Mclaughlin -- Angle Lecture; the Top Ten Lessons I Have Learned in Orthodontics.Pdf

4/8/2015

Top Ten Lessons I Have Learned in Orthodontics

Richard McLaughlin, D.D.S.

AAO 2015 San Francisco, CA

TOP TEN LESSONS I HAVE LEARNED IN ORTHODONTICS

1. Diagnosis and Treatment Planning

2. Importance of Staff

3. Bracket Placement

4. Arch Form

5. Non-extraction Cases

6. First Bicuspid Extraction Cases

7. Second Bicuspid Extraction Cases

8. Surgical Considerations

9. Finishing

10. Retention

The greatest challenges in orthodontics are in the area of diagnosis and treatment planning

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THIS CAN INCLUDE:

1) Incorrect diagnosis and/or treatment planning

2) Lack of acceptance by the patient

DIAGNOSIS AND TREATMENT PLANNING

• 60% - 20% - 20% Rule

• Can be very time consuming

• We need an efficient and accurate system

ACHIEVING THE GOAL

A systematic approach to each

aspect of treatment

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DIAGNOSIS AND TREATMENT PLANNING CHALLENGES

• Presentation of surgical cases

• Presentation of extraction cases

• Presentation of IPR cases

Build our story before we tell the story

DIAGNOSIS AND TREATMENT PLANNING

History Clinical Exam Records

CHECK LIST • TMJ’S and Musculature PROBLEM LIST

• Airway

• Perio Status-and Soft Tissue

• Habits

• Facial and Skeletal Pattern

• Dentition

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N.D. 77 INITIAL 74__ 12.8 yrs 3 40

31 121 0

-4 102 9

96 -7

82 SNA° SN-GoGn° 32 80 SNB° 2 ANB° F-Mand° 26

U1-Palatal plane° Pal-Mand° 28 110 ‐1 A-Na Perp mm U1 APO° 5 0 Wits mm 2 Occlusal Plane Angle L1 APO°

95 L1-Mand plane° ‐4 Pg-Na Perp mm

4 82 SNA° SN- 32 GoGn° 80 SNB° 2 ANB° F- 26 Mand°

U1-Palatal plane° Pal- 28 110 Mand° ‐1 A-Na Perp mm U1 APO°5 0 Wits 2 L1 APO°mm

95 L1-Mand plane° ‐4 Pg-Na Perp mm

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TMJs And Muscles

Airway

Perio Status

Habits

Facial & Skeletal Pattern

Dental Status

Edward H. Angle

Molar Relationship

Charles Tweed

Lower Incisor Position

90°

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Steiner Analysis 83 SNA 79 SNB 4 ANB

Michigan Growth Studies

90° Nasion A point Perpendicular

Pogonion

Bruce Epker and Larry Wolford

90° Subnasale Nasion Perpendicular

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William Arnett

Cephalometric X-ray in Natural Head Posture

Subnasale

N.D. 77 INITIAL 74__ 12.8 yrs 3 40

31 “ I DON’T USE CEPHALOMETRICS ANY MORE” 31 121 0

-4 102 9

96 -7

2014 JCO Study of Orthodontic Diagnosis and Treatment Procedures-Part 1

Table 3 Cephalometric Diagnostic Records

Percentage of the time a routine pre-treatment cephalometric X-ray taken

. 1986 - 90%

. 1996 - 90%

. 2008 - 74%

. 2014 - 64%

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Why is this occuring

and

is there a solution?

