Diagnosis & treatment planing /certified fixed orthodontic courses by Indian dental academy

DIAGNOSIS AND TREATMENT PLANIING IN ORTHODONTICS

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

“The first step toward cure is to
know what the disease is......”

The Goal of an Orthodontist..........
1.
2.
3.

To obtain optimal occlusion with in a
framework of skeletal bases.
With the nerves, muscles surrounding in
harmony.
Normal function and stability.
Without damage to the health of the surrounding tissues (PDL,
gingiva, TMJ, etc…).


3

The objectives of orthodontic
treatment (Jackson’s Triad):




Functional stability
Structural balance
Esthetic harmony


TO be spoken out by sir, No need of this
slide, thus delete it before presentation.







Although this is definitive, it is obvious that it means different
things to different persons, so much so that large segments
of orthodontic profession, if presented with single case, would
start out in different directions toward different objectives by
different orthodontic means.
The last should matter little except that orthodontists, being
committed to certain appliances with their inherent limitations,
are not free to be objective about their objectives.
Concepts and standards have been devised which are
subservient to appliance limitations.
These concepts and resultant orthodontic objectives are as
different as black and white.
A CRITICAL ANALYSIS OF ORTHODONTIC CONCEPTS AND OBJECTIVES
William L. Wilson –AJO-DO 1957


One century back EDWARD. H. ANGLE rightly said:
“In studying a case of malocclusion, give no thought to the



methods of treatment or
appliances

until the case shall have classified and all peculiarities and
variation from the normal in




type,
occlusion and
facial lines have been thoroughly comprehended.

Then the requirements and proper plan of treatment
become apparent”.

The orthodontist must …
1. Know normal features of occlusion and
dentofacial complex.
2. Recognize the various characteristics of
the malocclusion & dentofacial deformity.
3. Understand the nature of the problem and
the etiology, if possible.
4. Design a treatment plan based on the
specific needs of the individual.

Therefore, this presentation is
divided into following sections:
1. Know Normal features of occlusion and
dentofacial complex.
2. Recognize the Various characteristics of
the malocclusion & dentofacial deformity.
3. Understand the Nature of the problem and
the etiology, if possible.
4. Design a Treatment plan based on the
specific needs of the individual.

The Beginning …


1.
Normal Features
of Occlusion & Dentofacial Complex


Normal Growth


When the horizontal,
vertical and transverse
growth components of
maxilla and mandible
match that of each other,
normal growth results.

Frontal or lateral view of Occlusion


Cranio-Facial Structures


2.
Diagnosis
Recognizing the various
characteristics of the malocclusion &
dentofacial deformity.


Some diagnosis are
osis




Easy,
Many are difficult and
Few are impossible

yet all are important , for diagnosis is the
trump
tru factor in providing orthodontic care.
care.






Human head is the most complicated
anatomical complex in all creation.
Here the interrelationships are infinite and
the causes and effects of these
relationships are almost imponderable.






The more our knowledge increases the more our
ignorance enfolds.
enfolds
The vast stretches of the unanswered and the
unfinished will outstrip our collective
comprehension.
? @ ? * kK ? & ?
#?A?L?I?
W???Q?F?%
??






Malocclusion is one such relationship of the
components of the human head which has
remained enigmatic despite staggering
advances in our level of knowledge and
comprehension.
Our lore on this subject abounds with
clinical dogma, with sacred tradition, and
even with myth.




Diagnosis is most neglected by many for
various reason:
1.

2.

3.
4.

Poor knowledge of basic medical sciences (e.g.
anatomy, physiology, …)
Poor education / importance to treatment of a
case rather than diagnosis
Variability and individual perceptions
Uniqueness of each individual patient


Problem Oriented and Evidence
Based Diagnosis




The goal of the diagnostic process is to
produce a complete description of the
patient’s problems and make a problem list.
To obtain the problem list, a collection of
relevant information is required. This
collection is called a database.


The Database
It is obtained from 3 sources.
1. Patient history, & interview data.
2. Clinical (extraoral, functional & intraoral)
examination.
3. Analysis of diagnostic records (models,
radiographs, cephalograms, photographs
etc.).


Diagnosis & Treatment Planning Steps
Patient History
Clinical
Examination
Analysis of
Diagnostic Records

Data
Base

Classification

Problem List
= Diagnosis

Treat pathology
Treat pathology
(caries, gingivitis etc.)
(caries, gingivitis etc.)
Problems
in
priority
order

A
B
C
D

Possible
solution to
individual
problems

A
B
C
D

Optimal
Treatment
Plan


Mechanotherapy

How to recognize the various
characteristics of the malocclusion?

Class I malocclusion
 Class II malocclusion
 Class III malocclusion







Class I malocclusion could be a result of
normal growth of all structures, or
It could be a product of various diverse
growth of the various structures of the
dentofacial complex, compensating each
other, to create a balanced face.


Take a slide from Ali’s seminar on
“Dentoalveolar compensation and
anatomical basis for malocclusion”
Where a Negroid face which is of
dolicofacial pattern gets
compensated
by extra-wide ramus.
This makes the chin
more prominent.




Class II Malocclusion






One such malocclusion is Class II
malocclusion.
Since Class II malocclusion is recognized
easily by health professionals as well as by
patients and their families, especially in
cases of excessive over jet, the correction
of class II problems may constitute more
than half of the treatment protocol in a
typical orthodontic practice.

It is interesting to note that the process of
evolution in orthodontic diagnosis and
treatment planning has been gradual.
 Now, let us trace through history, the
history
changing perceptions on the etiology of
class II malocclusion.







