Monday, August 21, 2017

Orthodontics: Lecture Number One

Treatment Plan:
- Treatment planning gathers all knowledge towards finding the perfect treatment options for
the patient.
- Class I malocclusion: No skeletal discrepancy and the problem is dental.
- Class II and III malocclusion: There is a skeletal problem, but could also be dental but it’s
mostly skeletal.
- Normal occlusion has two conditions: 1- the line of occlusion is semi-circular 2- the molar,
canine, and central relationships are in class I. So even if the skeletal relationships are CI the
patient has dental malocclusion.
- Orthodontic analysis depends on three dimensions:
1- Sagittal(anterior posterior)
2- Vertical
3- Transverse.
- When a patient has skeletal Class I, this means that there is no skeletal discrepancy (there are
no problems antro-posteriorly) but there may be problems in the vertical or transverse
dimensions; or there are dental irregularities such as crowding and spacing.
❖ Spacing in Class I patients:
★ The most obvious spacing is the space between two incisors which is the
diastema. A diastema might be localized (median) or generalized;
★ Tooth- to- arch circumference discrepancies;
★ Missing or extracted teeth;
★ Irregularly shaped teeth ex: pig-shaped laterals;
★ Bolton discrepancy;
★ Trauma;
★ Large Tongue.

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✦ Diastema:

★ There are very mild diastemas and very large diastemas. Mild median diastemas are treated
by two approaches:
1- restorative treatment,
2- orthodontic treatment; like retroclining proclined incisors if the sella nasion angle is
suitable. If the upper incisors are straight retroclining them would result in a dished-in
face hence the inclination of the upper incisors is very important.
★ Diastemas always include doing a frenectomy; but whether it is done before, after or just
before treatment ends is a debate amongst orthodontists. The best solution is doing the
frenectomy almost before the treatment ends because throughout treatment there is a lot of
granulation tissue by the time the treatment ends. The frenectomy is done because of the
improper placement of the frenum; and this will prevent relapse. Scar tissue also pulls the
teeth together.
★ Diastemas are also caused by early extractions; the side anterior to the extraction site moved
distally hence producing a diastema and a shift in the midline. In order to treat this case the
midline should be reestablished; one arch could be stabilized and the other arch is mesialized
in order to close the diastema and to make space for an implant in the site of the extraction.
The diastema was closed and the space opened was used for an implant.
★ If there is a diastema in the upper arch (do a frenectomy) and spacing in the lower; whenever
there are generalized diastemas the patient should be informed of the possibility for life-long
retention.
★ Whenever there is a diastema check the frenum and always count the number of teeth. Since
it could be from the frenum, or a missing tooth, or both.
★ Retention is very important in diastema cases since whenever there is a war between soft and
hard tissues soft tissues always win.
★ Bad oral hygiene causes periodontitis and bone loss; the bone loss causes the teeth to drift
and move; when the teeth move labially there will be spacing; so it’s very important to check
the oral hygiene.
★ Bolton Discrepancy: Spaces are found because the meso-distal circumference of the teeth of
the upper arch does not coincide with the meso-distal circumference of the teeth of the lower
arch. It has anterior and posterior divisions which compares the sizes of the opposing teeth. If
the upper canine was the same size as the lower canine then there would be no spacing. This
reveals whether the problem has originated with the upper teeth or the lower teeth and which
of them should be targeted for therapy.
★ Trauma coud also cause spacing since trauma could cause the loss of the lateral and the
central and since the canine relies on the root of the lateral to erupt the canine will be