Cephalometrics should provide

objective back-up to

subjective observations

Conventional Cranial Based Cephalometrics- Five Plane Evaluation

• SN Plane • Frankfort Horizontal Plane • Palatal Plane • Occlusal Plane • Mandibular Plane

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F.T. BEGINNING 83 SNA 21.11 yrs 89 SNB 23 -6 0° 23

22 123 -5 1 -14 10

88 9

F.T. BEGINNING 76 SNA 21.11 yrs 82 SNB 30 -6 7° 23

22 123 -5 1 -14 10

88 9

S.S. BEGINNING 77 SNA 30.2 yrs 69 SNB 8

40 11° 29

28 117

9 1

3 2

101 -12

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S.S. BEGINNING 81 SNA 30.2 yrs 73 SNB 8 36 7° 29

28 117

9 1

3 2

101 -12

S.Z. 83 SNA BEGINNING 79 SNB 10.11 yrs 4 ANB

The “Wits” appraisal of jaw disharmony Alex Jacobson, MDS, MS, PhD

AJO-DO

November 2003 - Volume 124 Issue 5

Pages 470-479

or www.ajodo.org

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A.B. BEGINNING 84 14.1 yrs 79__ 30 5 ANB

27 112 -1 6

101 1 3 WITS

94 -12 OCCLUSAL PLANE ANGLE = 101

G.B. BEGINNING 87 __86 52.8 yrs 20 1 ANB

111 23 6 5 5 WITS 86 4

94 +8

OCCLUSAL PLANE ANGLE = 86

With Class I occlusions, the occlusal plane can vary from 80° to 110°, or a total 30°

This can effect the position of pogonion by 1.5 to 2 cm

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N.S. BEGINNING 73 17.0 yrs __66 7

104 49 -3 POSITIONALLY SENSITIVE 13 DENTALLY 3SENSITIVE 8 Po can vary 1.5 to 2 cm

94 -22

Conventional Cranial Based Cephalometrics- Five Plane Evaluation

•SN Plane • Frankfort Horizontal Plane • Palatal Plane • Occlusal Plane • Mandibular Plane

D.L. 75 BEGINNING 67__ 53.5 yrs 8 43

33 112 ‐1

‐3 10

83 ‐16

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G.E. BEGINNING 81 9.3 yrs 76__ 5 34

30 112 8 ‐1

‐0 2

87 ‐11

S.Z. 84 BEGINNING 79__ 10.11 yrs 5 35

98 38 5 4 -2 -0

80 2

Conventional Cranial Based Cephalometrics- Five Plane Evaluation

•SN Plane • Frankfort Horizontal Plane • Palatal Plane • Occlusal Plane • Mandibular Plane

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Orthodontists need to dentally compensate incisors in many cases

“There is often a tension in orthodontics between stability and esthetics”

Larry Andrews

S.Z. 83 BEGINNING __79 10.11 yrs 4 35

38 98 4

4 -2 0

81 1

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Tetragon: A Visual Cephalometric Analysis

Jorge Fastlicht, DDS, MS Journal of Clinical Orthodontics

Vol 33 2000 Number 6

Pages 353-360

or www.jco-online.com

Tetragon: A Visual Cephalometric Analysis

Jorge Fastlicht, DDS, MS

Mx 1

Occlusal Plane WITS

Md 1

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CLASS I Mx1-PP 115 POP Mx1-OP 8 57 0 Wits 20 65 Md1-OP OMP

95 Md1-MP

CLASS I Mx1-PP 110-115 POP Mx1-OP 8 57 0 Wits 20 65 Md1-OP OMP

90-95 Md1-MP

J.C. 75 75__ 0

38 113 High Angle -4 8 113 11 56 27 -3 -3 80 3 72

-8 72

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J.C.

81 78__ 3 27

21 117 -0 Low Angle 6 3 117 3 58 5 3 16 65 100 -6 100

S.W. 86 BEGINNING 84__ 2 32.6 yrs 11

-4 106 6 Low Angle 1 2

106 -2 68 6 2 3 72 105 10 105

CLASS II Mx1-PP 100 POP Mx1-OP 8 72 5 Wits 20 60 Md1-OP OMP

100 Md1-MP

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Z.D.

79 75__ 4 24

104 Class II -2 6 21 104 4 69 8 4 3 13 66 101 101 -11

CLASS III Mx1-PP 120 POP Mx1-OP 8 52 -5 Wits 20 80 Md1-OP OMP

80 Md1-MP

J.P.

