Module 15 - Treatment Planning 080306

National Orthodontics Programme Module 15- Treatment Planning
British Orthodontic Society 1




National Orthodontics Programme
British Orthodontic Society



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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


•
to assess them. We will also focus on the decision process relating to the need
r extractions.

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
fo


:
op ent)
ric Analysis) 21 – 25 (Treatment Techniques)
13 (Aetiology)

Note that this Module links closely with Modules
4 (Effect of respiration on facial devel m 14 (Diagnosis)
11 (Cephalomet
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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, 2
nd

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






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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



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Section 2 - Facial and smile aesthetics



Ackerman J L, Ackerman MB, Bresinger CM, and Landis J R 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


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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 of the arch eg 6-3/ 3 -1/ \1-3 \3-6 or more for greater accuracy. Use dividers and
ruler.

Brass wire: contour a piece to line of occlusion then straighten it out for measurement.

Calculation of space required:
Measure mesiodistal width of each tooth from contact point to contact point and summate. Sum of widths --
amount of space available = arch perimeter space deficiency (and vice versa)

Combination of Radiograph and Prediction Table Methods
Main problem with using radiographs is distortion of canine, therefore could use size of incisors from
Study models and size of unerupted premolars using films to predict size of unerupted canines.
A graph developed by Staley and Kerber from Iowa growth study data allows canine width to be read directly
from the sum of the incisor and premolar widths. This method can only be used for the lower arch and
requires periapical radiographs. For white children, it is quite accurate.
For white, Northern European children the Staley - Kerber method will give the best prediction, followed by the
Tanaka - J ohnston and Moyers approaches. These methods are superior to measurement from radiographs.
The Tanaka - J ohnston method is the most practical and simple.
For Black / Oriental patients direct measurement from radiographs is best approach.
If obvious anomalies in tooth size or form are seen in the radiographs, the correlation methods (which
assume normal tooth size relationships) should not be used.

Tooth Size Analysis
For good occlusion, the teeth must be proportional in size.
Approximately 5% of the population have some degree of disproportion among the sizes of individual teeth,
known as tooth size discrepancy. An anomaly in the size of the lateral incisor is most common.
Tooth size analysis / Bolton analysis is carried out by measuring the mesiodistal width of each permanent
tooth. A standard table (eg Proffit p. 170) is then used to compare the summed widths of the maxillary and
mandibular anterior teeth and the total width of all upper to lower teeth (excluding 7's and 8's)


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A quick check for anterior tooth size discrepancy can be done by comparing the size of the upper and lower
incisors (upper 2's should be larger than the lowers).
A quick check for posterior tooth size discrepancy is to compare the size of upper and lower 5's which should
be about equal size. A tooth size discrepancy of < 1.5mm is rarely significant.
Assumptions:
1. AP position of incisors is correct (retrusion accentuates crowding & protrusion alleviates crowding)
2. Space available will not change because of growth (class II, class III, long face, short face)

See Module 14 - Diagnostic procedures for Mixed dentition space analysis.

Estimation of the size of unerupted teeth
Measurement from radiograph requires an undistorted image, more likely with individual periapicals than an
OPG. There is a need to compensate for magnification by measuring an object that can be seen both in the
radiograph and on the SMs eg 1 ° molar:
True width of 1 ° molar = True width of U/E premolar
Apparent width 1 ° molar Apparent width WE premolar
The technique can be used in both arches for all ethnic groups

Estimation from Proportionality Tables
A reasonably good correlation between size of erupted permanent incisors and size of unerupted canines
and premolars has been tabulated for white American children by Moyers (Proffit p.168). Mesiodistal width
of lower incisors measured and is used to predict size of both upper and lower canines and premolars. Size
of lower incisors correlates better than size of upper incisors as the upper lateral incisor is a very variable
tooth. However, there is a Tendency to over-estimate size of unerupted tooth with this method, but it is fairly
accurate and no radiographs are required.

Tanaka and J ohnston prediction values:

Tanaka MM and J ohnston LE J . Am. Dent. Assoc. (1974) 88:798

One half of the mesiodistal width of the four lower incisors + 10.5mm
= estimated width of lower 3, 4 and 5 in one quadrant

One half of the mesiodistal width of the four lower incisors + 11.0mm
= estimated width of upper 3, 4 and 5 in one quadrant
This method has good accuracy but a small bias towards overestimation of tooth size. No radiographs or tables
required are required.

The clinical application of a tooth-size analysis
It is stressed, once again, that the analysis should be regarded as a useful guide and not as some utopian
vision that anchorage, growth, mechanics and patient compliance can be controlled with total accuracy.


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Bolton WA. The clinical application of a tooth size analysis. Am J Orthod 1962; 48: 504-29.
If the overall ratio > 91.3% the mandibular teeth are too wide compared to the maxillary teeth. The main
cause of tooth width discrepancy is a right-left asymmetry of mesiodistal tooth size.
If the anterior ratio is greater than 77.2% the total width of the lower six anterior teeth is relatively too
large. If it is reduced the discrepancy is due to an excess in maxillary tooth material.
Bolton also produced some tables. Once the Bolton ratio is calculated and the arch with the relatively smaller
tooth material determined, you can locate the actual figure corresponding to the arch tooth size on the
table. The ideal value for the size of the opposing teeth is read off the accompanying column. The difference
between the actual value and the ideal represents, in mm, the amount of excess tooth size in this arch.



