Diagnosis And Treatment Planning

In Orthodontics
A Problem Oriented Approach
Supervised by Dr Trefa Mahmud

Prepared by Bryar Jalal HameAmin

Introduction to the topic
The goal of diagnosis is truth—the facts about the patient’s situation
and problems.

On the other hand, the goal of treatment planning is not scientific

truth, but should be wisdom decision
Optimal Treatment Plan
Should consider:

(1) Timing of treatment, and its duration

(2) Complexity of the treatment that would be required,

(3) Predictability of success with a given treatment approach, and

(4) Patient’s (and parents’) goals and desires.

Timing of comprehensive
treatment
Begins when the last permanent teeth are erupting.

In this age group often are reaching the point of self-motivation for
treatment, which is evident in their improved ability to cooperate
during appointments and appliance and oral hygiene care
Patient Interaction in Planning
Treatment planning must be an interactive process.

Both ethically and practically, patients must be involved in the decision-

making process.
The logical sequence for treatment planning

1. Prioritization (the most important problem receives highest priority for

treatment)
2. Consideration of possible solutions to each problem
3. Evaluation of the interactions among possible solutions to the
individual problems
4. Development of alternative treatment approaches, with consideration
of benefits to the patient versus risks, costs, and complexity
5. Determination of a final treatment concept, with input from the
patient and parent, and selection of the specific therapeutic approach
(appliance design, mechanotherapy) to be used
Diagnosis
Must be :

1. Comprehensive and
2. Not focused on only a single aspect of what in many instances can
be a complex situation.
Patient information must be
collected through
(1) Interview

(2) Clinical examination

(3) Evaluation of diagnostic records

*Dental Casts

*Radiographs

*Photographs.
Questionnaire and Interview
The goals of the interview process are to establish the patient’s chief
concern through evaluating :

(1) Medical and dental history;

(2) Physical growth status; and

(3) Motivation, expectations, and other social and behavioral factors.

 How to know chief complain of the
patient?
Through asking questions like:
“Do you think you need braces?”

“What bothers you more about your teeth ,your bite or your appearance?”

“What do you want treatment to do for you?”

Medical and Dental History

Orthodontic problems are almost always the culmination of a

developmental process, not the result of a pathologic condition.

At least rule out some of the possible causes like :

1. Trauma,
2. Habits,
3. Periodontal disease,
4. Growth disturbance, and so on.
Three areas deserve a special
comment.

First condylar fracture (true facial asymmetry)

Second longterm medication

Third serious illness like patients with

1.Cancer chemotherapy and radiation therapy
2.Arthritis or osteoporosis
3.Glucocorticoids that can be toxic to bone,
4.High doses of resorption-inhibiting agents such as bisphosphonates
Physical Growth Evaluation
Rapid growth during the adolescent growth spurt facilitates tooth
movement, but any attempt at growth modification will surely fail in a
child who is beyond the peak of the adolescent growth spurt.
Eg.height–weight records
Another approach is to get an estimate of how much mandibular
growth remains,
This can be done by determining mandibular growth timing from the
vertebrae as seen in a cephalometric radiograph If vertebral maturation
shows delayed skeletal development, the mandibular growth spurt
probably still is in the future.
The stage of dental development should not be used to estimate the
stage of jaw growth. As we emphasized earlier , that correlates less well
with skeletal growth than almost any other developmental index.
Vertebrae as seen in a cephalometric radiograph is less useful in a teenager
with mandibular prognathism.
Hand–wrist radiographs not an accurate way to determine when growth is
completed
Serial cephalometric radiographs offer the most accurate way to determine
whether facial growth has stopped or is continuing, because you are not
inferring future facial growth changes, but measuring them.
Social and Behavioral Evaluation
The patient’s motivation for treatment, what he or she expects
as a result of treatment, and how cooperative or uncooperative
the patient is likely to be.

Motivation for seeking treatment can be classified as external or internal.

Self-motivation for treatment often does not develop until adolescence
What the patient expects from treatment is very much related to the
type of motivation and should be explored carefully with adults,
something else to do this because the patient expects that he or she
will experience greater social or job success.
Patient Cooperation
is more likely to be a problem with a child than an adult.
Two factors are important in determining this:

(1) The extent to which the child sees the treatment as a benefit

(2) The degree of parental control or parenting style.

Clinical Evaluation
There are two goals for doing this:

(1) Evaluate and document oral health, jaw function, facial proportions,
and smile characteristics and

(2) Decide which diagnostic records are required.

