Orthodontist Guide to Diagnosis and Treatment Planning

Orthodontist – The Smile
Architect

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


Department of Orthodontics and
Dentofacial Orthopaedics


More than just beautiful smiles…...


The Forgotten
Triad……


Diagnosis
• Diagnosis is the key to

• However, Diagnosis is no cake walk.

• Diagnostic aids help us to come as close
as possible to a comprehensive diagnosis.

COMPREHENSIVE
DIAGNOSIS


• However, in the field of orthodontics, at
the time of diagnosis, the treatment
objectives are set and the diagnosis, as
such, is considered only tentative until
those treatment objectives are achieved,
because the tissue response and the
duration, direction and magnitude of
growth varies in individual patients.

•

Hence, as a clinician, a thorough knowledge of
the normal is a must in order to recognize any
deviations from the normal.


Primary Spacing


Deep Bite
(Early Deciduous Dentition)
Eruption of first permanent molars
Attrition of Incisors
Forward movement of the mandible
due to growth

Edge-to-edge bite
(Late Deciduous / Early Mixed Dentition)

Incisal Liability

Usage in Inter-canine Width
Increase of Primary Spacing
Increased labial inclination of permanent incisors

Leeway space
0.9mm

1.7mm

Ugly Duckling Stage


Andrew’s Six Keys to
Normal Occlusion
Mesio-distal
Molar Inter-arch
Labio-lingual
Angulation
Relationship
Crown Inclination

+7º

18º

Key 3
2
1

5º

90º

Occlusal plane
90º
90º

-1º
16º

Andrew’s Six Keys to
Normal Occlusion
Curve of Spee
Absence of Rotation
Tight Contacts
not exceeding
Key 5 1.5 mm
6
4


Skeletal

Combination


Dental

Maxilla

Combination


Mandible

Planes


Combinations


Malocclusions in the Saggital Plane


Class II Malocclusion - Dental
Normal


Class II Malocclusion - Skeletal
Normal


Class III Malocclusion - Dental
Normal


Class III Malocclusion - Skeletal
Normal


Malocclusions in the Vertical Plane


Open bite


Deep bite


Malocclusions in the
Transverse Plane


Posterior Cross bite


Anterior Cross bite


Orthodontic Treatment
– Age no bar


Orthodontic Treatment

Preventive

Corrective

Orthodontic

Active Appliance
Therapy

Interceptive

Orthognathic

Camouflage

Adjunctive


Retention

Preventive Orthodontics
“Prevention is better than cure”
So, “Catch ‘em young”
•

Preventive orthodontics includes procedures
undertaken prior to the onset of a malocclusion
in anticipation of a developing malocclusion.

•

The following are some of the procedures
undertaken in preventive orthodontics:
1.
2.
3.
4.
5.

Parent education
Caries control
Supervision of timely tooth shedding
Space maintenance
Checkup for oral habits and habit breaking appliance
if necessary
6. Occlusal equilibration if there are any occlusal
prematurities
7. Extraction of supernumerary teeth
8. Management of abnormal frenal attachment

Space Maintenance
• Premature loss of deciduous teeth can cause
drifting of the adjacent teeth into the space.
• This can result in abnormal axial inclination of
teeth, spacing between teeth and sometimes a
shift in the dental midline, i.e. – malocclusion.
• Space maintenance is the maintenance of the
mesio-distal and vertical width of an arch space
created by the loss of deciduous dentition.
• The appliances/devices used or intended to be
used for this space maintenance are called
space maintainers.

Removable Partial Denture

Crown and loop

Lingual Arch

Distal Shoe


Habits
• A habit is ‘an act that has become fixed
due to repeated performance.’
• Oral habits in children have a definite
bearing on the development of occlusion.
• Frequently, children acquire certain habits
that may either temporarily or permanently
be harmful to dental occlusion and to the
supporting structures.

• However, when the habit is corrected while the
occlusion is still undisturbed and no
malocclusion has set in, it is termed as
preventive orthodontics.
• But, in case the habit has already caused the
onset of a malocclusion, the measures applied
to correct the habit are termed as ‘interceptive
orthodontics’.

Interceptive Orthodontics
“A stitch in time saves nine”
• Interceptive
orthodontics
includes
procedures that are undertaken at an
early stage of a malocclusion to eliminate
or reduce the severity of the same.


•

The
procedures
undertaken
interceptive orthodontics include:
1.
2.
3.
4.
5.
6.

Serial extraction
Correction of developing cross bite
Control of abnormal habits
Space regaining
Muscle exercises
Interception of skeletal malrelation

in

Serial Extraction
• The early mixed dentition is easily prone to
development of irregularities in the dento-facial
complex.
• When
such
potential
irregularities
are
recognized and anticipated, the planned
extraction of certain deciduous teeth and later
specific permanent teeth in an orderly sequence
and pre-determined pattern can help in guiding
the erupting permanent teeth into a more
favorable position.