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displaced. The canine is distalised into it’s rightful place and then a prosthesis is used to fill
up the place of the lateral incisor until the patient is over 18 years old and implants can be
used.
★ When there are spaces due to missing laterals, there are two opinions some say that space
should be opened up for the laterals and implants should be placed however, another opinion
is to reshape the canines to look like laterals. The most important result is an esthetic and
functional smile.
★ If the canines have erupted in the exact position of the laterals, there is no point in extracting
the premolars to create space for an implant. Reshaping is the treatment of choice. However,
when the crown of the canine is large in size the reshaping procedure becomes more difficult.
Also the reshaping procedure removes some of the tooth’s enamel hence the color becomes
brownish since the dentine is more see through. Hence doing laminates would be a more
esthetic solution.
★ Sometime the missing laterals could be unilateral or bi-lateral hence the treatment plan also
differs.
★ If the patient doesn’t want any orthodontic treatment, or there is a failure in the treatment or
relapse; then composite could be used to fill the diastema.
★ The more the patient has a class III profile (the maxilla is small) try to make spaces in order
to broaden the maxilla. The more the the patient has a Class II div I with increased overjet,
the spaces should be closed in order to create room to push the teeth in an reduce the overjet.
The canine is reshaped to look like the lateral, and in the space behind the canine the teeth
are retracted in order to reduce the overjet.
★ Some diastemas take a lot of space that there is no space for the lateral incisors to erupt
between the centrals and the primary canines. In such a case intervention is mandatory and
the two centrals are drawn closer to each other and the laterals can then erupt.
★ Diastimas can be closed using a removable appliance using either: a Z-spring or a long
labial bow. If the diastema is minimal then a Z spring can be used however if the diastema
was large then using a finger spring would result in a black triangle. So instead use a long
labial bow to retrocline the proclined centrals in order to close the diastema.
★ When treating spacing, it’s preferable that the patient is in full-arch. The patient should have
all permanent dentition fully erupted and in MICP, since during eruption and through out life
the teeth are pushed mesially so the spaces might be reduced naturally. Also the permanent
teeth are also needed for proper anchorage in fixed orthodontics.

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❖ Crowding:
★ Classification:
‣ 1-2 mm: mild/ minor;
‣ 3-5 mm: moderate;
‣ More than 5 mm: severe.
★ The problem is in the moderate cases of crowding since the dentist must decide between
extracting the teeth or not. In severe cases extraction is often the answer, and in the minimal
either inter-proximal stripping is done or any other sort of treatment. However, in the
moderate cases the dentist is faced with a tough decision.
★ If a young patient has localized crowding; entrapped lateral with some medial diastema a Z-
spring or T-spring is used to close the diastema and another is used to push the lateral out.
And if there is a proclined lateral then some spaces is created and a long labial bow is used to
push it back.
★ Reasons for crowding:
1. The timing of extraction of the primary teeth is important, if the primary canine is
not extracted (and the root might be ankylosed) the canines might push the laterals
labially since the teeth find the easiest ways to erupt and it would be easier to push
the laterals than an ankylosed tooth. Always extract primary teeth in their rightful
times;
2. Supernumerary teeth, if there are 5 incisor that are all the same the candidate for
extraction is the tooth with the least alveolar bone which is the weakest tooth;
3. Tooth-arch- circumference discrepancy, calculate the space on the study model to
assess whether the space is sufficient for the tooth if it’s aligned or is extraction
needed.
★ How to gain space in a skeletal class I patient with crowding:
1. Interproximal stripping, cylindering or re-approximation;
2. Expanding the maxilla posteriorly hence increasing the arch circumference;
3. Proclination of the upper incisors;
4. Distalization, if there is an early extraction of the E and the 6 has drifted into its
space then distalization is done.
5. Uprighting of the molars;
6. De-rotation;
7. Extraction.

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1. Re-approximation: the mesiodistal dimension of the tooth is reduced to gain space.
Interproxiaml re-approximation done for anterior and posterior teeth. It may be done with a
handpiece and bur, cylinder or manually using sandpaper like material. It’s indications are:
✴ When the arch deficiency is between 0.5 to 2.5 mm;
✴ Reapproximation creates a contact area rather than a contact point; hence making
relapse harder since contact areas create retention;
✴ Modify the morphology of regular tooth shape; when the patient has large centrals in
comparison to the laterals; there is a dilemma. If premolars are extracted they should
also be extracted in the lower arch to maintain a class I canine relationship, and when
the teeth are aligned the centrals appear too large.
★ Contraindications and disadvantages:
✴ Teeth with large pulps, re-approximation causes dentinal hypersensitivity;
✴ Small teeth;
✴ Patients with bad OH which are susceptible to caries;
✴ Stripping creates a rough surfaces which makes the teeth very prone to plaque
accumulation;
✴ Hypersensitivity of the teeth.

