderate crowding)
Irregular/Malpositioned Incisors (spaced and flared max incisors, max midline diastema, anterior crossbite)
            Posterior Crossbite
            Anterior Open bite
            Over retained Primary teeth and Ectopic Eruption
b)  Severe problems – focus on “Serial Extraction”
                        Skeletal
                        Dentofacial Problems related to incisor Protrusion
                        Space Discrepancies of 5mm or more
                        Serial Extraction
·           Applies to pts who meet the following criteria: 
1.      no skeletal disproportions
2.      class I molar relationship
3.      normal overbite
4.      large arch perimeter deficiency (10mm or more)
·               Procedure consists of 4 steps
1.      Extraction of primary lateral incisors as the permanent central incisors erupt (if necessary, often happens naturally)
2.      Extraction of primary canines as the permanent laterals erupt
3.      Extraction of primary fist molars, usually 6 to 12 months before their normal exfoliation, at the point when the underlying premolars have one half to two thirds of their roots formed
4.      Extraction of the permanent first premolars before eruption of the permanent canines.

8.  Treatment for Adolescents (Late mixed and early permanent dentition)
Dental Component
Late Mixed Dentition
Early Permanent Dentition
Alignment Problems
Spacing = no tx ??
Crowding & protrusion= serial extraction/space maintenance with appliances
Crowding: orthodontic appliances
interproximal reduction/Extraction
Spacing:  retraction/Restorative options
Transverse Problems
Excess = Constrict dental archform
Deficiency = Expand dental archform (RPE, fixed or removable appliances)
Excess = Constrict dental archform
Deficiency = Expand dental archform
Severe: surgery
Anteroposterior Problems
Camouflage
Growth Modification

Distalize or Advance Teeth
Camouflage
Surgery
Vertical Problems
Excess = Intrude teeth
Deficiency = Extrude teeth
Growth modification
Excess = Intrude teeth
Deficiency = Extrude teeth

Skeletal Component
Growing (Late Mixed Dentition)
Non-Growing(Early Permanent)
Alignment Problems


Mild:  Camouflage ??
Severe:  Surgery ??
Transverse Problems
Excess = No Treatment
Deficiency = RPE (max)/No Tx (man)
Mild:  Camouflage
Severe:  Surgery
Anteroposterior Problems
Excess = HG (max)/No tx (man)
Deficiency = Functional Appliances
Mild:  Camouflage
Severe:  Surgery
Vertical Problems
Excess = Functional Appliance
Deficiency = Functional Appliances
Mild:  Camouflage
Severe:  Surgery
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