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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 1 4/8/2015 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 2 4/8/2015 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 3 4/8/2015 N.D. 77 INITIAL 74__ 12.8 yrs 3 40 31 31 121 0 10 -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 5 4/9/2015 TMJs And Muscles Airway Perio Status Habits Facial & Skeletal Pattern Dental Status Edward H. Angle Molar Relationship Charles Tweed Lower Incisor Position 90° 6 4/9/2015 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 7 4/9/2015 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 10 -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% 8 4/9/2015 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 9 4/9/2015 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 10 4/9/2015 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 11 4/9/2015 A.B. BEGINNING 84 14.1 yrs 79__ 30 5 ANB 27 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 14 111 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 12 4/9/2015 N.S. BEGINNING 73 17.0 yrs __66 7 50 42 104 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 32 33 112 ‐1 10 ‐3 10 83 ‐16 13 4/9/2015 G.E. BEGINNING 81 9.3 yrs 76__ 5 34 30 30 112 8 ‐1 ‐0 2 87 ‐11 S.Z. 84 BEGINNING 79__ 10.11 yrs 5 35 29 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 14 4/9/2015 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 29 38 98 4 4 -2 0 81 1 15 4/9/2015 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 16 4/9/2015 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 43 35 38 113 High Angle -4 8 113 11 56 27 -3 -3 80 3 72 -8 72 17 4/9/2015 J.C. 81 78__ 3 27 21 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 3 -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 18 4/9/2015 Z.D. 79 75__ 4 24 20 104 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 24 23 120 -6 Class III 3 -8 2 120 54 6 -8 17 81 82 -1 82 19 4/9/2015 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 20 4/9/2015 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 21 4/9/2015 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.
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