J ohal AS, Battage J M. Dental Arch crowding: A comparison of three methods of assessment. Eur J Orthod
1997; 19: 543-551.

All methods are prone to error (landmark identification, individual interpretation, validity, proper archform
hence perimeter length. The Reflex microscope is not intended for clinical use (expensive, time consuming,
difficult also to assess tilted teeth as casts are clamped). The visual technique is easy but due to space being
assessed in a straight line (ruler), this may explain why crowding is overestimated. Brasswire method tends
to underestimate crowding as it could be that a ruler (sensitivity of 0.5mm) may underestimate tooth width.

Irregularity index (Little)
Calculates the sum of the distances between the tooth contact points measured in parallel with the occlusal
plane (reflects linguo/labioversion, displacement, and rotation). In proper occlusion the anatomic contact
points of adjacent teeth should abut one another. Can range from zero (perfect alignment) to large upper
limits. It is however insensitive to reciprocal rotations of adjacent teeth.

Conclusions
There is a modest correlation between these two methods because they provide complimentary information.
The Space Analysis is more attuned to tooth displacements while the Irregularity index is susceptible to
axiversions. The irregularity index is a measure of irregularity alone. It is not affected by divergent axial
inclinations or where teeth are displaced but do not overlap.


Selwyn-Barnett BJ . Rational of treatment for Class 11 Division 2 malocclusion. Br J Orthod 1991; 18: 173-181.



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Non-extraction may enable easier and more successful treatment of Class II/2 cases. This method may not
push the teeth out of the position of soft tissue balance. Extractions do not guarantee stability (Little) so some
lower incisor crowding following this non extraction approach is acceptable. Mild crowding does not justify
premolar. However prolonged/ permanent retention should be considered. It's OK when appropriate!


Braun et. al. The Curve of Spee revisited. Am J Orthod Dentofac Orthop 1996; 110: 206-210.
The result of this investigation suggests that the difference in arch circumference before and after leveling is
less that was found by others (eg. Germane, Garcia) As an example, a curve of Spee depth of 9mm would only
increase the circumference by 2.04mm after leveling. This would be associated with an incisor proclination of
3.2° (if canine width is kept constant).
This is less than that found clinically using continuous archwires and suggests that some proclination is
due to the mechanics, such as inserting a reverse curve into the wire.
The authors suggest using segmental archwires (such as Burstone's intrusion arch) to selectively intrude the
incisors or to extrude the premolars and molars. This may prevent unwanted excessive incisor proclination.


Germane N et al. Arch Length Considerations due to the Curve of Spee: A Mathematical Model. Am J Orthod
Dentofac Orthop 1992; 102: 251-255.

It was long assumed that I mm of arch circumference is needed to level each millimetre of Curve of Spee.
Previous workers such as Baldridge and Garcia found however that less than l mm of arch circumference
was required to level the curve. This study was to produce a mathematical model to quantify this.
A Catenary curve is narrower in the canine and second molar regions than a Bonwill-Hawley archform.
Therefore, for a given curve of Spee, the arch circumferences measured at either the first or second molars
are longer for the Catenary curve than the Bonwill-Hawley archform. This implies the type of archform has a
clinical impact on the amount of arch circumference.

Previously Baldridge and, separately, Garcia found a linear relationship ( less than 1 to 1 ) between arch
circumference/perimeter and curve of Spee but re-examination of the statistics used showed flawed analysis
and so a linear relationship could not be assumed. This nonlinear relationship is confirmed by this present
mathematical analysis. For the catenary curve the amount of arch circumference required for levelling is
consistently less than one to one for curves 10mm or less for the Bonwill-Hawley archform. The amount of
arch circumference was less than 1:1 for all curves of 10mm or less when the arch circumference was
measured at the first molars. The amount was also less than 1:1 for curves less than 9mm when arch
circumference was measured at the second molars. Yet the arch circumference required was more than 1:1
for curves of Spee or 10mm when the arch circumference was measured at the second molars using the
Bonwill-Hawley archform. Therefore, in Bonwill-Hawley archforms the amount of arch circumference
required for levelling the curve of Spee varies depending upon depth of curve and from where the arch
circumference is measured. Most preformed archwires at present are based on a catenary curve.



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Section 4 - Summary guidelines for the extraction of teeth
Assessing the lower arch crowding

Category

mms of crowding Extraction pattern
Consider:
Mild 1 to 4mm Non extraction or second premolars

Moderate 5 to 8 mm First premolars or second premolars

Severe 9+ mm First premolars
The choice of teeth for extraction for orthodontic purposes is dependant on the following factors:
General Factors
• Gross pathology, eg. caries, periodontal conditions, hypoplasia
• Gross Displacement
• Abnormal morphology.
Factors specific to the malocclusion
• Patients dental and facial aesthetics and profile.
• The A-P skeletal pattern
• The vertical skeletal pattern.
• The transverse relationship of the arches.
• Soft tissue factors, eg. Large flaccid tongue and lips etc.
• The degree of crowding.
• Site of crowding
• Whether it is an orthodontic or surgical treatment plan.
• The need for antero posterior movement of the teeth relative to the skeletal base for orthodontic
camouflage e.g. the reduction of an increased overjet.
• Space for flattening the curve of Spee and reduction of the overbite.
• Space for centreline correction.
• Space needed for correction of the molar relationship.
• The anchorage requirements of the proposed tooth movements.
o i) Tip and torque adjustments planned for the incisors
o ii)The inclination of the canines.
• Anchorage requirements and anchorage balance
• Age of patient - more difficult to close space in older pts.