78 82__ 26 -4

23 120 -6 Class III 3 -8 2 120 54 6 -8 17 81 82 -1 82

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S.Z. 83 BEGINNING __79 10.11 yrs 4 35 1) Cranial Base 29 as a Reference

38 98 4 4 98 2) Soft Tissue 19 64 -2 -2 0 19 80 81 81 1

S.Z. Bruce Epker and Larry Wolford BEGINNING 10.11 yrs

90° Subnasale

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS

-NATURAL HEAD POSITION True Vertical -WAX BITE IN CR Line

-RELAXED LIPS

SUBNASALE

AJO, SEPT. 1999

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NATURAL HEAD POSTURE LITERATURE

• Moorrees-Am J Phys Anthropol, 1958

• Cooke-AJO, March 1988

• Lundstrom and Lundstrom-AJO, March 1992

• Arnett and Bergman-AJO, April and May 1993

LUNDSTROM AND LUNDSTROM - NATURAL HEAD POSTURE AS BASIS FOR CEPHALOMETRIC ANALYSIS, AJO, MARCH 1992

• Sella-Nasion 5.3 sd

• Basion-Nasion 4.7 sd

• Porion-Orbitale 5.0 sd

• Natural Head Position 1.8 sd

• NHP is the most reproducible and accurate

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ARNETT SOFT TISSUE -8 CEPHALOMETRIC ANALYSIS 170 7 5 -19 -22 17 -15 15 15 -13 3 100 4 -1 26 8 21 115 3 3 57 -9 12 57 96 8 0 2 3 5 2 20 65 65 3 13 1 8 95 4 -5 2 47 51 -3 59 12

7 73 125

22 ARNETT NORMS AND STANDARD DEVIATIONS

UPPER ANTERIOR SEGMENT-HORIZONTAL Female STCA research values and (means) KIncisor torque to occl. plane 54.3° to 59.3° (57°) KIncisor tip to TVL -11.4 mm to -7.0 mm (-9) KLip thickness 10.8 to 14.4 mm (12) KLip to TVL 2.5 mm to 4.9 mm (3)

UPPER ANTERIOR SEGMENT-VERTICAL Female STCA research values and (means) Max. anterior height 23.6 mm to 27.8 mm (26) KLip length 19.1 mm to 22.9 mm (21) KIncisor exposure 3.1 mm to 6.3 mm mean (5) Inter-labial gap 2.0 mm to 4.0 mm (2)

LOWER ANTERIOR SEGMENT Female STCA research values and (means) Occlusal plane to TVL 93.8° to 97.4° (96°) LIncisor torque to occl. plane 61.1° to 67.5° (65°) LLip thickness 12.2 to 15.0 mm (13) LLip to TVL -0.5 mm to 3.3 mm (1) Soft tissue ‘B’ point -6.8 mm to -3.8 mm (-5) Soft tissue pogonion -4.5 mm to -0.7 mm (-3)

UPPER ANTERIOR SEGMENT-HORIZONTAL Male STCA research values and (means) KIncisor torque to occl. plane 54.8° to 60.8° (57°) KIncisor tip to TVL -13.9 mm to -10.3 mm (-12) KLip thickness 13.4 to 16.2 mm (14) KLip to TVL 1.6 mm to 5.0 mm (3) UPPER ANTERIOR SEGMENT-VERTICAL Male STCA research values and (means) Max. anterior height 25.2 mm to 31.6 mm (28) KLip length 21.9 mm to 26.9 mm (24) KIncisor exposure 2.7 to 5.1 mm mean (4) Inter-labial gap 1.3 mm to 3.5 mm (2) LOWER ANTERIOR SEGMENT Male STCA research values and (means) Occlusal plane to TVL 93.6° to 96.4° (95°) LIncisor torque to occl. plane 60.0° to 68.0° (64) LLip thickness 13.4 to 16.2 mm (15) LLip to TVL -1.6 mm to 3.2 mm (1) Soft tissue ‘B’ point -8.7 mm to -5.5 mm (-7) Soft tissue pogonion -5.3 mm to -1.7 mm (-3)

