diagnosis and tx planning Flashcards
general principles of tx planning and dx
history
examinaiton
differential diagnosis
special tests
diagnosis
tx plan
tx
outcome
history consists of
CO/ PMH/ PDH/ SH
examination consists of
extra and intra oral exams
differential diagnosis is
list of probables
special tests can be
radiographs
photos
3D lat cephs or CBCT
diagnosis is
decription of pathology/issue
IOTN
2 possible tx routes for ortho
accept
appliance
outcome for ortho tx measured with
PAR index
impact and success of tx, score before and after and assess reduction
differential diagnosis for oral ulceration
- Traumatic
- ROU – major or minor
- Behcet’s disease
- Stephen Johnson syndrome
- Viral causes – varicella zoster, primary herpetic or secondary herpetic stomatitis, pemphigoid
- Crohn’s
- Squamous cell carcinoma
Can narrow down from history.
difference between orthodontic and other dental dx
different describing what is there no real input into origin of malocclusion
importance of IOTN
index of orthodontic treatment need
NHS funded or not
dx in ortho
description of malocclsuion
determine the cause of the malocclusion
- are the causes dentoalveolar or skeletal?
- ortho tx alone or need surgical
e.g. class II div 1 incisor relationship
small teeth =
spacing
early loss of deciduous teeth=
crowding
digit sucking=
proclination and increased OJ
majority of cases cause of malocclusion
uncertain
lateral cephalogram looks at (3)
AP skeletal
vertical skeletal
class III incisors
cephalometry aids us as it
inform clinical impression
analyse better OJ, reverse OJ, high or low angle etx
why is the correct orthodontic dx important
- Orthodontic appliances can move teeth very well, but can modify skeletal relationship minimally
- A severe skeletal discrepancy may require surgical intervention
Careful planning is essential to ensure we don’t make mistakes
anterior x bite
dental or skeletal
dental
URA
z spring move 21 forward
6 weeks approx to end tx
anterior xbite
dental or skeletal
Maxilla hypoplasia and mandibular prognathism
braces won’t be effective – front teeth bite too forward, lowers too back.
Need to wait to fully grown and then do surgery
objective of orthodontic tx
To produce an occlusion which is:
- Stable
- Functional
- Aesthetic
And facilitate other forms of dentistry (crowns, bridges etc)
tx planning
- aim of tx
- tx plan in stages
- complex procedural
- Take time – do whilst pt not there so can think of multiple ideas and pros and cons
better with practice
- every pt is unique
- Realistic dentistry – bespoke to pt, fully aware of tx, risks and benefits (consent)*
tx plan should consider (11)
- future growth changes
- aetiology of malocclusion
- pts soft tissue profile
- retention
- stability
- pt wishes
- access to tx
- compliance
- space requirements
- aims of tx
- prognosis of individualised teeth
creates a priortised problem list –> definitive tx plan
how can access to tx affect tx plan
ortho is Long term tx – need to be able to attend frequently - location may hinder
how can future growth changes affect tx plan
Class III often grow adversely in teens
Can you harness growth - class II div1 (functional)
what does all the consideration of tx plan create
a priortised problem list –> definitive tx plan
2 differents options for aims of ortho tx
full correction of malocclusion (comprehensive)
compromise treatment
full correction of malocclusion has
(comprehensive)
- Class I incisor relationship (OJ/OB normal)
- Class I canine relationship
- Class I molar relationship (can accept class II)
- No rotations, spaces, flat occlusal plane (Andrew’s six keys)
compromise tx is
- Correct certain aspects accepting others
- E.g. accept buccal crossbite with no displacement
- upper teeth narrow sitting within lower teeth is functionally OK (3-3 fine, or 4s distal)
- E.g. accept buccal crossbite with no displacement
- May have to work within adverse skeletal pattern and leave residual OJ particularly in adults (they do not want surgery)
if no functional problem why try to tx
e.g compromise tx case
- Large OJ, plays flute in orchestra*
- Options – no Tx, orthognathic surgery, have compromised (couldn’t run 10% risk of numb lip as of flute)*
- Buccal segment at back not right, only 3 lower incisors, pt left canine is long and anterior
- OJ fixed
Not 100% but improved
stages of tx planning (4)
- Plan around the lower arch (angulation of LLS is stable)
- Decide on treatment in lower (ext/nonext)
- Build upper arch around lower
- aim for class I incisor and canine relationship
- OJ and OB normal – if uppers are normal size, shape and number (e.g. no peg laterals, micro)
- aim for class I incisor and canine relationship
- decide on molar relationship
- class I or full unit class III molar relationship
LLS in ortho
lower labial segment
just incisors
(perio inc canines)
why do we decide tx around lower arch
angulation of LLS
can’t really alter (lip, tongue - sit in zone of balance)
why is the aim for class I incisor and canine relationship
(if OJ and OB normal, normal size/shape/number teeth)
Want canine guidance class I – gold (upper behind lower), prevent wear due to group function
OJ – no where to go but sit further forward
3 components of examination of lower arch
- crowding/angulation of incisors in mandibular plane
- angulation of canines/centrelines
- curve of spee (or deepbite)
crowding/angulation of incisors in mandible considerations
- Space required? what are the options?