★ The interproximal stripping can take about 50% of the enamel thickness to avoid the
brownish color caused by dentine showing through see through enamel, and the
hypersensitivity. Fluoride gel application should be applied whenever re-approximation is
done.
★ The dentist must pay a great amount of attention while re-approximating using the handpiece
since any movement could give major results. However, the manual re-approximation is
forgiving since the effort needed to remove the enamel is great. Hence any re-approximation
in the anteriors should be done manually since it’s forgiving.
★ The guide in re-approximation is the posterior occlusion. When the posterior occlusion is
essentially perfect and a solid class I, and the centrals are large and can be modified, go with
stripping. Even if the laterals are larger than the centrals then reshape the laterals to make
them of similar sizes.
★ If there is a retroclined lateral and needs space. The central and canine are essentially in good
shape and are esthetic and symmetrical to the other side. Hence go posteriorly with the
shipping procedure for example mesial to the 6 and distal to the 5, and use the space to fit the
lateral. The re-apporximation isn’t necessarily done where the crowding is; an overview is
done. If the teeth on one side don’t match the teeth on the other side, or if the canine is much

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larger than the central incisor then stripping can be done, if however there is symmetry then
go posteriorly so that it does not show.
2. Expansion: If there is a V-shaped maxilla and expansion is to be done then the arch
circumference would increase and a diastema will be created. If the patient needs 2 mm of
space, has a v-shaped maxilla, or has a unilateral or bilateral cross-bite; then expansion is
done and the teeth are aligned without having to do stripping or extractions. The expansion is
posterior rapid or slow-expansion of the maxilla.
3. Proclination of the upper incisors: this is done using a utility arch. Proclination of the
upper incisors causes spaces. So if a patient is in CIII and the laterals have no space, the
proclining the centrals will create space for the laterals.
★ Proclination: Space is gained. Retroclination: space is taken.
4. Distalization: the older the patient and the more posterior teeth are available and fully
erupted the harder the distalization, however the younger the patient and if the 7 hasn’t
erupted then the distalization becomes easier. Distalization is preferably done in cases where
there has been an early extraction of the E and the 6 has drifted into it’s space, and so it’s
distalized back into it’s original space. The 6 should always be returned to where it originally
was if the E’s were extracted early. In a class II division I case and the patient has a returded
mandible but the patient does not want to do surgery; extract the 4’s and retrude the anterior
section; it’ll be much easier than distalizing the 6’s and the 7’s. There is nothing known as
non-extraction; if the distalization will start with the 7’s then the 8’s would have to be
extracted so how are the 8’s different than the 4’s. Also extracting the 4’s and retruding the
anterior section as one piece is much easier than disalizating the 6 which would take 9
months, and the 4+5 which would take 9 months and the anteriors need 9 months. There is
something called Ahamd Kalash Slider. Distalization is done in cases of early extraction of
E’s and mesial drifting and the 7’s have not yet erupted.
★ Distalization is done through an intra-oral mechanics like a distalization screw, or
any extra-oral mechanics that gives a distal force such as the headgear:
★ The high pull headgear: distal force and intrusion;
★ The low pull headgear: distal force and extrusion;
★ The combined headgear: causes distalization only.
★ The headgear can be used to make both skeletal and dental effects depending on
the amount of force and duration. The amount of force for skeletal effect is higher
than the dental. The timing is also different since in skeletal problems the patient
wears the appliance for 10-13 hours per day, however when it’s dental the patient
must wear the appliance for 20-21 hours per day.
★ The less the posterior teeth (erupted 7’s), the easier the distalization.

