OSCE DOC - Ortho Flashcards
Class 3 Malocclusion Treatment Options (6 mins)
20-year-old with class 3
Why treat this patient?
Aesthetics- dental, profile concerns
Dental health- attrition, gingival recession, mandibular displacement
Function- speech, mastication
Class 3 Malocclusion Treatment Options (6 mins)
20-year-old with class 3
Explain to the patient their treatment options.
- Accept and monitor
Mild
Unsure how growth and development will progress (not in this case due to patient’s age)
No concerns
No dental health indications (attrition, gingival recession, mandibular displacement) - Intercept with URA
Early correction of incisor relationship- procline uppers, retrocline lowers and good OB will maintain stability
URA to procline incisors over the bite + XLA of deciduous remnants, good OB will maintain stability
Can be done if class III incisors develop due to early contact on permanent incisors
Notice patient’s age in scenario, this might not be possible - Growth modification
Growing patient
With functional appliance (reverse twin block, Frankel III, chin cup) or (RME and protraction headgear) or TADs
Notice patient’s age in scenario- this might not be possible
Encourages maxillary growth
4.Camouflage with fixed appliances
Accept underlying skeletal classification problem, move teeth with fixed ortho to hide it
- procline uppers and retrocline lowers
- risks of ortho- decal, root resorption, relapse, gingival recession
Usually together with XLA U5s and L4s (most likely lowers to reduce necessary tipping)
Favourable features- growth stopped, mild to moderate class III, average or increased overbite, able to reach edge to edge incisor relationship, little or no dentoalveolar compensation
- Orthognathic surgery with combined orthodontics
Surgical manipulation of the mandible and / or maxilla to produce optimal aesthetics / function
Done if patient has aesthetic or functional concerns / growth completed / moderate – severe discrepancy (ANB <-3 degrees)
Surgery not done until fully grown
Multidisciplinary team- careful planning
- orthodontics, maxillofacial surgeon, clinical psychologist, technician, etc.
Presurgical orthodontics- 12-18 months
- arch alignment, arch coordination, de-compensation
- can make it look worse at first, because need to undo the dentoalveolar compensation
Post-surgical orthodontics- 6 months
Total time 36 months
Ask if they have any questions, they can contact if they have any other questions
*Note Patient Age
** LIFELONG RETENTION REQUIRED
Ortho Discussion- Class II Div 1
Using study models/photos to discuss classification (class II div 1)
Explain to the patient what class they are and what that means.
Skeletal classification
Class 2 – maxilla more than 2-3mm in front of mandible; increased OJ; ANB >4o
Incisor classification:
Class II div 1 = lower incisor edge lie posterior to the cingulum plateau of the upper central incisors. The upper central incisors are proclined or of average inclination and there is an increased OJ
What are some dental factors of a class 2 div 1 patient?
- Increased OJ – incisors proclined or average
- Variable of OB
- Can have good alignment, crowding or spacing in dentition
- Habitually parted lips may lead to drying of the gingivae and exacerbation of any pre-existing gingivitis
Ortho Discussion- Class II Div 1
Using study models/photos to discuss classification (class II div 1).
What are some reasons that these patients would want treatment?
Concerns regarding aesthetics
Concerns regarding dental health
Prominent incisors are at risk of trauma especially with incompetent lips
OJ >9mm 2x likely to suffer trauma – IOTN 5A
Ortho Discussion- Class II Div 1
Using study models/photos to discuss classification (class II div 1).
What is the management of these patients and explain to them their treatment options.
Treatment options C2D1
* Accept- low motivation, low IOTN, minimal aesthetic issues, mild OJ
* Attempt growth modification (pubertal growth spurt)- twin block (distal
movement/retroclination of uppers AND mesial movement/proclination of lowers)
* URA- very mild and favourable OB
* Camouflage- fixed appliance (fixes incisor relationship)
* Orthognathic surgery (Males 18-20/Females 16-18)
Retained ULA and Unerupted UL1 (6 mins)
Photos of discoloured 61 and labial / buccal segments of an 8-year-old.
