Ortho Summary Sheet PDF

Preview

Summary

summary of orthodontics seminars and lectures for year 3...

Description

Ortho Summary Sheet Extended orthodontic analysis Extra-oral assessment:  Skeletal classification - Anteroposterior  class 1/2/3 - Vertical  high / average / low - Transverse  symmetry / asymmetry  Soft tissues - Lips  competent / incompetent - Nasolabial angle  increased / average / decreased Intra-oral assessment:  Incisor classification  class 1, 2/1, 2/2, 3  Overjet mm  Overbite - Increased (traumatic?) / average / decreased - Complete (tooth / palate) - Incomplete - Anterior open bite  Centerlines  Canines  class 1/2/3  Molars  class 1/2/3  Crossbites  anterior / posterior, associated displacement?  Crowding  mild / moderate / severe  Oral hygiene  Dental health Radiographs: OPT:  Teeth present / root development  Bone levels / pathology  Condyles  Limited for caries detection / root pathology IOPA  Trauma  Root quality Upper anterior occlusal  Anterior pathology BW’s  Not a usual ortho x-ray  Look for caries Cephalometry

  

Scientific measurements of head and face using lateral skull radiograph Standardised / reproducible Indications: - Diagnosis of skeletal, dental & soft tissue relationships - Treatment planning of AP & vertical changes in skeletal / dental relationships - Monitoring of treatment progression - Audit / research - Growth assessment

Developing a problem list:  This is the diagnosis  Provides summary of case  Helps manage the case / formulate a treatment plan  Follow the ortho assessment sheet & identify differences from average  Include non-ortho problems such as poor OH, caries, perio Methods of growth prediction:  Stature (height)  Secondary sexual characteristics  Family history  Cervical spine maturation  Cephalometric templates  Hand-wrist radiographs  class 2 pts should grow favorably (downwards & forwards)  class 3 pts may grow unfavorably IOTN Benefits of orthodontic care - Aesthetics - Maximize social and education development - Improve quality of life - Function – mastication & speech IOTN = objective measure of orthodontic treatment need Systemic approach – assess initial need, assess change, assess outcome IOTN allows you to pick out the worst feature of trait of your problem list.

Index:

 

Scale used to objectively quantify a feature / trait – assigns a number to something so you can rank it Helps priorities problem list

General requirements of an index:  Clinically valid - Sensitive  identify those with a need - Specific  identify those without a need  Reliable  Objective  Acceptable to profession and public  Require minimal judgement  Administratively simple  Cheap IOTN consists of:  dental health component  aesthetic component Graded by aesthetic component

M – missing teeth O – overjet C – crossbite D – displacement O – overbite Why?     

Missing clinically (impacted) – resorption Missing clinically (hypodontia) – function / aesthetics Increased overjet – trauma Reverse overjet – function / speech / aesthetics Crossbite with displacement – attrition / trauma / TMJ / possible growth problems

 for purposes of IOTN a tooth cannot be impacted if it has eruption  tooth is considered impacted if it is unerupted and there is >4mm of space between the adjacent permanent teeth Missing teeth:  Grade 5 – extensive hypodontia more than 1 tooth missing in any quadrant  Grade 4 – less extensive, 1 tooth missing in any quadrant

Displacement of contact points:  Spacing is not generally recorded in DHC  If spacing is associated with a tooth deviating from line of arch the contact point displacement is recorded  Displacements between deciduous and permanent teeth are not recorded  Contact point displacements due to rotation are not recorded

Tipped teeth = DHC 4 Supernumerary teeth = DHC 4

Occlusal trait

Class 1  lower incisor edges occlude on or below the cingulum plateau of the upper incisors

 60% of population Features:  Skeletal AP - Usually skeletal 1 - Can be mild skeletal 2/3 with dentoalveolar compensation (eg if skeletal 2 then lower incisors will be Proclined)  Skeletal vertical – usually within normal limits  Skeletal transverse – commonly acceptable symmetry  Soft tissues – favourable (competent lips, NLA average)  Dental - Class 1 incisors so OJ/OB within normal limits - Buccal segments often class 1 but maybe not if early loss of deciduous teeth - Crossbites:  local / segmental  unilateral with / without displacement  bilateral – usually narrow maxilla  scissor bite – usually local  Bimaxillary proclination - Proclined upper & lower incisors commonly seen in afro-Caribbean pts  Dental - Crowding  small teeth  large teeth  extra teeth  early loss of deciduous - Spacing  large teeth etc  frenal attachments IOTN usually score on  Missing – impacted  Crossbite – with displacement  Displacement of contact points Treatment considerations:  Crowding: - Amount (mild 0-4mm, mod 5-8mm, sev 9+)

