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Module 15- Treatment Planning British Orthodontic Society 1 National Orthodontics Programme Module 15- Treatment Planning British Orthodontic Society 1 National Orthodontics Programme British Orthodontic Society WWWeeelllcccooommmeee tttooo MMMoooddduuullleee 111555 TTTrrreeeaaatttmmmeeennnttt PPPlllaaannnnnniiinnnggg About the National Orthodontics Programme The National Orthodontics Programme was launched in December 2004 following a successful British Orthodontic Society Foundation Award application. A primary aim of the project was to develop a modular learning resource housed in a Virtual Learning Environment for postgraduates in orthodontics (www.ole.bris.ac.uk). This consists of 40 online modules and a series of online assessments. The resource aims to maximize the use of academic staff time and significantly reduce the amount of traveling to teaching bases by Specialist Registrars. The resource has been developed by all UK dental schools as authors or coauthors. It is at the discretion of each dental school as to how the resource is best used in their courses. We hope you enjoy using this unique and pioneering resource. National Orthodontics Programme Module 15- Treatment Planning British Orthodontic Society 2 Personal Welcome This Module is intended to outline the structured way in which assessing the data collected should be interpreted to produce an appropriate treatment plan for the individual patient. We shall look at the social and patient factors which might affect the treatment planning process. We will look into those factors identified from the diagnostic data which are important in producing an appropriate treatment plan for the individual patient having identified the aetiology of the malocclusion, the aims and objectives to be produced in treatment including the occlusal and aesthetic outcomes Learning Outcomes Candidates should be able to 1. Carefully collect patient information and diagnostic data, and construct a problem list. 2. Thoroughly understand the need for and use of diagnostic investigations and their analysis. 3. Differentiate between problems requiring brief examination of review and problems requiring thorough investigation and planning. 4. List aims of treatment including both features of the malocclusion that could be accepted. 5. Formulate an appropriate treatment plan, including strategy for treatment and retention, therapeutic measures, timing, sequence of their application, prognosis and estimated treatment and retention times. 6. Suggest alternative treatment plans including comprehensive and compromised plans appropriate to the circumstances and be able to discuss the risks and benefits of each. Objectives At the end of this module candidates should be able to: • Identify what aspects of the appearance and function of the teeth and face are the source of concern to the patient. • Explain where we would like to place this occlusion both horizontally, vertically and transversely within the face. • Identify those diagnostic features, which we need to identify, to decide how we can determine the best way of satisfying these requirements. • How to plan a structured and systematic method of analysing the collected data and interpreting it to produce a clearly identified stepwise plan for treatment and to identify the risks and benefits of such treatment and the stability of the result. • A list of diagnostic features relating to these aspects is clearly required and also all decisions about how best to assess them. We will also focus on the decision process relating to the need for extractions. Note that this Module links closely with Modules: 4 (Effect of respiration on facial develop m ent) 14 (Diagnosis) 11 (Cephalometric Analysis) 21 – 25 (Treatment Techniques) 13 (Aetiology) National Orthodontics Programme Module 15- Treatment Planning British Orthodontic Society 3 Introduction The treatment planning process is described in the following and you should read the full texts in: • Mitchell M. An introduction to treatment planning, Chapter 1, An introduction to Orthodontics, 2nd edition. Oxford University Press, ISBN 0 19 263184 5. • Sandy J, Harry D, Orthodontics Parts 1-12, Br Dent J 2003. • Proffit WR Contemporary Orthodontics Chapters 6 – 8 3rd Edition. Mosby. • Birnie DJ, Harradine NWT. Excellence in Orthodontics Course. • McDonald F, Ireland A. Diagnosis of the Orthodontic Patient (Chaps 9-10) The principles of treatment planning may be learned in the early part of training. However, to apply these principles for appropriate planning, especially for the more difficult cases, one must have an understanding of treatment techniques and mechanics and the effectiveness and limitations of these various approaches. A knowledge of stability and retention procedures also plays a part in the decision making