PA of a dilacerated floating 21 that could be anything.
Please discuss possible causes of a retained 61.
Trauma to A- causing damage to the 21
* - Complications- ankylosis, arrested tooth (21) formation, dilaceration, displacement, odontome, ectopic
* Lack of permanent successor / hypodontia- developmentally absent
* Ectopic tooth germ
* Crowding
* Supernumerary- tuberculate most common
* Pathology
* Retained primary tooth, infra occluded
Retained ULA and Unerupted UL1 (6 mins)
Photos of discoloured 61 and labial / buccal segments of an 8-year-old.
PA of a dilacerated floating 21 that could be anything.
What are some possible signs that the 61 is damaged and the 21 isnt going to erupt?
- Discolouration
- Radiographic signs of damage, dilacerated roots, ankylosis, ectopic position, absent successor
- Lateral has erupted before central
- Opposite central has been erupted for >6months
Retained ULA and Unerupted UL1 (6 mins)
Photos of discoloured 61 and labial / buccal segments of an 8-year-old.
PA of a dilacerated floating 21 that could be anything.
What investigations can you carrying out?
Radiographic localisation for ortho treatment
- Another PA or anterior occlusal, or alternatively OPT and occlusal, CBCT for 3D view
Retained ULA and Unerupted UL1 (6 mins)
Photos of discoloured 61 and labial / buccal segments of an 8-year-old.
PA of a dilacerated floating 21 that could be anything.
How would you manage this patient and explain to the patient their possible treatment options.
Always palpate- usually U1 is buccal and central (high)
Assess deciduous tooth (mobile?), radiograph
Options:
1. Leave and monitor- inform of possible cyst or resorption
2. Extract retained A (leave U1) and space maintenance (warn of cyst formation risk)
3. Surgical removal of both teeth and space maintenance
- (and plan for replacement if extracted- bridge / RPD until fully grown, then implant)
- Refer for orthodontic opinion / treatment- inform of possible ortho treatment benefits and risks
4. Autotransplantation
- Create space for eruption of 1- probably not if dilacerated
Other options:
- Extract retained A and hope spontaneous eruption (very unlikely since dilacerated)
- Expose (closed or open) +/- bonding / traction (won’t work if dilacerated)
N.B Key point here is that the tooth is dilacerated so alot of normal treatment options arnt possible.
Ectopic Canines, OJ, OB, Peg Lateral (6 mins)
Problems
Increased OJ (1 mark)
Increased OB (1 mark)
Peg lateral (1 mark)
Ectopic canine (4 marks)
Please explain to the patient the dental health implications of each of these problems.
OJ- risk of trauma (also psychosocial, speech, mastication, dry mouth if incompetent lips) (1 mark)
OB- risk of trauma (palatal ulcers, gingival recession lower anteriors) (1 mark)
Peg lateral- crowding, spacing, overeruption opposing
Ectopic canine- risk of root resorption (also ankylosis and failure to move in response to traction, and potential need for complex restorative solutions with associated long-term complications and maintenance) (1 mark)
Risk of cyst formation (1 mark)
Please briefly explain how you would determin if this ectopic canine is buccal or palatal?
Detailed use of parallax and explanation (4 marks)
Parallax- OPT and oblique occlusal radiographic views- had to explain how you get your answer
Vertical parallax- SLOB
Explanation- the tube head shifted up from OPT to oblique occlusal, the canine moved together with the tubehead compared to the incisor. According to SLOB rule, the canine is palatal to the incisor (or PAL rule)
Moves opposite so the canine is impacted buccally
Main risks of Orthodontic treatment (prevention)
- Decalcification
- good case selection- motivated, good OH, low caries risk
- OH- brushing 2 x daily focussing on gingival margin and bracket, inter-bracket
cleaning after every meal - diet advice- limit sugar and frequency
- fluoride supplements- 2800/5000ppmF toothpaste, 225ppmF MW, FV
- Root resorption- 1mm over 24 months (worse if prolonged high force movement,
intrusion, torque, blunt roots, previous trauma, nail biting) - Relapse- retainers
- Soft tissue trauma- ulceration
- Recession of gum
- Tx failure
- Allergy to any of the materials used, nickel
Decalcification (6 mins)
Patient wants you to go back over advice on how to avoid decal. Diet advice. Toothbrushing instruction and prevention.