 -

How to make space  extractions, increase arch length by expansions, proclination or distalising Combination Spacing: Can keep space open for prosthesis / close space if 1 tooth missing in quadrant Combination of opening / closing spacing for multiple missing teeth

Treatment options: Accept:  Pt declines treatment  OH poor  Medical history contraindicates  IOTN low (can still have private ortho) Extractions only:  Well aligned arches except for a tooth which is excluded from arch requiring an extraction Upper removable appliance & extractions:  Compliant pt  Generally adolescents  Removable appliances can only tip teeth  Good for tipping back mesially inclined canines  Good for expanding buccal segments Fixed appliance & extractions:  Can achieve bodily movement of teeth  Good for 3D control of tooth movement  Need good OH  Appliance of choice for most cases Multidisciplinary treatment:  Ortho + restorative for hypodontia cases  Ortho + surgical for impacted teeth  Ortho + max fax for orthognathic cases Class 2 div 1  Lower incisors lie palatal to cingulum plateau of the upper incisors  upper incisors are Proclined or average inclination and there is usually an increased OJ  20% of population

Features: Skeletal AP  Generally skeletal 2  Commonly due to retrognathic mandible  Can be prognathic maxilla



When skeletal 1 can be due to habit or dentoalveolar relationship

Skeletal vertical  LAFH average or reduced  If increased makes receding chin look worse Skeletal transverse  Acceptable symmetry Lips  Lower lip covers 1/3 to 1/2 of upper incisors – stable  Important as stability of OJ reduction dependent on lower lip control  Lower lip trap behind upper incisors increases OJ Swallowing  Must have anterior oral seal to swallow without effort  In some class 2 pts find it hard to make anterior oral seal  incompetent lips, increases OJ as oral seal is obtained by tongue to lower lip which can cause an incomplete overbite Tongue  Adaptive tongue thrust  Endogenous tongue thrust – usually habit from baby rare and difficult to treat Respiration  Chronic nasal obstruction, enlarged adenoids, mouth breathing  Cases altered head posture  class 2 profile Dental  Proclined upper incisors  Increased OJ  Dentoalveolar compensation  Proclined lower incisors may make malocclusion appear less severe than it actually is  OB usually deep  often incomplete  Buccal segments usually class 2  Sometimes crossbites Habits  Must be of sufficient duration to cause a change  Proclined upper incisors  Retroclined lowers  Unilateral crossbite without displacement  Asymmetric AOB  Do not treat patients unless habit has ceased Other considerations  Trauma  increased risk of trauma when OJ > 9mm (twice as likely)  Growth  usually favourable  IOTN usually scores on overjet Treatment considerations:  Is the pt actively growing or not?  What is the Aetiology of the malocclusion (skeletal, soft tissue, dental, habit or combination?)

Treatment options: Accept:  Pt declines treatment  OH poor  Medical history contraindicates  IOTN low (can still have private ortho) Extractions only  Not usually an appropriate option for these cases Upper removable appliance & extractions:  Compliant pt  Generally adolescents  Removable appliances can only tip teeth  Good for tipping back mesially inclined canines Functional appliances  Only considered if pt is growing  Should have skeletal Aetiology  Dental arches should be generally well aligned Fixed appliance & extractions:  Can achieve bodily movement of teeth  Good for 3D control of tooth movement  Need good OH  Appliance of choice for most cases Class 2 div 2  lower incisors lie palatal to cingulum plateau of upper incisors  upper incisors retroclined and there is usually increased OB  OJ is reduced  10% of population Features: Skeletal AP  Generally skeletal 2  Commonly due to retrognathic mandible  Common to see prominent chin button and marked labio-mental fold Skeletal vertical  LAFH reduced  Usually due to anterior growth rotation Skeletal transverse  Commonly acceptable symmetry  Square lower jaw  Prominent gonial angles Lips  

Lower lip covers 1/3 to 1/2 of upper incisors – stable Low LAFH leads to high resting lower lip line retroclining the upper incisors