- Extraction or non extraction?
- habits? STOP
curve of spee (or deepbite) consideration in mandible
need time to level off
angulation of canines in mandible consideration
canines
- tip forward – can easily tip back;
- tip back and crowding – harder to tip forward again- effort
centreline of mandible considerations
need to extract to shift
balance extractions to try and keep place
examination of upper arch considerations
- crowding/angulation of incisors to the maxillary plane
- angulation of canines/centrelines
canines class II and OJ
and place appliance to try and resolve
if place appliance to remove OJ still left with some as canine class II
- Need to get canine behind lower canine to have chance of class I and normal OJ
teeth in occlusion examination (ICP) (6)
- Incisor relationship
- OJ
- OB (curve of spee)
- Centrelines
- Canine relationship
- Molar relationship
crowding assessment Qs and 2 techniques
Do you need to extract teeth?
- Measure space available and space required
- Overlap technique
crowding assessment - space available and space required
Estimate space available
- A + B + C + D = arch length or space available
- Divide into 4 sections
- Mesial 6 to distal 2
- Distal 2 to centreline
- Centreline to distal 2
- Distal 2 to mesial 6
- Divide into 4 sections
- Measuring how much bone you have – space*
- Teeth reference points*
Then Estimate width of all teeth anterior to first permanent molars
- 1 + 2 + 3 + 4 + 5 + 6 + 7 + 8 + 9 + 10 = space required
Estimate degree of crowding
- Space available = 69mm
- Space required = 74mm
- Discrepancy = -5mm
Callipers on models – tedious
crowding assessment overlap
Eyeball how much teeth overlap each other – contact points
Quicker than measuring with callipers
mild lower arch crowding
0-4mm
moderate lower arch crowding
5-8mm
severe lower arch crowding
8+mm
management options of mild lower arch crowding (0-4mm)
- non-extractions (stripping)
- extract 5s
stripping
Interproximal enamel reduction
- Metal sandpaper between teeth
0. 5mm space per surface so can be quite large 3-3 (12mmm)
mild crowding
moderate lower arch crowding management options
(5-8mm)
- extract 5s
- extract 4s
severe lower arch crowding management option
(8+mm)
extract 4s
approx space of lower 4s
7mm
why extract lower 4s over lower 5s in more severe lower crowding situations
Lower 5 may look bigger than lower 4 but get less space due to mesial drift of 6
- no appliance needed – whereas 4 will need appliance to close space
But don’t do in severe crowding as wont get enough space and lose space due to mesial drift – lose credibility with pt
if you extract in lower arch then
extract in upper arch
to get molar relationship I
- want to avoid molar relationship III
get class I canine too
e.g. both lower 4s extracted, extract both upper 4s
if you don’t extract in lower arch…
don’t necessarily extract in upper
- extract in upper arch (MR class II )
- depend on OJ or crowding
- distalise UBS using headgear (MR class I)
- difficult, time-consuming
- e.g. Incisors and canine both class I, OJ and OB normal*
- But molars are class II (one unit forward) – acceptable
malocclussion and incisor relationship
interchangeable
malocclusion is defined by incisor relationship
ortho dx
- class II div1 malocclusion
- class II sk base
- increased OJ
- increased OB
- severe crowding lower arch
- moderate crowding upper arch
- rotations
soft tissue point A
innermost curvature below the nose
soft tissue point B
innermost curvature below the mandible
if soft tissue point A and B are more than 2-3mm apart get
class II
rotations present mean
need a fixed retainer for life to prevent rotations coming back
is 8mm crowding in lower arch
severe crowding
extraction of 4s required
- mentally move lower canines until the lower arch is aligned
- If include the canines in LLS tempted to bring laterals forward to round arch off – UNSTABLE*
- So to create space need to move 3s back into space vacated by 4s, then can deal with crowding without proclining them*
how to achieve class I canine in this case
remove lower 4s (severe crowding), retract canines to allign lower arch
then to get upper canines in correct position they need to be retracted so extract upper 4s
treatment plan for this pt
Comprehensive
Relief of crowding
- Extractions UL4, UR4, LL4, LR4
U/L fixed appliances
- Correct rotations and align
- Reduce OB
