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Chapter

7
Treatment Planning
Nigel Harradine
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Introduction
The previous chapters have considered four key elements that should influence our treatment planning – the
occlusion, the face, the smile and tooth and gingival aesthetics, and the chapter on the extraction - non-extraction
decision examined that important choice. This chapter discusses how we should merge these elements into a plan
for an individual patient. For example, having gathered all the relevant data, should we first consider the profile, the
occlusion or the smile? An initial comment is that this will vary with the needs and wishes of a particular patient.
Another factor will be the practical biomechanical possibilities for that individual patient. For example, how much
anchorage is realistically available in this case?

The patient's actual complaints

We should always be as certain as possible about the things which concern the patient. For example: Is the patient
bothered by the prominent upper teeth or also by the receding chin? This may profoundly affect the chosen plan
in cases of borderline skeletal severity. Is the patient bothered by the appearance or function of an anterior open
bite or is it the long face or the gummy smile that are the main concern? This may strongly influence the choice
between TAD assisted orthodontic mechanics and a Le Fort osteotomy.

Patient compliance
Motivation for treatment and compliance with treatment are important factors in planning treatment. These factors
are discussed in the chapter entitled Motivation, Compliance and Satisfaction in Orthodontics. However, the most
important recurring factor in achieving good compliance seems to be the relationship between the patient and the
orthodontist.

Age
It is usually easiest to treat patients before or during the pubertal growth spurt. It is at this time that the patient is
often at their most compliant, has fewer social distractions and is a time when the tissues are in a state of rapid
turnover. As the patient gets older, treatment is still possible but the scope or ease of treatment change diminishes.
For some specific treatments – such as orthognathic surgery - the optimal treatment time may be slightly different.

The problem list

Having gathered all the relevant data, we would strongly advocate the compilation of a problem list before deciding
on treatment aims and subsequently, treatment means. The advantages of a problem list can be summarised as
follows:

• it turns a mass of data into a short and relevant list

• no problems are forgotten – at the treatment planning stage or later
• it focuses thought on the actual problems
• it enables problems to be recorded as fully noted, even if the subsequent list of treatment aims
includes a decision to accept a problem rather than to attempt to resolve it.

These are powerful advantages in making good plans, in keeping track of treatment aims during treatment and in
recording the limitation of treatment aims. A list of treatment aims will of necessity address all the items in the
problem list and will lead to a rational selection of the best means of treatment for that patient.

The sequence of forming a plan should therefore be:

• compile a problem list

• list the treatment aims
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• list the treatment means

David Sarver has suggested producing a list of problems to solve and a list of features that the orthodontists wishes
to protect during treatment (eg: solve deep overbite but protect incisor display).

General and specific treatment aims

Any specific list of treatment aims will be compiled against an underlying set of general treatment aims or principles.
For example, we need to have answers to all the following questions:

• what final occlusion do I normally aim for?

• what general aims do I have about changes in arch width and shape?
• what do I believe is desirable/achievable regarding vertical tooth position?
• what general aims do I have for anteroposterior lower incisor position?
• what are my general views about the effects of extractions and what factors influence my choice of
extractions?

All these questions are addressed in one of the chapters of this manual. It will not surprise readers to hear that we
feel that every orthodontist needs views on these questions that are based on the best available evidence, although
it needs to be recognised that the current evidence is far from ideal on many of these points. A paper by Lysle
Johnston (1998) is typically iconoclastic on this subject and very well worth a read. It is entitled The value of
information and the cost of uncertainty: who foots the bill?

Factors which influence estimation of space requirements

The challenges involved in estimating the most appropriate arch line and therefore the crowding for an individual
are discussed in the chapter The Extraction Non-Extraction Decision. Other factors significantly influence the planning
of space requirements.