Upper lateral incisors have short clinical crown height and escape the action of lower lip  Lower incisors can also be retroclined by strap like lower lip leading to bimaxillary retroclination Muscles  High bite forces in class 2/2 cases prevents vertical growth Crowding  Upper incisors retroclined and therefore positioned on arc of smaller circumference manifests as lack of space for upper lateral which can become proclined and rotated  Often lower incisors are retroclined too causing crowding OB  Lack of occlusal stop to eruption of lower incisors leads to increased OB  Acute crown root angle  Potential for traumatic OB Crossbites  Lingual crossbite (scissor bite) IOTN  Amount of overjet of lateral  Contact point displacement on laterals  OB Treatment options: Accept:  Pt declines treatment  OH poor  Medical history contraindicates  IOTN low (can still have private ortho) Extractions only  Not usually an appropriate option for these cases Upper removable appliance & extractions:  Compliant pt  Generally adolescents  Removable appliances can only tip teeth  Also good for reducing deep overbites in growing pts Functional appliances  Only considered if pt is growing  Should have skeletal Aetiology  Dental arches should be generally well aligned Fixed appliance & extractions:  Can achieve bodily movement of teeth  Good for 3D control of tooth movement  Need good OH  Appliance of choice for most cases Multidisciplinary treatment:  Ortho + restorative for hypodontia cases  Ortho + surgical for impacted teeth  Ortho + max fax for orthognathic cases

Class 3  lower incisor edges lie anterior to cingulum plateau of upper incisors  5% of population

Developing Mixed dentiti  early reco treatment w

ple

Ideal occlusion: Andrews 6 keys:  Correct molar relationship  Correct angulation (mesio-distal)  Correct inclination (bucco-lingual)  No spaces  No rotations  Flat curve of Spee What sort of problems might you see?  Abnormal tooth eruption  Abnormal tooth form  Abnormal tooth number  Premature loss of deciduous teeth  Poor prognosis of 6’s  Median diastema  Trauma  Crossbite  Habits Unerupted upper central incisors:  Idiopathic  Trauma to deciduous A  Loss of space  Supernumerary blocking eruption  Dilaceration  Treatment  where is tooth? Create / maintain space / remove obstruction  Try to remove physical obstructions asap as 75% of incisors will spontaneously erupt once space is available  If this doesn’t happen expose & bond a gold chain Supernumeraries  Extra teeth  80% appear in anterior maxilla  Most common cause is failure of eruption of upper central incisors  10% midline diastemas due to supernumeraries

Dilaceration:  Abnormality of crown-root angulation  usually sharp bend in root  Causes = developmental / trauma  Usually central or lateral incisor  Can cause failure of eruption  Management = orthodontically align / extract Premature loss of deciduous teeth:  Due to – caries, premature exfoliation, planned loss  A’s and B’s = usually little impact  C’s = unilateral loss CL shift therefore balances  D’s = unilateral loss CL shift generally not as marked as C  E’s = results in 6 moving forwards and loss of space for 5 – maintain space if possible  Maintainers  removable, fixed, lingual arch, transpalatal arch

Median d  ‘u  Usually disappear when upper 3’s erupt  If present after 3’s erupt it will persist  Causes of persistence = physiological, small teeth, missing teeth, prominent frenum

Crossbites:  Anterior or posterior  Anterior – usually one or more of upper incisors  Posterior – buccal crossbite, lingual crossbite / scissor bite  Main consideration  check whether there is a displacement Crossbite with displacement:  Premature contact  Important to carry out orthodontic assessment  Important to correct displacements Submerged / infraoccluded teeth:  Tooth fails to achieve occlusal relationship with opposing teeth  Commonly lower E’s  Causes = idiopathic / ankylosis / missing permanent successor / ectopic permanent successor  If successor present  extract deciduous tooth  If no successor  accept deciduous only, occlusal onlay, leave space if lost, orthodontically close space Digit sucking:  Incomplete OB or asymmetric AOB  Unilateral crossbite with displacement  Lower incisors retroclined  Upper incisors proclined Habit management:  Motivation to stop  If < 7 years can result in spontaneous improvement within 6 months  Habit breaker ? Management of impacted teeth Ectopic tooth = located away from normal position Impacted tooth = failure of a tooth to erupt (usually due to crowding or an obstruction) Supernumerary = presence of excessive teeth in the oral cavity

Aetiology:

    

Crowding Obstruction – supernumerary / soft tissue Ectopic position of crypt Primary failure of eruption Syndromes

Impacted upper central incisor: Aetiology  Supernumerary  Trauma  Dilacerated  Retention of primary  Impaction against fibrous tissue  Cyst

Impacted canines:

  

Long path of eruption, passing along distal root surface of lateral Should be palpable at 10 years in buccal sulcus Eruption 11-12yrs