23 Upper Anterior Segment – Horizontal Numbers

Upper Incisor Tip Projection Mx 1 ‐ TVL

Upper Incisor Inclination Mx1 –Mx OP

Upper Lip Thickness Mx1 Labial ‐ ULA 12 57 ‐9 3 ‐ Upper Lip Anterior ULA ‐ TVL

24 Upper Anterior Segment – Vertical Numbers

Mx Anterior Height Sn’ –Mx1 Tip

Upper Lip Length Sn’ –ULI

26 21 Upper Incisor Exposure UL1 –Mx 1 Tip 5 ‐ 2

Inner Labial Gap UL1 – LLS

25 Lower Anterior Segment Numbers

Lower Lip Thickness LL Inside – LLOutside 96 Mx Occlusal Plane 65 Lower Lip Anterior Mx OP ‐ TVL 13 1 LLA

Lower Incisor Inclination ‐5 Soft Tissue B Point Md1 –Md OP B’ Soft Tissue Pogonion ‐3 Pog’ ‐ TVL

26 ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Anterior Segment – Numbers

Mx Anterior Height Upper Incisor Inclination Upper Lip Length Upper Incisor Tip Projection 21 Upper Lip Thickness 26 Upper Lip Anterior 12 Upper Incisor Exposure 57 ‐9 3 96 5 2 Inner Labial Gap Mx Occlusal Plane 65 13 1 Lower Lip Anterior Lower Lip Thickness ‐5 Lower Incisor inclination Soft Tissue B Point

‐3 Soft Tissue Pogonion AJO, SEPT. 1999

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TMJs Soft Tissue And & Muscles Incisors- Anterior Segments Airway

Perio Status Transverse Dimension Habits

Facial & Skeletal Pattern Remaining Dentition- Canines, Dental Status Premolars, Molars

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Horizontal Numbers

Upper Incisor Inclination

57 -

AJO, SEPT. 1999

Mx1-PP 115 POP Mx1-OP 8 57 0 Wits 20 65 Md1-OP OMP

95 Md1-MP

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ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Horizontal Numbers

Upper Incisor Tip Projection

Upper Incisor Inclination

57 -9 -

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Horizontal Numbers

Upper Incisor Tip Projection

Upper Incisor Inclination

Upper Lip Thickness 12 57 -9 -

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Horizontal Numbers

Upper Incisor Tip Projection

Upper Incisor Inclination

Upper Lip Thickness 12 57 -9 3 - Upper Lip Anterior

AJO, SEPT. 1999

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ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Vertical Numbers

Mx Anterior Height

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Vertical Numbers

Mx Anterior Height

Upper Lip Length

21 26

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Vertical Numbers

Mx Anterior Height

Upper Lip Length

21 26 Upper Incisor Exposure 5

AJO, SEPT. 1999

30 4/8/2015

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment – Vertical Numbers

Mx Anterior Height

Upper Lip Length

21 26 Upper Incisor Exposure 5 2

Inner Labial Gap

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment – Numbers

96 Mx Occlusal Plane

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment – Numbers

96 Mx Occlusal Plane 65

Lower Incisor inclination

AJO, SEPT. 1999

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Mx1‐PP 115 POP Mx1‐OP 8 57 0 Wits 20 65 Md1‐OP OMP