Oral Health

The health of oral hard and soft tissues must be assessed

Before orthodontic treatment begins, any disease or pathologic

condition must be under control.
The patient’s oral hygiene status should be recorded and documented
by clinical photographs
But Why ?
Jaw and Occlusal Function

Evaluate normal coordination and movements.

If not
Cerebral palsy or
Severe neuromuscular disease,
normal adaptation to the changes in tooth position produced by
orthodontics may not occur,
Oral function
Four aspects require evaluation:
1. Mastication (including but not limited to swallowing),
2. Speech,
3. The possibility of sleep apnea related to mandibular deficiency,
4. The presence or absence of (TMJ) problems
Speech problems can be related to malocclusion, but normal speech is
possible in the presence of severe anatomic distortions.

Sleep apnea can be related to mandibular

deficiency and perhaps to other jaw
discrepancies and occasionally
this functional problem
is the reason for seeking
orthodontic consultation
TMJ Dysfunction
Jaw function is more than TMJ function,
As a general guideline, if the mandible moves normally, its function is
not severely impaired,
while restricted movement usually indicates a functional problem.
For that reason, the most important indicators of joint function ?
are the amount of maximum opening and the ability of the mandible to
translate beyond the hinge movement
It Is Important To Note

*mandiblular shifts laterally or anteriorly.

*unilateral crossbite due to shift

*true unilateral crossbite

*“Sunday bite”

*pseudo–Class III malocclusion

Systematic Examination of Facial and Dental
Appearance
Can be done in three steps:

1. (Macro-esthetics) facial proportions in all three planes of space

2. (Mini-esthetics) dentition in relation to the face

3. (Micro-esthetics) teeth and gingiva in relation to one another

Macro-Esthetics: Facial Proportions:

Assessment of Developmental Age

The degree of physical development is much more important than
chronologic age in determining how much growth remains.
Facial Esthetics Versus Facial Proportions.
Distorted and asymmetric facial features are a major contributor to
facial esthetic problems, whereas proportionate features are generally
acceptable even if not beautiful.
Frontal Examination
A small degree of bilateral facial asymmetry exists in essentially all
normal individuals.
Facial proportions and symmetry in the
frontal plane
Vertical Facial Thirds
Avoid treatment that would
change the ratios in the wrong
direction for example, treatment
with interarch elastics that could
rotate the mandible downward
in a patient whose face already
is too long for its width.
Facial analysis
Three goals that are:
1.Anteroposterior relation
Assessed when the patient is sitting upright or standing
2. Evaluation of lip posture and incisor
prominence

Excessive incisor protrusion (common) or

retrusion (rare)
is important because of the effect on space within the dental arches.

Bimaxillary dentoalveolar protrusion, meaning simply that in both jaws

the teeth protrude

Not bimaxillary protrusion in which the fault is in the jaw bones

The teeth protrude excessively if (and only if ) two conditions are met:

(1) The lips are prominent and everted and

(2) the lips are separated at rest by more than 3 to 4 mm (lip incompetence).
excessive protrusion of the incisors is revealed by prominent lips that
are separated when they are relaxed, so that the patient must strain to
bring the lips together over the protruding teeth .
For such a patient, retracting the teeth tends to improve both lip
function and facial esthetics.
On the other hand, if the lips are prominent but close over the teeth
without strain, the lip posture is largely independent of tooth position.
For that individual, retracting the incisor teeth would have little effect
on lip function or prominence.
Lip posture
1. By using two linee from :
true vertical line passing through (soft tissue point A)
true vertical line passing through (soft tissue point B)
Measuring the distance between them
If (separated by more than 3 to 4 mm) is considerd
protrusive
2. the E-line of cephalometric analysis

3. nasolabial angle

A mildly obtuse angle is considered normal.

One indicator of lip protrusion caused by overclosure is the labiomental
fold angulation
Normally somewhat obtuse; a greatly decreased angle indicates
overclosure.

Throat form
3 .evaluation of mandibular plane angle.

The inclination of the mandibular plane to the true horizontal should be

noted.
The mandibular plane is visualized readily by placing a
finger or mirror handle along the lower border.
 Mini-Esthetics: Tooth–Lip Relationships and
Smile Analysis.
Symmetry

Relationship of the dental midline of each arch to the skeletal midline of that jaw

A second aspect of dental–soft tissue relationships is the vertical relationship of

the teeth to the lips at rest and on smile.
Lip height
Excessive incisor display,
Causes:
1. Long lower third of the face
2. Short upper lip

Recording lip height could be at the philtrum and the commissures

can clarify the source of the problem.
Smile Analysis
Transverse Cant Of The Occlusal Plane but is better described
as A Transverse Roll Of The Esthetic Line Of The Dentition

Dentists detect a transverse roll at 1 mm from side to side, whereas

laypersons are more forgiving and see it at 2 to 3 mm ,but at that point,
it is a problem.