Oral hygiene
Toothbrushing and single tufted TB for brackets
Interdental brushes and superfloss
OHI should include:
- Minimum twice per day very thoroughly
- Dry toothpaste, methodical, 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 mins, spit don’t rinse
- Brushing after meals- as brackets trap food / plaque
- Disclosing tablets to identify missed areas
Diet advice
Limit sugar amount and frequency
Avoid snacks between meals- limit sugar intake to <3 times daily
Avoid hard / hot foods, fizzy drinks, sports drinks, sticky sweets, chewing gum
Ideal drinks are water or milk, crackers, cheese, fruit is acceptable snack buy be careful of fat in cheese and natural sugar / acid in fruit
Watch out for hidden snacks in foods such as tomato soup or ketchup
Rinse mouth after eating
Fluoride
Toothpaste
- Duraphat- 2800ppm (0.619%)- 5000ppm (1.1%)
- Twice daily, ordinary toothpaste at other times
- Warn re overdose and children
Mouthwash
- Daily 0.05% fluoride mouthwash (225ppm)
- Use between meals, not after brushing
Fluoride varnish
- Profluoroid (22600ppm)- not duraphat- because duraphat stains?
- Every 4 months- this is for prevention, not used for treatment of decal as it seals it in
Prescriptions
Sodium fluoride toothpaste 0.619% (2800ppm)
- send 75ml
- label- brush teeth for 1 minute after meals using 1cm before spitting out, twice daily
Sodium fluoride toothpaste 1.1% (5000ppm)
- send 51g
- label- brush teeth for 3 minutes after meal using 2cm, before spitting, 3x daily
Ortho- URA (6 mins)
Faults, activation, delivery checks and care instructions
Required to fit upper removable appliance to a 9-year-old. Examine the prescription and the appliance, look for defects and answer the examiner’s question.
Asked about FABP, show how to make adjustments to Adam’s clasps and activate palatal finger spring. Prior checks before delivery and care instructions.
These were common faults the gave with the URA components,
Z-spring encased in acrylic
UR6 Adam’s clasp arrowhead fault
UL6 Adam’s clasp flyover fault
How would you retify these errors?
Take impressions and remake the URA
Fill out ARAB for retraction of canines or a canine (not buccally placed)
Retracting canines
Please construct URA to retract canines
A- 13/23 palatal finger spring and guard 0.5mm HSSW
R- 16/26 Adam’s clasps 0.7mm HSSW + 11/21 Southend clasp 0.7mm HSSW
A
B- self-cure PMMA
Fill out ARAB for retraction of buccal placed canines.
Retracting buccally placed canines
Please construct URA to retract buccally placed canines
A- 13/23 buccal canine retractor 0.5mm HSSW + 0.5mm ID tubing
R- 16/26 Adam’s clasps 0.7mm HSSW + 11/21 Southend clasp 0.7mm HSSW
A- fine since only moving two teeth
B- self-cure PMMA
Fill out ARAB for correction of an anterior crossbite
Anterior crossbite
Please construct URA to correct anterior crossbite
A- Z-spring 0.5mm HSSW
R- 16/26 Adam’s clasps 0.7mm HSSW + 14/24 Adam’s clasps 0.7mm HSSW
A
B- self-cure PMMA / posterior bite plane
Fill out ARAB for correction of a posterior crossbite
Posterior crossbite
Please construct URA to expand the upper arch
A- midline palatal screw
R- 16/26 Adam’s clasps 0.7mm HSSW + 14/24 Adam’s clasps 0.7mm HSSW
A- reciprocal anchorage
B- self-cure PMMA / posterior bite plane
What are the components of an adams clasp?