Management of impacted canines:  Extraction of C’s - 10’13 years - May help normalize the position of canine  No treatment - Poor motivation - Warning: potential risk of resorption / cystic change  Orthodontic alignment - Surgical exposure  well-motivated / favourable position - Treatment can take 2-2 ½ years - Long term retention - Very rarely the canine may be ankylosed  Surgical removal - Canine in unfavourable position - Poorly motivated pt - Severe crowding  Autotransplantation - Insertion of a tooth / developing tooth germ from one site to a surgically created socket - V sensitive technique – risk ankylosis Buccal canines:  Buccal impaction associated w crowding  Generally, will erupt spontaneously when crowding is relieved  If severe crowding, and good 2-4 contact consider SR of 3 Impacted premolars:  Impaction most commonly due to early loss of E’s  loss of space

 

If impacted the 5’s will usually erupt lingually Severe crowding consider XLA 4  5 to erupt (rather than SR of 5)

Impacted 6’s:  Males > females  Maxillary > mandibular  Aetiology: crowding, ectopic positioning, unfavourable E crown morphology

Hypodontia Hypodontia = developmental absence of one or more teeth excluding third molars, can affect primary / secondary dentition Prevalence:

Aetiology:

General features / associations:  Extra-oral  retrusive maxilla  reduced LFH  Intra-oral  increased OB  bimaxillary retrognathia  delayed dental development  microdontia  ectopic canines  rotations  transpositions  taurodont  alveolar atrophy Management options for patients with hypodontia: Open space = recreate, distribute, leave space for a prosthetic replacement Close space = use orthodontics to close any residual spacing associated with the missing tooth Options for one unit missing in any quadrant: Missing 8’s:  No major issues  Means no potential for pericoronitis / impaction and therefore no need for surgical removal  Helpful if present (but not essential) if 6’s are lost due to caries Missing lateral incisors:  Open space  if uncrowded or spaced, helpful in class 3 incisor relationships  Close space  helpful in class 2 div 1 cases, if there is a lack of space, align upper 3’s next to upper 1’s Missing premolars:  Open space:  if uncrowded or spaced  if pt not keen on ortho  can leave E in situ if sound or not infraoccluded  even if intraoccluded can place onlay to restore occlusal contact  consider position of 4 and 6  if E poor can leave space unrestored  Close space:  if crowded & extractions would have been required anyway

 if diagnosed early, electively remove E early Options for 2 or more teeth missing in any quadrant: More severe hypodontia:  Generally, a combination of opening (redistributing) space and closing space  Can only really close one unit of space orthodontically  +/- build ups of small teeth  Restore spaces with denture / bridge / implants or combination Summary:  Hypodontia is genetic – check family history  Options for one unit missing in any quadrant are either open or close space – decision is multifactorial and includes cost  Options for more severe hypodontia are combination of opening and closing space  often Andrews ideal occlusion is very difficult to achieve  restore function and aesthetics as best as possible Removable appliances Mode of action = removable appliances are only useful where the desired tooth movement can be achieved by ‘tipping’ the tooth / teeth as opposed to fixed appliances that produce bodily tooth movement.

Removable appliance components = passive or active Passive components  do not produce tooth movement via direct application of a force to a tooth Wire components: - Clasps and bows used to secure appliance in place  retention Acrylic components:

-

Framework connecting active components Bite planes (anterior or posterior)

Components to secure appliance in place = retention Posterior teeth  Adams clasps (0.6mm SS in premolar teeth 0.7mm SS on molars) Anterior teeth  Southend clasp (0.7mm SS wire)  Shortlabial bow (0.7mm SS wire)

Active components: Springs:  Springs for buccolingual tooth movement  Springs for mesiodistal tooth movement Buccolingual tooth movement:  Anterior teeth – ‘Z’ spring / reverse cantilever spring, wire size depends on size and number of teeth being moved



Posterior teeth – ‘T’ spring

Mesiodistal too  Palatal fi

ment: ng – 0.5mm SS wire with coil and guard

Force needed for tooth movement:  30 g of force is needed for successful tooth movement of a single rooted tooth  You have control over wire thickness, wire length and amount of deflection by adjusting the spring

 is we double the length of the wire we will decrease the force 8 times but if we double the thickness of the wire we will increase he force 16 times Orthodontic screws:  Useful when you need to use the tooth you want to move to also retain the appliance in place – pt turns screw twice per week  0.5mm of tooth movement per week Bite planes: Flat anterior bite plane:  to ensure a bite plane has the correct dimensions the following information must be on the prescription sheet: 1. Overjet measurement 2. Height required of biteplane occluso-gingivally described in thirds of the upper incisal height Pos...