Correction of developing cross bite

Pre treatment

Post treatment


Interception of Habits
• Interception of the habit will cause interception of
the developing malocclusion effected by the
habit.
• Some of the common oral habits:
–
–
–
–
–
–

Thumb sucking
Tongue thrusting
Mouth breathing
Bruxism
Lip biting
Nail biting

Buccinator Mechanism
Thumb sucking


Thumb sucking


Tongue Thrusting

Pre treatment

Post treatment


Mouth Breathing
Oral Screen

Pre treatment

Post treatment


Space Regaining


Interception of Developing
Skeletal Malrelationship


Interception of developing skeletal
class II

Pre treatment

Post treatment


Interception of developing skeletal
class III

Pre treatment

Post treatment


Corrective Orthodontics
“Better late than never”
Corrective
orthodontics
includes
procedures undertaken to correct a fully
established malocclusion.
These corrective procedures may be:
 Orthodontic
 Orthognathic (Surgical)

Envelope of discrepancy
10

6
4
10

5

2

Orthodontics
alone
7

2
Growth modulation &
orthodontics
5
Orthodontics and orthognathic
surgery

12

15

Orthodontic Corrective
Measures
• It includes the following:
Active Appliance Therapy
Camouflage
Adjunctive Orthodontics
Retention

Active Appliance Therapy


Case 1


Pre Treatment – Extra Oral


Pre Treatment – Intra Oral


Pre Treatment - Occlusal


With Appliance


Post Treatment - Extraoral


Post Treatment- Intraoral


Post Treatment- Occlusal


Pre treatment

Post treatment


Case 2


Post Treatment – Extra Oral


Post Treatment – Intra Oral


Case 3


Pre Treatment – Occlusal


Post Treatment – Occlusal


Case 4


Pre Treatment - Extra Oral


Pre Treatment Radiograph – Lateral Cephalogram


Post Expansion – Intra Oral


Post Expansion - Occlusal


Post Treatment - Occlusal


Post Treatment – Lateral Cephalogram


Case 5


Pre Treatment – Lateral Cephalogram


TREATMENT PLAN:

• Growth still remaining, hence reverse pull
headgear
• RME for expansion of narrow maxilla
• Fixed therapy with PEA mechanics


Mid Treatment – Reverse Pull Head Gear


Mid Treatment – Intra Oral


Mid Treatment – RME


End of Orthopaedic Phase – Extra Oral


End of Orthopaedic Phase – Intra Oral


End of Orthopaedic Phase – Occlusal


Mid Treatment – Fixed Therapy


Fixed Therapy – Intra Oral


Fixed Therapy – Occlusal


Fixed Therapy – Lateral Cephalogram


Pre treatment

Present Status


Orthognathic
• Orthognathic surgeries are major surgical
procedures carried out along with
orthodontic therapy to correct dento-facial
deformities
or
severe
oro-facial
disproportions involving the maxilla, the
mandible or both in combination.


•
1.
2.
3.
4.
5.

Steps involved in orthognathic surgery:
Diagnosis (pre operative evaluation)
Pre-surgical orthodontics (reverse
orthodontics)
Mock surgery
Surgery and stabilization
Post-surgical orthodontics

Pre Treatment - Intra Oral


Pre Treatment Lateral Cephalogram


Pre Surgical (After decompensation) – Extra Oral


Pre Surgical (After decompensation) – Intra Oral


Pre Surgical (After decompensation) - Occlusal


Pre Surgical (After decompensation) – Lateral
Cephalogram


Occlusal Splint


Post Surgical – Extra Oral


Post Surgical – Intra Oral


Post Surgical – Lateral Cephalogram


Pre Treatment

Pre Surgical


Post Surgical

Pre Surgical


Present Status – Intra Oral


Present Status – Occlusal


Pre Surgical – Lateral Cephalogram


Post Surgical - Occlusal


Post Surgical - Lateral Cephalogram


Present Status – Extra Oral


Present Status - Occlusal


Present Status - Lateral Cephalogram


Camouflage
• ‘Disguise of guns, ships etc effected by
obscuring outlines with splashes of
various colours.’
- Oxford Dictionary
• ‘To deceive observation, or plan as a false
front.’
- Webster’s Dictionary

• The orthodontist uses ‘camouflage’ treatment in
cases where the ideal treatment protocol was/is
not possible due to some reason or the other, to
try and improve the dental occlusion and facial
esthetics.
• The term ‘camouflage’ is chosen to emphasize
that successful treatment must produce
“acceptable” facial esthetics as well as
“acceptable” dental occlusion.

Mid Treatment


Post Treatment - Extra Oral


Post Treatment - Intra Oral


Post Treatment - Lateral Cephalogram


Adjunctive Orthodontics
• Adjunctive orthodontic treatment is tooth
movement carried out to facilitate other
dental procedures necessary to control
disease and restore function.


Case 1
Increasing pontic space


Case 2
Correcting traumatic occlusion


Retention
“It’s not over till it’s over”
“I will give you half my fees if you can retain what I
have achieved”
• Retention is the phase following active
orthodontic treatment aimed at stabilization of
achieved orthodontic correction or holding of the
teeth in ideal functional esthetic occlusion.

Retention is necessary for three reasons:
 The gingival and periodontal tissues are affected by
orthodontic tooth movements and require time for
reorganization, when an active appliance is removed.
 After treatment, the teeth are in unstable condition.
So the soft tissue pressures constantly produce
relapse tendency.
 Growth changes can alter orthodontic results.

• Aids to retention:
 Natural Aids
 Surgical Aids
 Mechanical Aids


A beautiful smile…

… is your choice.


A

is contagious -

Lets start an

epidemic!

Thank you

Orthodontist Guide to Diagnosis and Treatment Planning

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