Facial attractiveness is defined more by the smile than by soft tissue

relationships at rest.
Two Types Of Smiles:
1. The posed or social smile
is reasonably reproducible and is the one that is presented to the world
routinely.
2. The enjoyment smile (Duchenne smile) varies with the emotion being
displayed
The social smile is the focus of orthodontic diagnosis.
In smile analysis, the oblique view and the frontal and profile views are
important.
1. Amount of incisor and gingival
display on smiling.
Although some display of gingiva is acceptable and can be both esthetic
and youthful appearing, the ideal elevation of the lip on smile for
adolescents is slightly below the gingival margin with 2 mm of tooth
coverage, so that most but not quite all of the upper incisor can be seen.

More important, the acceptable range of tooth display is from minimal

tooth coverage of 1 mm up to 4 mm coverage of the incisor crown.
Beyond that, the smile appearance is less attractive.
2. Transverse dimensions of the smile
relative to the upper arch
Broad smile may be more attractive than a narrow one, but what does
that mean exactly?
Prosthodontists consider excessively wide buccal corridors (sometimes
called “negative space” the transverse width of the dental arches can and
should be related to the width of the face).
Too broad an upper arch, so that there is
no buccal corridor, is unesthetic.

Buccal corridor evaluation is subjective and

that during clinical studies it has been shown
to be unreliable
3. The smile arc.
Is the contour of the incisal edges of the maxillary anterior teeth relative to the
curvature of the lower lip during a social smile
*Consonant(when matchs)
*Flattened (nonconsonant) smile arc can pose either or both of two problems:
1.It is less attractive, and
2.It tends to make you look older ?
(because older individuals often have wear of the incisors that tends to flatten
the arc of the teeth).
The only one that by itself can change the rating of a smile from
acceptable to unesthetic, is the smile arc.
Another feature that draws negative attention to the smile isexcessive
inclination of the upper teeth as they tip toward the left or right .
Both dentists and laypersons notice an
unesthetic quality of the smile when
this inclination exceeds a 2-mm deviation
from the normal, but
tolerate a tilt less than that.
Cant of occlussal plane
A transverse cant of the occlusal plane is less tolerated in the full-face
view, but more upper to lower midline discrepancy is acceptable.
When patients have complaints about these specific smile components,
it is best to have them point out what concerns them while they are
looking into a large mirror that lets them see their entire face,just as
others will view them in real life encounters.
How much teeth should be visible on
smiling ?
Micro-Esthetics: Close-up Dental Appearance.

Subtleties in :

Tooth proportions and

Shape and color of teeth
Gingival contours and heights

“cosmetic dentistry” in recent years.

Width Relationships and the
“Golden Proportion”
The apparent widths of the maxillary anterior teeth on smile, and their
actual mesiodistal width, differ because of the curvature of the dental
arch such that not all of the lateral incisors and only a portion of the
canine crowns can be seen in a frontal view.
Height–width Relationships Of
Teeth
The tooth widths are in relation to one another and the height–width
proportions of the individual teeth.
the width of a visible tooth
(i.e., incisors through premolars)
should be about 80% of its height
Connectors and Embrasures
The connector (also referred to as the interdental contact area) is
where adjacent teeth appear to touch and may extend apically or
occlusally from the actual contact point.
In other words, the actual contact point is likely to be a very small area,
and the connector includes both the contact point and the areas above
and below that are so close together they look as if they are touching
Black Triangles
Black triangles in adults usually arise from loss of gingival tissue related
to periodontal disease, but when crowded and rotated maxillary
incisors are corrected orthodontically in adults, the connector moves
incisally and black triangles may appear, especially if severe crowding
was present
Tooth Shade and Color

Changes with increasing age

The teeth appear lighter and brighter at a younger age and darker and
duller as aging progresses ?

A normal progression of shade change from the midline posteriorly is

an important contributor to an attractive and natural-appearing smile.
Gingival Heights, Shape, and
Contour.
Central incisor has the highest gingival level,
the lateral incisor is approximately 1.5 mm lower,
and the canine gingival margin again is at the level of the central incisor.

Both laypersons and dentists readily recognize differences of more than

2 mm.
Gingival shape

Maxillary lateral incisors

half-oval or half-circle

Maxillary centrals and canines

more elliptical

Gingival zenith
Summary Conclusion
• Question and Answer
Thanks