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Section 5 - Treatment of Borderline Extraction / non extraction
Cases
Extraction pattern in mild / moderate crowding problems
• Contemporary guidelines for orthodontic extraction in Class I crowding and / or protrusion (Proffit).
• Less than 4mm arch length discrepancy: extraction rarely indicated.
• Arch length discrepancy 5 to 9mm: non-extraction or extraction treatment possible. The
extraction/non-extraction decision depends on both the hard- and soft-tissue characteristics of the
patient and on how the final position of the incisors will be controlled. Non-extraction treatment
usually requires transverse expansion by uprighting across the molars and premolars.
• Arch length discrepancy 10 mm or more: extractions always required.

First premolars
If the crowding is mild, extraction of first premolars may result in residual spacing. The loss of first
premolars is recommended for moderate to severe crowding, especially to allow buccally placed and
crowded canines to erupt. If fixed appliances are the used to close the remaining space, there is a danger of
overretracting the labial segment, which may have deleterious effects upon the profile. Consider extracting
teeth further distal in the arch.
Second premolars
• Congenital absence of second premolars and crowding of the arch
• Hypoplasia of the second premolars and crowding of the arch
• Severe displacement of the second premolar
• Mild to moderate crowding (2-4mm per quadrant)
• Where space closure by forward movement of the molars rather than retraction of the labial
• segments is indicated whilst taking into account the molar relationship.

Second permanent molars
Indications:
• Facilitation of distal movement of the upper buccal segments.
• Correction of moderate Class II malocclusion in mature adolescents with limited growth potential.
• Do not expect more than 4mm distal movement.
• Ideal patient with less than full cusp Class II molar relationship.
• Relief of mild lower premolar crowding (1-2mm of space in premolar region).
• Provision of additional space for the third molars and thus reduction of the likelihood of their
impaction.
• Prevention of lower labial segment crowding.

Expansion
Before deciding whether arch expansion is appropriate, the aetiology of the individual arch form needs to be
identified. The method of expansion can then be determined. However, of expansion in the intermolar
region may not provide more than one half to one third within the arch.


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Distal movement of molars
Indications in the upper arch:
• Class I with mild upper arch crowding, or mild II division 1 with a well aligned lower arch and
molar relationship less than half a unit Class II.
• When extraction of both upper first premolars does not give a sufficient space to complete
alignment and/or overjet reduction in the upper arch.
• Where early unilateral loss of a deciduous molar had resulted in mesial drift of the first permanent
molar.
• Where upper arch is crowded but a median diastema is present.

Enamel interproximal reduction
Interproximal enamel reduction (stripping) can be effectively used to gain space in the upper and lower
arches and also to coordinate tooth sizes between the two arches.
Each tooth has 0.75 to 1.25 mm of interproximal enamel surface
It is safe to remove 0.25mm of enamel from the contact areas of these teeth
In theory, 22 tooth surfaces available from mesial of the first molar on one side to the other, a total of
5.5mm of space can be gained. However, in practice, interproximal reduction is usually performed on upper
and lower incisors only.


Section 6 - Treatment of Patients with Skeletal disproportion
There are three possible approaches:
1. Functional Appliance therapy (Growth modification).
2. Camouflage of the skeletal jaw discrepancy by orthodontic tooth movement. Extractions are usually
necessary to allow movement of the teeth relative to the skeletal base in an effort to camouflage
the skeletal discrepancy. The dental occlusion is corrected but the skeletal discrepancy remains.
3. Combined orthodontic and orthognathic surgical treatment. This involves surgical correction of the
jaw discrepancy in combination with orthodontic treatment to position the dentition to produce
optimal facial aesthetics and occlusion.
Considerations for each of the possible approaches
Functional Appliance (Growth Modification)
See Module 22
The ideal patient for functional appliance treatment

i) Class II division I malocclusion in patients with excellent remaining growth potential.
ii) Non-extraction due to well aligned arches.
iii) Skeletal mandibular retrusion.
iv) MM angle average or reduced with an increased overbite.
v) Maxillary incisors proclined.


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vi) Mandibular incisors retroclined.
vii) Class 111 malocclusion eg Frankel 111, face mask or reverse twin blocks although with
limited success.