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★ When intra-oral distalization is done; the 6 is distalized and by the force in the
transeptal fibers the 5 follows.
★ When distalization is done, two things should be done: 1- over-correction: don’t
leave the patient in a Class I relationship; over correct, 2- stabilize for at least 6
months so relapse doesn’t occur.
5. Uprightening of molars: When there is an early extraction of the E’s the six would be tilted;
hence when the the molar is uprightened then space is gained.
6. De-rotation: de-rotating posterior teeth creates space; while de-rotating anterior teeth
requires space.
7. Extraction: Before deciding on extraction (which is the last option), there is a certain criteria
that should be met.
1. The skeletal relationship;
2. The proclination of the upper anterior teeth;
3. Overjet and overbite: increased or reduced;
4. Anchorage requirement;
5. Amount of space required;
6. Facial growth;
7. Soft tissue;
8. Esthetics***.
★ The skeletal relationship: extraction could be done in all cases (CI, CII, CIII). In CI
extractions of the upper and lower first premolars are done in serial extractions (C’s and D’s)
or if there is severe crowding. In skeletal CII either the maxilla is prognathic or the mandible
is retrognathic, if the patient refuses to under go surgery and the nasiolabial angle allows it,
then extraction of the upper 4’s is done and the anterior segment is retracted. In skeletal CIII
the lower 4’s are extracted and the anterior segment is retracted. This is camouflage.
★ The proclination of the upper anterior teeth: when the upper anterior teeth are proclined
the 4’s are extracted and the teeth retracted;
★ Overjet and overbite: If the patient has crowding and a shallow overbite, extraction is
preferable. When the patient has crowning and a deep bite then distalization is done. When
the vertical dimension is increased (overbite is decreased) extraction is done either of the
lower 4’s or the upper 5’s since this case has a CIII tendency. The Fulcrum of the TMJ: the
closer to the fulcrum the overbite gets more reduced, for example the openbite is 2mm, and
the teeth are distalized for 1 mm, the openbite will become 3 mm. Hence, the teeth should
not be distalized towards the fulcrum and extraction is the treatment of choice

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(mesialization). On the contrary if there is a deep bite and the teeth are distalized then the
overbite will be reduced.
★ Anchorage requirement: in a CII Div I patient, the teeth are to be retracted using total
fixed orthodontics an elastic is used to retract the anterior segment using the posterior
segment, however the posterior segment might move mesially which is contraindicated.
Hence anchorage is the retraction of the anterior segment without the mesiallization of the
posterior segment. There is maximum posterior, maximum anterior, moderate and absolute
(mini-implant).

๏ Extractions:

๏ Upper and lower incisor extraction: It is rarely indicated to extract an upper anterior tooth
unless it’s been traumatized previously. However, when there is severe crowding in the
lower anteriors (centrals and laterals) and there is a class I molar relationship, if the
premolars are to be extracted; in order to maintain the canine CI relationship both upper and
lower 4’s should be extracted. An easier solution would be extracting one central or
lateral incisor. There are two problems with this solution: 1- the midline is lost (however in
patients with a large lower lip the midline doesn’t show, 2- life-long retention is mandatory.
Or if the incisor is very malpostioned. Also if there is a supernumerary tooth is available.
‣ General rule for lower incisor extraction: CI molar relationship, CI premolar
relationship, CI canine relationship, and the overjet and overbite are perfect. Hence
one incisor is sacrificed and 4 premolars are saved.
‣ In the upper arch the incisors are extracted if they are supernumerary teeth or if the
posterior occlusion is perfect and the lateral is entrapped palatally and the patient
doesn’t want a complicated treatment plan then the lateral could be extracted and the
canine reshaped. Another option is extracting a premolar and distalizing the canine
to make space for the lateral. Or if the teeth are transpositioned (canine is in the
place of the lateral incisor). Never extract the centrals.
‣ Canines are never extracted unless they are impacted in a very risky position where
their exposure might cause bone loss or hurt adjacent teeth and when they are
extruded without their natural alveolar bone and attached gingiva they don’t look
esthetic. So the canines are extracted and the premolars are shaped as canines.
Always check the impact of the canines on the adjacent teeth since these canines
might have caused resorption of the roots of the incisors so remove the incisors and
reshape the canines or use laminates. Hence since canines are in the corner of the
mouth and have such long roots they are never extracted unless there is an absolute
indication like ectopic eruption.

