01.A lady over 40 years presents requesting orthodontic treatment. What factors would influence you in prescribing such treatment compared with that of a child of 12 years of age?
02.Under what circumstances correction of posterior cross bite is desirable. Describe the appliances that you would use.
03. Describe the criteria that indicate limitation for orthodontic treatment.
04.Discuss the factors that limit orthodontic treatment.
The objectives of orthodontic treatment must be to produce a occlusion which is healthy Functionally adequate and stable. It is not always possible to carry out an ideal treatment plan to achieve all the above objectives in all patients. It may be necessary to modify treatment plan since in certain situations long term comprehensive treatment plan can jeopardize the general health of the individual. Can cause devitalization. Root resorption of the teeth and periodontal damage,
Factors which impose limitations on orthodontic treatment.
Attitude of the patient.
A child undergoing treatment should actively participate in the treatment carrying out instructions given regarding appliance wear. Therefore, cooperation is very important in orthodontic treatment. A child who is aware of the effects of the malocclusion on his facial appearance and seek treatment on his own is more cooperative than a child who is persuaded by parents to accept treatment.
One should not carry out orthodontic treatment in an antagonistic patient even if the malocclusion is severe. It is better to defer treatment until the child is convinced of the merit of orthodontic treatment.
Psyhological behavioural problems.
A child who has a poor progress in school and learning disability or mentally subnormal has a short attention span. It un vise to offer a complicated orthodontic treatment to such a patient who does not have the skill required to wear and maintain the appliance accurately. It may be a good idea whenever possible to reduce the patient responsibility in carrying out treatment as for example in a case with a cross bite better results can be obtained with a simple fixed appliance rather than with a removable appliance.In adult patients extra care should be taken to assess psychological status since many attribute to their failure of life to the malocclusion. And it is very difficult to produce a satisfactory occlusion which will be acceptable to the patient
2. Age and growth of the patient
The progress of the treatment is strongly influece by growth. The accelerated facial growth at puberty is very important and it is the most favourable time to correct many occlusions which has skeletal problems. The treatment mechanics available is very limited in an adult patient who has completed growth.
History of cardiac defects rheumatic heart disease are not absolute contra indications for orthodontic treatments but if there is any surgical procedure involving which can lead to bactereamia should be performed under antibiotic cover. If there is gingival inflammation certain orthodontic appointments like hand scaling like hand scaling may require pre medication to minimize the chance of developing bacteremia.
Epilepsy. Patient with a history of epilepsy has a potential medical emergency during orthodontic treatment since the orthodontic appliance can damage during convulsions with possible danger of airway obstruction if the condition is n ot controlled properly. Even if the patient is under control longer term medication with dialantin sodium can lead to gingival hyperplasia which lead to periodontal problems during orthodontic treatment.
Fixed appliance treatment which tends to food stagnation is better avoided in epileptic patients.
Patients with diabetics even with good systemic control may experience rapid loss of periodontial tissue during orthodontic treatment.
Patients with longterm steroid therapy for systemic illnesses can mask inflammatory reactions, they may not manifest signs of periodontal disease during orthodontic treatment and give rise to severe damage to periodontal tissue.
Ptents with arthritic disorders may require special treatment plan because of predilection to degenerative changes in the condyle. It is important to minimize the force on the TN joint during orthodontic treatment.
A patient with caries prone mouth is not suitable for fixed appliance treatment since decalcification of teeth can progress under the band and brackets causing further damage Teeth with deep restorations may be undergoing pulpal degenerations the extraction pattern of teeth should be modified in such cases.
Traumatized teeth impose limitations on orthodontic treatment since even it may have been treated endodontically and have been asymptomatic for many years may become sensitive and develop periapical pathology once tooth movement has begun. Therefore, patient with history of trauma to the teeth and to the jaws should eb carefully examined for formation of root , fracture of roots apical blunting and signs of root resorption and the treatment plan should be modified accordingly.
Teeth that are unerupted or impacted can interfere with alignment. Teeth adjacenet to them leading to root resportion if treatment is attempted. Treatemnt plan should be modified and deferred to reduce the risk of damage. For example alignment of lateral incisor in a case with impacted canines which close to the root of lateral incisor. Unerupted supernumerary teeth in the midline may interfere with diastema closure. Unless they are removed surgically.
Teeth with minor dilacerations can be aligned orthodontically But severely dilacerated teeth may need surgical removal.
Problem related to failure of eruption.
Ankylosis of primary or permanent tooth may limit orthodontic treatment. If ankylosis occur in a growing child continued vertical development of other teeth leave ankylosed teeth behind so it appear submerged. The teeth cannot be brought into alignment by orthodontic means since there is no periodontal membrane. In cases with primary failure of eruption teeth so fail to erupt due to abnormalities in periodontal ligament. Abnormal periodontal ligament does not respond to orthodontic forces even if they are ot ankylosed when orthodontic force is applied after surgical exposure teeth become ankylosed making orthodontic alignment impossible.
Gingival and periodontal problems.
Orthdontic tooth movement depend on the integrity of healthy periodontium. There is a bone resorption and deposition on the socket wall in response to orthodontic force without permanent damage to periodontium. But if there is periodontal disease at the beginning of the treatment appliance can cause food stagnation and brushing techniques may be less effective which can lead to further damage to periodontal condition. Therefore orthodontic treatment should not be attempted without controlling periodontal disease.
In certain patients there may be juvenile periodontosis with gross destruction of alveolar bone. Orthodontic treatment should not be attempted until the condition is fully under control. Even space closure following loss of first molar or incisor due to disease should be undertaken when it is completely cured.
Periodontal disease is more common in adult patients with loss of crestal bone. The amount of tooth movement is limited. If there is lack of bone support.
Cleft of gingival.
There may be gingival clefts due to lack of attached gingiva specially in the mandibular lateral segments this can give rise to deep pockets and periodontal problems. If orthodontic treatment is to be carried out it is necessary to do periodontal surgery by free gingival grafts. Before undertaking orthodontic treatment. If not these teeth best extracted to relieve crowding of labial segment.
Gingival hyperplasia may be seen in upper labial segment in class II division 1 cases with gross lip incompetence due to drying of labial gingivae. This is not a contra indication for treatment. In fact once the maloclusin is corrected and when the patient obtain lip seal it regresses. But if the paitnet is on dilantin sodium gingival hyperplasia may need gingivectomy gingivplasty before undertaking orthodontic treatment.
Defects of bone.
Clefts. Teeth can be moved only through the bone in cases with clefts teeth cannot be moved across the cleft. The position of the tooth should be accepted or cleft should be filled with bone graft before attempting alignment
Dehisence. ( vertical splitting) or fenestration ( round holes )in alveolar bone can limit orthodontic tooth movemtn. When there is such defects on labial alveolar bone especillay with prolcined upper incisors retraction of the teeth by tipping movement is impossible since the root may penetrate through the bone leading to deep periodontal pocket. During expansion of upper arch by movement of teeth extent if the expansion will be limited if there is such defects on buccal alveolar bone.
Skeletal problems of all three planes of space will limit orthodontic treatment
Soft tissues – lips and the tongue
Incorrect diagnosis and treatment plan.
Choice of appliance