Camouflage Orthodontic Treatment
• Consider the camouflage of the A-P, Vertical and Transverse skeletal discrepancies.
• With extraction of teeth it is possible to obtain correct molar and incisor relationships despite an
under-lying Class 2 or Class 3 skeletal relationship.
• Considerable retraction of the upper incisors can be accomplished for most patients before
problems are encountered with the following:
• A relatively prominent appearance of the nose.
• An unaesthetically obtuse nasolabial angle.
• A lack of palatal bone into which to retract the upper incisors. This can be judged on the pre-
treatment ceph by judging the degree of retraction necessary to achieve the correct lower incisor
edge to upper incisor root centroid relationship.
• The functional orthodontists would claim that over-retraction of the upper incisor teeth in
camouflage cases limits the functional movement of the lower jaw and causes temporomandibular
joint dysfunction. There is however a lack of convincing evidence in the literature to support this
idea.
• Proclination of the lower incisors may result in the loss of labial bony support and labial gingival
recession. In the more severe Class 2 patients it may be possible to obtain a good dental occlusion
only at considerable expense of facial aesthetics. The upper incisors must be displaced a long way
distally to compensate for a retrognathic mandible. The aesthetic result in these cases is increased
prominence of the nose and an overall appearance of lower facial deficiency with an obtuse
nasolabial angle.
• Ironically improvements in orthodontic mechanics that allow for greater displacement of the teeth
have made it possible to obtain occlusal correction in Class 2 patients that go beyond the limits of
successful camouflage from an aesthetic point of view.
Camouflage for the Class 2 patient:
I n this line of treatment the extraction spaces are used to produce dental compensation, and
extractions are planned accordingly. For example a Class 2 patient with a mild to moderate mandibular
deficiency:
i) Both upper first premolars are removed to allow retraction of the maxillary anterior teeth and
non extraction in the lower arch to produce a class 11 molar relationship.
ii) Extraction of the teeth in the lower arch is planned to create space for levelling and alignment.
iii) I f extractions are necessary generally lower second premolars are chosen in an effort to avoid
retroclining the lower labial segment and working against the orthodontic camouflage and
changing the anchorage balance during space closure.
iv) Class I I elastics are helpful.
Camouflage for Class 3 Patients
Camouflage with Class 3 patients is generally less successful than in Class 2 patients. Excessive retraction of
the lower incisors makes the chin more prominent, and even minimal retraction often magnifies the facial
aesthetic problems associated with Class 3 skeletal malocclusions. Camouflage is therefore only suitable for
mild Class 3 skeletal problems and certainly is much more successful in Class 2 patients.
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It is important to note that extraction of teeth provides space for the displacement of teeth only in the AP
plane of space. Therefore in the patient who also has a vertical or transverse skeletal problem the extraction
of teeth for camouflage will not address the problems in these planes of space.
However,
i) I n the lower arch lower first premolars are often extracted to allow retroclination of the lower
incisors.
ii) I n the upper arch the patient would be treated either non-extraction or with the extraction of
upper second premolars to avoid retroclination of the upper incisors which would work against
the Class 3 camouflage.
iii) Class I I I elastics are useful.
However, space requirements in both arches, incisor position and planned movements together with
anchorage balance considerations must be taken into account rather than the simple application of a
predetermined formula for the extractions required.

Considerations of Age, Growth and Treatment Limitations

Class I skeletal base
In the A-P assessment of class 1 skeletal base, there is obviously no concern with the skeletal base
assessment as the jaws are in a `normal' relationship.
The following points are of importance in the case of a borderline extraction/ nonextraction case, in
assessment of the A-P position of the soft tissues and incisor teeth.

Soft tissue profile
The lips should be assessed clinically for protrusion (e.g. fleshy everted lips as in cases of bimaxillary
protrusion) or retrusion, with thin lips together with mentalis activity. Lip competence should also be
evaluated.

Dentoalveolar assessment
The degree of crowding and incisor protrusion must be considered together with the soft tissue
assessment above. As well as clinical assessment, the study models and lateral ceph can be referred to.
The APog line can be used as an aesthetic guide for the lower incisor position. Raleigh Williams (1969)
claimed that the lower incisor edges should be at or near the APog line for optimum aesthetics and stability.
Houston and Edler (1990) however, found that the APog line was not a position of stability.
If there is a borderline amount of crowding, e.g. 4 - 5mm, the decision may be made to extract if it was felt
that the profile would become too protrusive with a non extraction treatment plan, or conversely not to
extract if it would become too retrusive.
It may even be the case that if no crowding exists, but the lips were incompetent and the profile
unacceptably protrusive, that the decision to extract is made.
It must be kept in mind however, that the the A-P position of the lower labial segment should not generally
be altered (Mills 1968) with some exceptions to the rule. However, one might compromise aesthetics for
stability and vice versa.

Class 2 skeletal base
The borderline treatment decisions for class 2 cases fall into those between: Functional / camouflage
and Camouflage / surgery. The following considerations should be taken into account in the A-P assessment.

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Skeletal base
The patients' skeletal base should be assessed with the patient in the natural head posture. It must be
established where in the facial skeleton the problem lies (i.e. prominent maxilla, or retrognathic mandible)
and the severity of the relationship ( mild, moderate or severe)
The lateral ceph can be referred to for confirmation of the clinical findings, by looking at the ANB angle and
the Wits analysis

Soft Tissues
The soft tissue profile must be examined as for the class I cases, examining the lips for competence and
prominence etc.
The extent to which the soft tissues camouflage the underlying skeletal pattern should also be evaluated.
The prominence of the nose and chin are important to assess, as is the naso-labial angle and chin-throat
length.
Dentoalveolar

• The degree of crowding and dental protrusion should be evaluated.
• The angulation of the incisors i.e. proclined or upright should be determined.
• The amount of bone available palatal to the incisor teeth should be assessed on the ceph, as this
may identify a limiting factor for camouflage treatment.
• The A-P relationship of the molars and canines should be identified as these will help in
determining anchorage requirements.