process. Thus, in many ways, the understanding of treatment planning comes after an understanding of all the other modules rather than first. Your understanding and correct application of your knowledge will therefore evolve over the training. Practical application of the principles over the three-year training period is encouraged, by practice case presentation, with both trainers and your peers. It does begin to make sense towards the end! This module provides notes as an adjunct to aid the understanding of the process but there is no substitute for practical exercises and discussion. The notes within this module should be read in conjunction with the above texts. Content 1) Treatment planning considerations 2) Effects of treatment on facial and smile aesthetics 3) Notes on Space Analysis and Tooth Size Discrepancy 4) Guidelines for extraction 5) Treatment planning in borderline cases Dentoalveolar - extraction v. non extraction Skeletal - A/P - Vertical - Transverse 6) Treatment of patients with Skeletal disproportion 7) Risk Benefit analysis and informed consent 8) Summary 9) Bibliography National Orthodontics Programme Module 15- Treatment Planning British Orthodontic Society 4 Section 1 – Basic principles to Treatment Planning Remember that it is not necessary to treat every malocclusion and the benefits to the patient should be carefully assessed prior to undertaking any orthodontic treatment. Sandy J, Harry D, Orthodontics Parts 1-12, Br Dent J 2003. Once the aetiology of the malocclusion is understood and the problem list and the aims of treatment established, the treatment plan should consider: • Oral health. Removal of pathogy, eg caries, must be the primary concern in any treatment plan. • Lower arch • Upper arch • Incisor position and buccal occlusion to be produced • Appliance prescription and mechanics • Retention Oral health Lower arch Plan the lower arch first. The size and form of the lower arch should generally be accepted but consider the aetiology of the malocclusion to determine if any changes in arch form are acceptable. Consider space requirements in 3 planes of space. Upper arch and the buccal occlusion. Plan the upper arch around the lower and the incisor and molar relationship to be achieved. As the degree of crowding and overjet increase, then the space and anchorage requirements will also increase and it is more likely that extractions, as opposed to distal movement, will be indicated. The key to achieving a Class 1 incisor relationship is to obtain a Class 1 canine relationship and it is this objective which can help direct you to assessing the space requirements in the upper arch and also give an insight into the difficulties and limitations of treatment. The final molar relationship can then be determined. Appliance prescription and mechanics Planning the space requirements and the occlusal movements will lead to the decisions relating to the anchorage requirements and anchorage balance for these movements, appliance design and mechanics required. This plan should then be laid out in a step by step logical progression through treatment to retention. Appliance choices are covered in the modules 21-25. Retention See Retention – Module 25 National Orthodontics Programme Module 15- Treatment Planning British Orthodontic Society 5 Section 2 - Facial and smile aesthetics Ackerman JL, Ackerman MB, Bresinger CM, and Landis JR A Morphometric analysis of the posed smile Clinical Orthodontics and Research :2-11 • Exactly what aspects of the appearance and function of the teeth and face are of concern to the patient. • The relationship between aesthetics and incisor position • Aesthetics of smile – incisor show and smile width / the smile mesh • Aesthetics versus stability • Extractions and facial aesthetics and variability of soft tissue response. See Module 14 - Diagnostic procedures National Orthodontics Programme Module 15- Treatment Planning British Orthodontic Society 6 Section 3 – Notes on Space Analysis and Tooth Size Discrepancy Study Model Analysis in Orthodontic Diagnosis Kirschen RH, O'Higgins EA, Lee RT. The Royal London Space Planning: An integration of space analysis and treatment planning Parts 1 and 2. Am J Orthod Dentofac Orthop 118: 456-61 • Identify asymmetry within the dental arch (Centre line discrepancy and asymmetric molar relation). • Requires comparison between amount of space available and amount of space required to align teeth properly. • Analysis can be carried out directly on the dental casts or by computer and reflex metrograph. Calculation of space available: Measure arch perimeter from one first molar to the other over the contact points of posterior teeth and incisal edge of anteriors. Segmental approach: divide the dental arch into segments that can be measured as straight line approximations
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