95 Md1‐MP

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment – Numbers

Lower Lip Thickness

96 Mx Occlusal Plane 65 13

Lower Incisor inclination

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment – Numbers

Lower Lip Thickness

96 Lower Lip Anterior Mx Occlusal Plane 65 13 1

Lower Incisor inclination

AJO, SEPT. 1999

32 4/8/2015

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment – Numbers

Lower Lip Thickness

96 Lower Lip Anterior Mx Occlusal Plane 65 13 1 -5 Lower Incisor inclination Soft Tissue B Point

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment – Numbers

Lower Lip Thickness

96 Lower Lip Anterior Mx Occlusal Plane 65 13 1 -5 Lower Incisor inclination Soft Tissue B Point

Soft Tissue Pogonion -3 AJO, SEPT. 1999

N.D. INITIAL 77 __74 12.8 yrs 3 40

31 121 0

10 121 -5 47 12 -5 9 19 66 96

96 -7

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N.D. INITIAL 12.8 yrs

29 25 102 9 47 -4 13 3 5 66 15 7

-4

-6

N.D. BEG/PREDICTION SN AT S

N.D. BEG/PRED

PALATAL PLANE AND PALATAL CURVATURE

MAND SYMPHYSIS AND MAND PLANE

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Facial Keys to Orthodontic Diagnosis and Treatment Planning -Part I & II

Arnett, G. W. & Bergman, R. T. American Journal of Orthodontics April & May, 1993

Fig 3.20

The transverse dimensions is about four factors:

Midline, Cant, Yaw and Widths

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N.D.

Patient: N.D.

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ARCHWIRE SEQUENCE

.015 multistrand .016 round heat activated .0175 multistrand .016 x .022 rectangular heat activated .014 round stainless steel .016 round stainless steel .019 x .025 rectangular .018 round stainless steel heat activated .020 round ss heat treated

.019 x .025 & .017 x .025 .019 x.025 & .017 x.025 rectangular ss heat treated rectangular ss heat treated

ARCHWIRE SEQUENCE

NON EXT.

.019 x .025 & .017 x .025 .019 x .025 & .017 x .025 rectangular ss heat treated rectangular ss heat treated

ARCHWIRE SEQUENCE

1st BICUSPID EXT. .015 multistrand .016 round heat activated .0175 multistrand .016 x .022 rectangular heat activated .014 round stainless steel .016 round stainless steel .019 x .025 rectangular .018 round stainless steel heat activated .020 round ss heat treated

.019 x .025 & .017 x .025 .019 x.025 & .017 x .025 rectangular ss heat treated rectangular ss heat treated

38 4/8/2015

ARCHWIRE SEQUENCE

1ST BICUSPID EXT. .015 multistrand .016 round heat activated .0175 multistrand .016 x .022 rectangular heat activated .014 round stainless steel .016 round stainless steel .019 x .025 rectangular .018 round stainless steel heat activated .020 round ss heat treated

.019 x .025 & .017 x .025 .019 x.025 & .017 x.025 rectangular ss heat treated rectangular ss heat treated

ARCHWIRE SEQUENCE

2nd BICUSPID EXT. .015 multistrand .016 round heat activated .0175 multistrand .016 x .022 rectangular heat activated .014 round stainless steel .016 round stainless steel .019 x .025 rectangular .018 round stainless steel heat activated .020 round ss heat treated

.019 x .025 & .017 x .025 .019 x.025 & .017 x.025 rectangular ss heat treated rectangular ss heat treated

ARCHWIRE SEQUENCE

.019 x .025 & .017 x .025 .019 x.025 & .017 x.025 rectangular ss heat treated rectangular ss heat treated

39 ORTHODONTIC VTO Name: ______MIDLINE MOLAR POSITION

Right 1st molar Midline Left 1st molar

Overjet ____mm Overbite____mm Crossbite

LOWER ARCH DISCREPANCY

3 x 3 7 x 7

Right Left Right Left

Crowding/Spacing-Anteriors

C/S-Bicuspids (E-L space)

C/S-Molars

Curve of Spee

Midline

Incisor Position

Initial Discrepancy

Stripping

Expansion

Distalizing 6 6

Extraction

Remaining Discrepancy

THE DENTAL VTO

Right 1st Midline Left 1st molar molar ( ) cuspid cuspid ( )

( ) ( )