Functional appliance therapy (Growth Modification)
Obviously age plays a significant consideration in this decision, in that once past the pubertal growth spurt,
growth modification would not be the treatment of choice.
If however the child still has good growth potential, the decision may not be so easy. The following, are points
to consider when planning treatment;
1. If the profile is retrognathic, the patient may have more benefit from a functional appliance rather than
camouflage, even with the use of headgear (a type of growth modification itself). Research by Tulloch
has shown that although both headgear and functional appliances restrain maxillary growth and
encourage mandibular growth, those that had headgear had approx. 1mm more maxillary restraint and
those that had a functional appliance had approx. 2mm more mandibular growth.
2. Soft tissue profile- if the patient has a prominent nose and chin, obtuse naso-labial angle or thin lips, it
may be beneficial to err on the side of caution when deciding whether or not to extract (as discussed
above). Treatment with a functional appliance initially, may eliminate the need for subsequent extractions,
as anchorage is gained during this phase of treatment. Research by Paquette Beattie and J ohnston (1992)
demonstrated that in borderline II/1 cases, the non extraction cases where 2mm `fuller' than the
extraction cases.
3. In a case with upright upper incisors, or already fairly proclined lower incisors, functional appliances may
need to be avoided, as the functional appliance would encourage further tipping of the incisors in an
unfavourable direction.
4. In cases where the anchorage requirement is high e.g. the molar relationship is a full unit II, functional
appliances can be beneficial.

5. If the patient will obviously need extractions to resolve other problems, it may be prudent not to go for
a two phase treatment as this may prolong the treatment plan.


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Camouflage/ surgery
The patients in this category will be older adolescents or adults, where there is little or no growth potential.
Obviously the more severe skeletal patterns will make successful camouflage more difficult as either the
tooth movements are not possible (due to lack of alveolar bone to move the teeth into) or a compromise of
facial aesthetics.
It may be possible to get the teeth into a good occlusion, but at the expense of the facial profile. In these
cases a combined approach to treatment should be considered
A thorough assessment of the effects of any planned tooth movements on the soft tissues should be made.
In these borderline cases it may not be possible to achieve both occlusal and aesthetic goals and a
compromise may have to be reached.


Refer to the following for very useful information on considerations in the treatment of borderline cases:
Proffit WR Contemporary Orthodontics 3rd Edition Chapter 8. Pub. Mosby. Page 282 Fig 8-46.

This contains guidelines proposed by Proffit to identify the limits of Skeletal relationships in Class 2 beyond
which camouflage would not be successful.

Class 3 Skeletal base
The borderline treatment decisions for patients with a class 3 skeletal base are between those of
Camouflage (+/- functional appliance therapy) and orthognathic surgery with orthodontic treatment.

Skeletal assessment
The severity of the skeletal base discrepancy should be determined, as well as identifying where in the facial
skeleton the problem lies, i.e. is it the mandible that is too prognathic or the maxilla that is too retrusive?
See Arnett and Bergman (1994).
The cephalometric assessment can help to indicate the severity of the skeletal base discrepancy.
Soft tissue assessment

As before.
Dentoalveolar assessment
The degree of crowding, and incisor protrusion are again important, in particular the extent to which
dentoalveolar compensation has occurred.
The patient should be examined clinically for any anterior displacement, which may be present if teeth are in
x-bite, as this can give an exaggerated appearance to the malocclusion.
The patient should be examined to see if they can achieve an edge to edge relationship.

Camouflage/ Surgery
This borderline is reached sooner in Class 3 cases than class 2 cases.


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The facial profile is often exaggerated by camouflaging the malocclusion, as the lower incisors are retracted
the chin becomes more prominent.
Approximate values for the amount of proclination and retroclination of the upper and lower incisors
respectively that can be achieved in order to camouflage a class III malocclusion are 120
0
and 80
0
The ANB difference should be used as a guide. Kerr suggests that an ANB difference of greater than
– 4
0
would indicate the need for surgery. (others suggest that – 2
0
is more realistic). (Kerr, 1994).

Clinically, if the patient can achieve an edge to edge relationship, this would indicate that camouflage maybe
possible.
As with class 2 cases, the effect of camouflage of the facial profile must be assessed. If this is likely to cause
aesthetic problems, a combined approach should be considered.
When Skeletal Discrepancy outside the limits of Orthodontic camouflage treatment alone. The
characteristics of a surgical case are
1. Severe Skeletal discrepancy .or dental alveolar problem.
2. Adult patient
3. Younger (post pubertal) with severe or progressive deformity.
4.Good medical and dental health.

Some degree of dental compensation accompanies most skeletal jaw discrepancy. If they are to reposition
surgically this dental compensation must be removed.
The borderline case orthodontic /surgical is common for adolescent Skeletal 2 cases. No RCTs exist and
probably never will! Some data does give some guidance:
Post growth with >10mm OJ , short mandible, proclined lower incisors and or long face, would indicate a
problem too great for camouflage.

Augmentation genioplasty may be considered as an adjunct to Class 3 camouflage but the risk of severe
resorption of upper incisors increases 20 fold when the lingual plate is contacted when torquing upper incisors
back during Class 3 camouflage and tipping them labially in Class 3.

Failed camouflage with resorbed roots may undermine retreatment with surgery. Lower labial segment moved
2mm forward is unstable unless severely retroclined initially. Likely to occur in Class 3 camouflage when Class
111 elastics used unless lower premolars ext.

Borderline Vertical Discrepancies
Borderline vertical discrepancies often present diagnostic dilemmas. Treatment planning is complicated by
the fact that vertical mandibular growth continues well into adulthood and perhaps indefinitely. Determining
whether future growth will follow an anterior or posterior pattern of rotation can also be difficult and
unpredictable. Vertical growth is generally beneficial in deep bite malocclusions but in high angle cases
worsens the prognosis.
To treat or not to treat?