The effect on available space of anteroposterior expansion/retraction

The ‘traditional’ rule of thumb is that 1 mm of labial movement will provide sufficient space for 2 mm of crowding
(1mm on each side of the arch). This rule of thumb assumes a rectangular arch form. In fact, with a much more
realistic parabolic archform, the situation is more complicated and in general the labial movement will need to be
greater than 1 mm to produce 2 mm of space. The paper by Steyn et al (1996) demonstrates this and interestingly,
also calculates the effect of different arch depths and widths on the anterior movement of incisors required to
accommodate a given amount of crowding. In general, the wider the intercanine distance and the shallower the
arch depth from the canines to the mid-incisor point, the greater the A-P expansion required to accommodate a
given amount of crowding (or conversely the greater the A-P retraction of incisors for a given amount of interdental
stripping) and in cases presenting a specific dilemma, inspection of the table in the paper by Steyn is recommended.

In a given instance, the labial movement of lower incisors in a non-extraction case is frequently greater than that
required to accommodate the crowded teeth. This reflects the additional use of class 2 traction and the degree of
control of lower incisor inclination with occlusal plane levelling. For example, in non-extraction cases Saelens and
De Smit (1998) found that to accommodate crowding of only 4 mm required an average of 5 mm of labial movement
of lower incisors and not the 2 mm which the rule of thumb would have estimated. It will be seen in the chapter on
self-ligation that there may possibly be less incisor proclination and greater lateral arch expansion in some cases if
light forces and self-ligating brackets are employed to align crowded arches, but this has yet to be supported by
evidence. The choice of torque for the lower incisor brackets should be strongly influenced by the need to limit
lower incisor proclination. For example, in the light of research on slop or play between the bracket and the wire,
we use a minus 11˚ torque prescription when undesirable labial tipping of the lower incisors is to be prevented. This
topic is covered in some detail in the talk entitled “Let’s Talk About Torque” in this course and is discussed in the
chapter on The Development of Preadjusted Appliance Systems.
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The effect on available space of lateral expansion

Lateral expansion has been found to have less effect on arch perimeter than A-P expansion. An interesting paper
by Noroozi et al (2002), demonstrates the ability of an algorithm based on two measurements of arch width and
two of arch length to predict the arch perimeter increase which will result for any given A-P or lateral expansion.
These authors again find that A-P expansion is much more effective than lateral expansion in providing space. Their
formula also predicts approximately 1mm of arch length gain for 1mm of incisor labial movement. This is half of the
‘rule of thumb’. In the lateral dimension, each mm of canine expansion gives 0.6 mm of space and each mm of
second molar expansion gives 0.3 mm.

Key point: Because dental arches are far from rectangular, 1 mm of labial incisor movement gives
approximately 1 mm of extra arch length, not 2 mm. i.e. more labial movement of incisors is required to
accommodate crowding than you might think.

The amount of curve of Spee

The historical rule of thumb for this factor was 1 mm of space required for every 1 mm depth of curve of Spee. This
has been shown to be an excessive calculation of space required. Germane and Staggers (1992) found a non-linear
relationship and a less than one to one ratio for curves shallower than 9 mm. A more recent study by Braun et al
(1996) found an even smaller effect - namely that a very deep curve of 9 mm only requires 2 mm of additional space.
The strong tendency for labial flaring of lower incisors associated with non-extraction levelling of curves of Spee is
therefore mainly due to choices in the biomechanics employed rather than to the space requirements. This will be
discussed further in the chapter on Managing Overbites and is also referred to in the section on bracket prescriptions
in the chapter on The Development of Preadjusted Appliance Systems.

Patterns of extractions
The chapter on The Extraction Non-Extraction Decision has discussed the overall question of extractions in
orthodontic treatment and the three chapters on treatment planning have included related reference to the
influence of extractions on the occlusion, the face and the smile. There remain some additional factors which should
influence our planning in relation to extractions.