๏ Premolars: If there is crowding the rule is: either extract upper 4’s or lower 5’s. The more
anterior the crowding extract the 4’s, the milder the crowding anteriorly and more posteriorly
then extract the 5’s. In a moderate crowding case, if the 4’s are extracted then there would be

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spacing and the facemask could be used to close the spaces. However, in such a case it’s
more preferable to extract the 5’s in moderate crowding cases. Also, when extraction is
indicated; check the periodontal support of the teeth and extract the tooth with the least
periodontal support.

๏ Molars: If the molars are absolutely destructed then it would be nonsensical to extract the
premolars, hence the destructed 6’s are extracted. Latency period is about one week and it’s
between the extraction and the orthodontic treatment. The 4 and 5 are distalized a little bit
and the 7 drifts mesially.

๏ If there isn’t sufficient space for the eruption of the laterals then the path of eruption for the
laterals is palatal. And there are 4’s, 5’s, 6’s. And the 6’s are destructed. So extract the 6 and
retract the canine along with all the molars and protrude the lateral. On the other side then
extract the 4 on the other side in order to preserve the midline.

๏ If the 6’s are already extracted, then mesalize the 7’s.

๏ 7’s are rarely extracted. However when distalization is indicated the 7’s are extracted and
some interseptal bone is removed and the movement of the 6 is calculated.

๏ 8’s are extracted if it’s causing discomfort, or if it’s not in the occlusion where the upper has
erupted and the lower hasn’t then there will be pocket formation and it should be extracted.
❖ Transverse Discrepancy:
★ In a skeletal Class I, there might be a buccal cross-bite or a scissor bite. The buccal
crossbite could be unilateral (always check if there is deviation) or bilateral; it’s treated with
rapid palatal expansion such as the Hyrax screw which could be bonded or banded.
Scissor bite is very difficult and usually found on one tooth, it’s treated with fixed
orthodontics.
❖ Vertical Discrepancy:
★ In skeletal Class I, there might be a normal overbite, edge-to-edge, or posterior open bite.
When the patient is edge-to-edge the dentist must be careful since the patient has a Class III
tendency, so the treatment must be very meticulous as to not cause any extrusion in the
posteriors because the slightest extrusion causes an open-bite.
★ In posterior open-bites, the tongue could be very large (macroglossia) hence preventing the
teeth from interdigiation.
★ In rare cases, there is occlusal cant where a side has MICP and the other side is in an
openbite.
★ Deep overbite is also a probability. Which is the most forgivable vertical discrepancy in the
regard of extrusion of the posterior teeth since in all other cases a minor extrusion will cause
an openbite. The deep bite is treated by: 1- Intrusion of the anteriors, 2- Extrusion of the
posteriors by using anterior bite-planes if the patient is young and growing.

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★ In patient with anterior open-bites there are 3 treatment: 1- Extrusion of the anteriors, 2-
Intrusion of the posteriors, 3- combination of both. The decision is made depending on the
patient’s smile line. If the patient has a low smile line then extrusion of the anteriors can be
done, however if the patient has a gummy smile then intrude the posterior teeth. The
intrusion is done though a high-pull headgear or any mechanics to intrude the molars such as
mini-implants. When intrusion of the posterior teeth is done the mandible auto-rotates
upward and forward hence the anterior open-bite is reduced.
★ Some types of orthodontic treatments need overcorrection. But all cases need retention for at
least 2-3 years up to life-long retention.
★ Stability vs retention vs

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