For decades together class II was
erroneously considered a purely sagittal
problem.
Pioneered by Dr. Angle’s classification of
malocclusion based on anteroposterior
relationship of first molar, probably
thousands of class II of all hues and varities
were treated as basically sagittal
discrepancies, often with disastrous results.



It was not the orthodontists alone who were
guilty of nescience, but even the surgeons
jumped onto the bandwagon and restricted
themselves to sagittal correction of what
was actually a problem involving more than
one plane.




The Angle system of classification still
remains at the core of orthodontic diagnosis
a century after its development, even
though this classification scheme is not
sensitive to imbalances in the vertical and
transverse dimensions.




First now let us see, how malocclusions
such as Class II develop as sagittal
discrepancy.


SAGITTAL PLANE
Prognathic Maxilla
Retrognathic Mandible
Combination of the two

A N I MA TI O N

Normal Mandible, Prognathic
Maxilla

2


Prognathic
Maxillary Dentition

2


Normal Maxilla, Retrognathic
Mandible.


Prognathic maxilla, Retrognathic
mandible.

2




Can also be because of decreased cranial
flexure, the posterior positioning of glenoid fossa
which neutralizes the horizontal growth of
mandible ending up in Class II.


Case 01 


VERTICAL DISCREPANCY






With the passage of time, inevitably there was
gain of knowledge and wisdom and the focus now
began to shift towards other etiologic possibilities
of class II malocclusion
It was schudy in 1964, who brought into focus the
vertical dysplasia causing and affecting the class
II malocclusion.
Until then investigators had never explored the
vertical dimension of the posterior aspect of the
face. But here were the secrets to be found.


Vertical Discrepancies


2

Discrepancies in the vertical dimension occur in the form of a
long face or a short face syndrome.


Rotations of Mandible


The rotation of the mandible due to vertical
growth discrepancies also has to be
distinguished.

H & V G R O WTH
MO R PHI N G S
3


Vertical Maxillary Excess


Vertical maxillary excess brings about a clockwise
rotation of the mandible and a class II situation.


Decreased Condylar Growth


Decreased condylar growth and decreased ramal
height swings the mandible backward.


Excess Condylar Growth


Excessive condylar growth causes forward rotation of the
mandible leading to a class II deep bite situation.






During the 1940s and 50s even class II due
to vertical maxillary excess were treated
with cervical pull headgear.
This accentuated the problem rather than
solve it.

Flash Player Movie




The disastrous results obtained led to the
realization that the traditional cookbook
approach of treating all class II
malocclusions with either



A bite jumping appliance or
a kloehn’s cervical headgear

might not be the right approach after all.






Now the concept changed such that when facial
morphology indicated that vertical growth had
been excessive or that condylar growth had been
deficient, the plan was to inhibit the downward
growth of the maxillary molars.
When it is determined that vertical growth is
deficient, the choice is to stimulate the vertical
growth of the alveolar processes.




This quantum shift in knowledge about the
causative factors of class II malocclusion
brought into light an entirely new gamut of
treatment possibilities.




Now let us look at some class II cases with
predominant vertical discrepancy and their
treatment options.


TRANSVERSE


DISCREPANCY

It has only been during the last two
decades or so that the role of transverse
dimension has been a topic of interest to
the typical practicing orthodontist.




Infact, the skeletal imbalances in the
transverse dimension often are ignored or
simply not recognized, and thus the
treatment options for such patients by
necessity are more limited than if these
transverse skeletal problems were
recognized.




Many class II malocclusions, when
evaluated clinically have no obvious
maxillary constriction.






When a set of study models of the patient are
“hand articulated", how-ever, it becomes obvious
that when the dental casts are placed with the
posterior dentition in a Class I relationship, a
unilateral or a bilateral cross bite is produced.
This indicates the presence of maxillary
constriction as a component of class II
malocclusion.


FOOT AND SHOE MECHANISM




Richen Bach and Taatz in 1971 used the example
of a foot and a shoe, with the foot representing
the mandible and the shoe representing the
maxilla.
If the shoe is too narrow, it is impossible for the
foot to slide fully into the shoe. By widening the
shoe, the foot slides forward into its usual
position.

Flash Player Mov ie




When treating in the mixed dentition, the
first step in the treatment of mild to
moderate Class II malocclusions
characterized, at least in part, by mild
mandibular skeletal retraction and maxillary
constriction may be expansion of maxilla.




The patients can be left in a over expanded
position with contacts still being maintained
between the upper lingual cusps and lower
buccal cusps of the posterior teeth.






Widening the maxilla often leads to a
spontaneous forward posturing of the
mandible during the retention period.
After 6 to 12 months, the spontaneous
correction of the class II relationship can be
seen in many mild to moderate class II
patients.




The net result of this change in outlook has
been a reduction in the number of
functional jaw orthopedic appliances that
now are used in the treatment of mild to
moderate class II malocclusion.


3.
The Etiology
The Nature of the Problem
(If Possible)


Deep Mento-Labial Sulcus


Mouth Breathing


Enlarged Tonsils


Infantile swallow


Tongue thrust swallow


Hyperactive mentalis


FUNCTIONAL ANALYSIS


Normal Closure (Without Shift)


Posterior shift of Mandible

8
8

7
7
7


7
8
88

VERTICAL RELATIONSHIP

TRUE DEEP BITE

PSEUDO DEEP BITE


LATEROGNATHY


LATEROCCLUSION


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