- Reduce OJ
- Correct the incisor, molar and canine relationships to class I
Retain
- U/L thermoplastic retainers
- PBR 2-2
PBR what and cons
Permanent bonded retainer (fixed retainer for rotations, LLS crowding/spacing - tell at beginning as these will relapse)
- Time consuming
- Don’t always work – deep bite can bite off
- If chew chewing gum or hard foods – wire can bend overtime – acts like a brace – move teeth unwanted
thermoplastic retainer
retainer of choice - where for as long as can
(unless rotations/LLS crowding/spacing as will relapse so need bonded retainer)
if the overjet needs to be reduced can it be done by tipping movements or will bodily movements be needed
Large OJ but teeth not proclined – do not want to tip then back (class II div 1 -> div2)
- Need to move them bodily not tip
if all the space for extractions will be used to reinforce anchorage (HG)
Usually taken 50:50 front and back teeth
- But sometimes need all for uppers so canines can move into class I – may need headgear to keep molars fixed
- Temporary anchorage device – screw into bone to tip anchorage balance on your side – pull against screw not teeth
issue here
Proclined upper incisors but have space that can use
- but canines relationship is class II , still have residual OJ so need to extract some teeth to retract canine to reduce OJ
Canine is distally tipped
- anchorage demanding – move root a long way for correct angulation
Q around molar relationships
- Will there be residual space in the buccal segments at the end of treatment?
- What will the final molar occlusion be?
- Class I or II
- e.g.*
- Be class II – molar drift forward due to upper extraction*
- Canine will become class I from class II*
retention phase
Retainers needed to hold teeth in position after active movement
- Holley or essix type or fixed retainer (some cases)
writing an ortho tx plan
- Diagnosis
- Problem list orthodontic summary main points
- Treatment plan
- List successive stages stating the tooth movements to be carried out and appliances to be used
- Estimate length of treatment
- Fixed appliance 24months, non extractions maybe 18 months, ectopic canine 2.5 years – normally can vary
- If it is not possible to give a detailed plan, indicate when it will be reviewed (i.e. following the eruption of teeth, or if plan not going as thought or plan difficult for pt)
6 tx options for everyone
- accepet malocclusion
- extractions only
- URA +/- extraction
- functional appliances +/- extraction
- fixed appliances+/- extraction
- complex treatment involving ortho and restorative tx or otho and orthognathic surgery
risks to warn pt of if they do not want tx/accept malcclusion
No one died from malocclusion
Warn of risks
- resorbing roots,
- unerupted may have cystic change
ortho tx which is just extractions (no appliances)
Drift ortho
- pts don’t want tx
- class I with severe crowding,
assess OPT
URA
+/- extractions
bad OH
Functional appliance
+/- extractions
class II
large OJ
fixed appliance
+/- extractions
camouflage underlying skeletal relationship
- class II with OJ -> give class I without affecting aP relationship
how to go throught tx options
everyone has them all
some more apllicable that others
go through methodically from 1-6 (accept malocclusion to complex tx with ortho +restorative or +surgery)
3 limitations of ortho tx
- Effects of orthodontic treatment are almost purely dento-alveolar and tooth movement, with little effect on skeletal pattern
- Need bone
- Tooth movements are limited by the shape and size of alveolar processes
- Cannot affect skeletal base pattern
- Teeth will only remain stable in a position where there is equilibrium between the forces of soft tissues, the occlusion and the periodontal structures. All other positions are unstable and will be prone to relapse
who does simple ortho tx
- May be carried out by the general dental practitioner (relatively straightforward and can be managed by a URA)
who does complex ortho
- Requires the skill of a specialist practitioner or a hospital specialist
Go through proper training – don’t be too ambitious, know limitations.
timing of ortho tx
Some treatments rely on growth for success and should be used during adolescent growth spurt for maximal effect
- E.g. overbite reduction, functional appliance therapy
Refer in if in any doubt – small window to enhance growth, better to check young