Patients do not generally complain about an increase in overbite, or a reduced overbite, but it is obviously an
aim of comprehensive orthodontic treatment to correct a vertical discrepancy.
If the malocclusion is mild and aesthetically acceptable to the patient, it may be wise not to embark on
treatment. An increased overbite treated with the preadjusted edgewise appliance will require a long course
of treatment and the benefit to the patient may be small. If the overbite is reduced, an AOB can develop or
worsen significantly due to the extrusive nature of orthodontic forces and, again, is probably best untreated
particularly with the unpredictable nature of late mandibular growth.
Camouflage / Functional Appliance therapy
Whether a particular malocclusion is tackled by orthodontic camouflage or functional appliance therapy
(growth modification) is usually a question of the patient's age and AP discrepancy.
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Deep bite malocclusions are particularly amenable to growth modification and treatment can be initiated
early in the pre-pubertal phase with functional appliances and anterior bite planes. High angle cases must be
handled more carefully with modifications such as high pull headgear, buccal bite blocks, chin caps,
microscrew implants etc.
Since orthodontic mechanotherapy is extrusive in nature, camouflage treatment is more suited to correction
of deep bite malocclusion than open bite tendencies. Also, because vertical growth continues into late
adolescence, correction of increased overbite can be attempted beyond the pubertal growth spurt when
there is a degree of useful vertical growth remaining. Relative intrusion of the lower incisors (molar
extrusion) is therefore accompanied by growth in posterior face height, which prevents excessive steepening
of the mandibular plane.
In "non-growing" adults however, an overbite must be corrected by true intrusion of the lower incisors,
which is limited in amount, as molar extrusion is probably unstable.
Camouflage in high angle cases is more challenging as intrusion of the buccal segments is practically
unattainable and extrusion of the labial segments is unaesthetic and unstable. Often, the treatment is best
delayed until late adolescence when the effect of remaining growth on the occlusion can be discerned. If
camouflage is attempted, extrusive orthodontic forces must be carefully controlled to avoid exacerbating the
downward and backward rotation of the mandible, which worsens both AP and vertical relationships.
Borderline extraction decision
In a low angle patient with increased overbite, premolar extractions should be avoided since retraction of
the lower labial segment will worsen the overbite and also because excess space is difficult to close due to
the patient's strong musculature. Instead, arch lengthening, a small amount of arch expansion or extraction
of second molars should be considered in preference.
In high angle cases, anchorage can be lost rapidly and space can be closed with relative ease, therefore
where space requirements are borderline, it is better to extract.
Borderline Orthognathic Cases
At best our assessment of what can be achieved orthodontically is semi-quantitative; there are guidelines,
but no strict cut off points to determine whether correction is feasible by orthodontic means alone or
whether an orthognathic approach is indicated. Proffit describes an "envelope of discrepancy" to judge
whether the severity of the malocclusion is within the limits of orthodontic correction or growth modification
alone.
The decision is based on the patient's concerns as much as the operator's boundary for orthodontic
correction. Even if is possible to correct the occlusion by orthodontic camouflage; the facial profile and
aesthetics may override the decision. This is more likely to apply to long face malocclusions and VME, as
patients are less likely to seek treatment for a short face discrepancy.
Obviously, the age of the patient is all important and a deep overbite that may be correctable with
orthodontics in an adolescent will require surgery in an adult. Other patient related factors must also be
taken into consideration such as a wish to avoid surgery at all costs, or a medical history that contraindicates
or complicates orthognathic surgery.
The vertical relationship cannot be assessed in isolation and if superimposed on a skeletal discrepancy in
another dimension the complexity of the case is obviously increased and possibilities for camouflage
reduced.

Borderline transverse skeletal discrepancies
Transverse discrepancy is defined as a discrepancy in the buccolingual relationship of upper and lower
teeth or maxilla to mandible.
Transverse discrepancy of the teeth is commonly known as posterior crossbite and can affect primary and
secondary dentition. The prevalence of posterior crossbite in all dentitions seem to vary between 8 - 19%
with predominance for unilateral crossbite (Foster and Hamilton 1969; Day and Foster 1971). Leighton
claimed that crossbite should not be routinely treated in primary dentition because of the high rate of
spontaneous correction (1966).

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Treatment planning
Depending on the severity and age of the patient at presentation
Options include:
• Primary dentition - removal of premature contact especially C's in children
• Extraction / Non extraction to include asymmetric extractions to correct dental asymmetry
• URA with midline screw and posterior capping
• Quad helix
• Rapid Maxillary Expansion (RME) for children before fusion of mid-palatal suture
• Surgically assisted RME for adults
• Functional appliances
• Head gear
• Fixed appliances to include asymmetric torque
• J oint orthodontic / orthognathic surgery
• Orthognathic surgery
• Distraction osteogenesis
• J oint orthodontic / restorative dentistry
• For soft tissue discrepancy bone grafts and implants may be considered
• Consider bracket prescription and placement


Summary: Characteristics of the Patient for Camouflage Treatment
i) Too old for successful growth modification.
ii) Mild to moderate Class 2 skeletal relationship or mild Class 3 skeletal jaw relationship.
iii) Reasonably good alignment of the teeth so there is space available for AP correction, as not all of
the space created by the extraction is used for the alignment of crowded teeth.
iv) Acceptable vertical proportions, neither extremely low angle (deep bite) or extremely high angle
(anterior open-bite tendency).