If the lower arch is non-extraction:

Then non-extraction is our treatment of choice in the upper arch. If the case is suitable for functional appliance
treatment for class II correction, then this is definitely our preferred option. The extraction of upper second molars
has been advocated by some clinicians if the upper second molars have erupted, the upper third molars are present
and of good size and at least half a unit of distal movement is proposed. Waters (2001) has reported that this
achieved 1.2 mm additional distal movement of the upper first molar and 5 degrees less incisor proclination, but
this should be weighed against the long -term disadvantage of having a smaller more conically rooted third molar
in place of a second molar. We almost never extract upper or lower second molars. (One exception is when
intruding molars with TADS in the presence of unerupted 8s).

Although non-extraction is our treatment of choice if the lower arch is non-extraction, extraction of upper first
premolars is much less demanding on anchorage and the occlusal disadvantages of a class II molar relationship are
slight (see Andrews 1989: Straight Wire: The Concept and Appliance pages 182-187). If the initial molar relationship
is much more than half a unit class II and the case is not very suitable for functional appliances (for example in an
adult), we would usually advocate extraction of upper first premolars, assuming that the face does not require
surgical advancement of the mandible. A class II molar relationship does carry an increased chance of small residual
spaces in the extraction sites. This is due partly to the difference in mesiodistal width between two premolars and
one first molar and partly to the second premolars being teeth that are more frequently disproportionately small.
Such occlusal imperfections may be considered much more acceptable than the consequences of insufficient
anchorage to correct a class II relationship. A recent new factor in this decision between aiming for a class I or class
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II molar relationship is our ability to distalise buccal segments with miniscrews (See chapter on Temporary Anchorage
Devices in Orthodontics).

If lower premolars are extracted:

Then upper premolars are almost always extracted. If the upper canines are at an ideal angulation or more distally
angulated and must move distally by much more than half a unit, then extraction of upper first premolars is
recommended.

Therapeutic diagnosis
Extractions are irreversible and undesirable unless clearly an overall advantage. Treatment response can be
unpredictable. In a number of cases, it is sensible to start non-extraction and align the arches before making a
decision on extraction. If extractions are then carried out, very little treatment time has been lost and the need for
the extractions has been demonstrated to clinician and patient. The potentially different response to alignment
with very gentle wires, self-ligating brackets, occlusal disclusion and early light class II elastic traction has in our view
increased the occasions when this approach is sensible. It is important to start such treatment with the clear
understanding that if the clinician decides after some visits that extractions are required that this is a decision that
must be implemented.

References
Andrews LF (1989)
Straight Wire. The concept and appliance
Published by LA Wells Co. San Diego
ISBN 0-9616256-0-0

Braun S, Hnat WP and Johnson BE (1996)

The curve of Spee revisited
American Journal of Orthodontics and Dentofacial Orthopaedics 110: 206-10

Germane N and Staggers JA (1992)

Arch length considerations due to the curve of Spee: a mathematical model
American Journal of Orthodontics and Dentofacial Orthopaedics 102: 251-5

Johnston LE (1998)
The value of information and the cost of uncertainty: who foots the bill?
Angle Orthodontist 68: 99-102

Kremenak CR, Kinser DD, Harman HA, Menard CC and Jakobsen JR (1992)
Orthodontic risk factors for temporomandibular disorders (TMD) 1:premolar extraction
American Journal of Orthodontics and Dentofacial Orthopaedics 101:13-20

Noroozi H, Djavid GE, Moeinzad H and Teimouri AP (2002)

Prediction of arch perimeter changes due to orthodontic treatment.
American Journal of Orthodontics and Dentofacial Orthopaedics 122:601-607

Steyn CL, Harris AMP and du Preez RJ (1996)

Anterior arch circumference adjustment - how much?
Angle Orthodontist 66: 457-462

Waters D and Harris EF (2001)

A cephalometric comparison of maxillary second molar extraction and non-extraction treatment in patients with
Class 2 malocclusions
American Journal of Orthodontics and Dentofacial Orthopaedics 120:608-613
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