Camouflage should be avoided in the following situations
i) Severe Class 2 or Class 3 skeletal discrepancy and patients with a significant vertical skeletal
discrepancy.
ii) Patients with severe crowding and protrusion of the incisors in which all the extraction space will be
required to achieve alignment of the incisors and none will be available for AP displacement of the
incisors.
iii) Patients with excellent remaining growth potential who, perhaps, would be most appropriately
managed with growth modification.
iv) Non-growing adults with more than a mild or moderate skeletal discrepancy, who perhaps would
best be managed with orthognathic surgery.





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Borderline Patients - Possibilities and Limitations
One of the most difficult decisions facing the clinician is whether the patient with a borderline skeletal
discrepancy can be successfully treated by orthodontics alone. The decision must be made from the very
beginning as the orthodontic preparation for surgery differs significantly from the orthodontic treatment for
camouflage.
Ill advised attempts to camouflage problems that are too severe extend treatment time and compromise the
final result, on the other hand, unnecessary surgery should be avoided.
The problem facing clinicians therefore, is how to decided which patients have the potential to be
successfully camouflaged, and which are better surgical candidates.
Factors that are helpful in making this decision are as follows:
General Factors
i) The patient's health status - are they a good risk for surgery and a general anaesthetic from a
health point of view?
ii) The specific nature of the patient's complaint - is it related to the appearance of the dentition or the
appearance of the face?
iii) The patient's view of the acceptability of the surgical treatment plan.

Factors Specific to the Malocclusion
Facial Aesthetics - when considering the prominence of the nose and the obtuseness of the nasolabial
angle, the clinician needs to ask the question; will retraction of the upper incisors achieve a good dental
occlusion at the expense of facial aesthetics? Similarly, does retaction of the lower incisors in relationship
to the chin in Class 111 cases detract from overall facial aesthetics?
The Vertical Skeletal Pattern - in a borderline case one would be more likely to attempt camouflage
in a low MM angle case rather than a high angle case as any molar extrusion as a result of
mechanotherapy would be helpful in a low angle case. In high angle cases at the limits of orthodontic
treatment any molar extrusion would rotate the mandible downwards and backwards and exacerbate
both the vertical and anterioposterior discrepancy. It is worth noting that a lot of these patients have got
an increased vertical dimension as they have already experienced vertical growth with a posterior
rotation of the mandible and this is likely to continue during treatment in most high angle cases.
The AP Discrepancy - will it be possible to displace the teeth sufficiently on the apical bases to disguise
the skeletal discrepancy? Will it be possible to retract the upper incisors into a secure lower incisor edge
to upper root centroid relationship? Would it be appropriate to consider advancement of the lower incisor
edges to help this correction?
The Transverse Discrepancy - if surgical treatment is needed for a co-existing transverse discrepancy
or skeletal asymmetry it would probably be easier to tackle the AP discrepancy during the surgery as
well.
Space Requirements - will crowding of the teeth take up all the extraction spaces, including the space
needed to reduce the overjet? If so then camouflage would be difficult and surgery may be more
appropriate.





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Summary of Orthodontic Camouflage for Skeletal Malocclusion in Borderline Cases
Acceptable result likely when following factors are present:
i) Average or low FMPA with average or reduced face height.
ii) Mild AP jaw discrepancy.
iii) Crowding of less than 4-6mm per arch.
iv) Normal soft tissue features nose, lips and chin.
v) No transverse skeletal problem.
Poor result likely if patient has the following factors:
i) Long vertical facial pattern with high FMPA and increased lower face height.
ii) Moderate or severe AP discrepancy.
iii) Crowding greater than 4-6mm per arch.
iv) Exaggerated facial features with prominent nose or chin or obtuse nasolabial angle.
v) I f there is a transverse skeletal component to the overall malocclusion.

I ndications for a Combined Orthodontic and Surgical Approach to Treatment
General factors:
i) Good general health suitable for surgery and general anaesthetic.
ii) I nformed consent with the patient understanding the risks and benefits of surgery.
Factors relating to the malocclusion:
i) Severe Class I I or Class I I I malocclusion.
ii) Deep overbite in non-growing patient.
iii) Skeletal anterior open bite.
iv) Extremes of vertical excess or deficiency in the maxilla or mandible.
v) Skeletal asymmetry.


Patients with the above problems may have the following complaints.

i) Concern regarding their facial or dental appearance.
ii) Difficulty with eating or drinking.
iii) Gingival hyperplasia due to mouth breathing
iv) Trauma to the gingival tissues.


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The aims of treatment in combined orthodontic and surgical management are:

i) Good facial aesthetics.
ii) Good dental aesthetics.
iii) Functional occlusion.
iv) Future health of the oral facial tissues.
v) Stable result.
vi) Minimum morbidity.

Extractions Patterns in Patients Being Prepared for Surgery.
The importance of deciding on surgery or camouflage from the outset is further illustrated by the
difference in extraction patterns needed in the two approaches.

The Surgical Management of Class 2 Patients
The extraction pattern for the same patient would be quite different if mandibular advancement were
being planned.
i) The extraction of the lower first premolars to align the lower arch and decompensate for
proclination of the lower incisors is often necessary.

ii) The upper arch is often treated non-extraction, or by extraction of upper second premolars to
avoid the retraction of the upper labial segment.
iv) Class I I I elastics are often useful in decompensation.

The Surgical Management of Class 3 Patients
The extraction pattern is typically as follows:
i) The extraction of upper first premolars in crowded cases, allowing alignment of the arch and
decompensation of the upper incisors.
ii) The lower arch is typically treated non-extraction or in exceptional circumstances lower second
premolars may be considered.
iii) Class I I elastics are helpful to aid decompensation.

I n borderline cases if satisfactory aesthetics and functional occlusion can be achieved by either
orthodontic camouflage or combined orthodontic and surgical treatment then each approach must be
carefully explained so that an informed decision may be reached by the patient.
Returning to a discussion of the patients concerns (in the form of a prioritised problem list) often helps
to clarify the treatment expectations and suggest the appropriate treatment choice.
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Section 7 – Risks and Benefit Considerations in Orthodontics
See Modules 17 and 18.
Presentation of the Treatment Plan to the patient and parent to include Risks and Benefits of
treatment before informed consent for the agreed treatment plan can be confirmed.

The last step of treatment planning is to present the proposed treatment to the patient and, if appropriate,
their parent or guardian. Often there is more than one possible option and each should be presented to the
patient with an explanation of the relative merits. The appliances to be used should be shown. The nature of
the patient's role and responsibilities during treatment should be explained and in particular the compliance
and effort required. Decalcification and periodontal damage if tooth brushing and dietary advice is not
followed should be explained and if the treatment involves headgear or elastic traction, this should also be
discussed. It is wise to overestimate treatment times. The potential risks of orthodontic treatment should be
explained to the patient so that their informed consent to the treatment is obtained. However, it is important
that any risks should be put in context. It may be helpful if some written material is provided to back up the
information that is given at the consultation, and the patient is allowed some time to reflect upon the
proposed treatment at home before reaching a decision on whether or not to go ahead.

Benefits
1. Improved facial aesthetics and improved psychosocial well being. Good evidence that this is an important benefit
in patients with severe malocclusions.
2. Avoidance of trauma to prominent incisors
3. Decreased susceptibility to pathological migration of incisors
4. Avoidance of impaction of third molars
5. Avoidance of TMJ dysfunction - little evidence for this
6. Periodontal disease - little evidence that orthodontic treatment will help prevent periodontal disease in the future.
7. Caries - little evidence that orthodontic treatment will make the teeth less susceptible to decay.

Risks
1. Decalcification.
2. Periodontal disease
3. Loss of alveolar crest height.
4. Gingival recession. And root resporption
5. TMJ dysfunction? - little evidence for this
6. Risk of partial or complete treatment failure
7. Risk of relapse
8. Risks associated with extractions or surgery. eg Risk of GA
9. Risk of bacterial endocarditis in at risk patients.
The risks and benefits are to be considered fully so that an informed decision can be made.


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Section 8 – Summary of features important in Diagnosis and
Treatment Planning

Refer to Module 14 – Diagnostic procedures for further reading.

• Patient complaints
• Pathology
• The A-P and vertical skeletal pattern and incisal inclinations
• The transverse skeletal and dental relationships
• Facial and Soft tissue profile
• The Lips
• The occlusion and arch form
• TMD
• Age and sex and Growth potential
• Patient Compliance
• Mixed dentition assessment

Having identified these features and understood the aetiology of the malocclusion develop the
problem list
1. The Problem List
The development of a prioritized problem list

• Patient’s concerns and motivation
• Pathology
• Skeletal Pattern in 3 planes
• Soft Tissue relationships
• Dentoalveolar including Tooth size discrepancies
• Age and growth potential of the patient
• Social Factors
• Other

2. The Treatment Aims

3. The Treatment Plan

• Understand the principles of treatment planning
• Understand the limitations of Orthodontic treatment
• Determine the post treatment lower incisor position and stable arch form
• Determinethe of space requirements
• Extractions vs. non- extraction treatment and facial profile
• Distal movement of molars
• Enamel stripping
• Expansion
• Factors which influence the extraction choice within each category of crowding
• The curve of Spee and crowding
• The effect on available space by antero-posterior expansion/retraction
• Treatment decisions for the “borderline” patient
o Surgery / orthodontic
o Extraction / non extraction
• Appliances to be used.
• Anchorage control and anchorage balance.
• The prevention of lower labial segment crowding.
• Retention


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By interpreting all the diagnostic data and taking into account the patient’s concerns, the aims of treatment
and then a treatment plan can be identified. The key to treatment planning is to understand the aetiology of
the malocclusion, which in turn helps to develop a problem list. The solutions to these problems can be
listed in a structured manner, commencing with pathology. This list then helps to develop the aims of
treatment and a chronological treatment plan, with the aims and plan being re-evaluated throughout
treatment to ensure proper progress. 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.

Timing

The total time required for the Module and assessment is 20 hours.


Treatment Planning Slideshow

Essay Title:
Discuss the relative merits of the various techniques advocated for the reduction of
increased overbite.

In addition - 60 minute essays: to be updated at intervals by individual schools:
1. Discuss the orthodontic decisions that have to be made when a 13 year old girl presents
with an unerupted maxillary canine.
2. What factors may affect your choice of method of reducing a deep overbite in the
treatment of a class 11 malocclusion.
3. Describe the differential diagnosis of Anterior Open Bite and indicate how your findings
may affect treatment planning.
4. Discuss the process of treatment planning of a patient with a severe Class 111
malocclusion that will require a combined orthodontic and surgical approach.


It would be useful to look at the cases available in the BOS Members’ section - login required.





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Section 9 - Bibliography
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Assessment

Visit the discussion board to discuss any of the thoughts outlined above



Congratulations - You have now completed Module 15.
Please remember to complete the module assessment so we can keep improving the module content.