Top Ten Lessons I Have Learned in Orthodontics
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1 4/8/2015 Top Ten Lessons I Have Learned in Orthodontics Richard McLaughlin, D.D.S. AAO 2015 San Francisco, CA TOP TEN LESSONS I HAVE LEARNED IN ORTHODONTICS 1. Diagnosis and Treatment Planning 2. Importance of Staff. Bracket Placement 4. Arch Form 5. Non-extraction Cases 6. First Bicuspid Extraction Cases 7. Second Bicuspid Extraction Cases 8. Surgical Considerations 9. Finishing 10. Retention The greatest challenges in orthodontics are in the area of diagnosis and treatment planning 1
2 4/8/2015 THIS CAN INCLUDE: 1) Incorrect diagnosis and/or treatment planning 2) Lack of acceptance by the patient DIAGNOSIS AND TREATMENT PLANNING 60% - 20% - 20% Rule Can be very time consuming We need an efficient and accurate system ACHIEVING THE GOAL A systematic approach to each aspect of treatment 2
3 4/8/2015 DIAGNOSIS AND TREATMENT PLANNING CHALLENGES Presentation of surgical cases Presentation of extraction cases Presentation of IPR cases Build our story before we tell the story DIAGNOSIS AND TREATMENT PLANNING History Clinical Exam Records CHECK LIST TMJ S and Musculature Airway Perio Status-and Soft Tissue Habits Facial and Skeletal Pattern Dentition PROBLEM LIST
4 4/8/2015 N.D. INITIAL 12.8 yrs SN-GoGn 2 F-Mand SNA SNB ANB Pal-Mand 28 U1-Palatal plane A-Na Perp mm U1 APO 5 0 Wits mm 2 Occlusal Plane Angle L1 APO L1-Mand plane 95 4 Pg-Na Perp mm 4
5 SN- GoGn SNA SNB ANB F- Mand 26 Pal- Mand 28 U1-Palatal plane A-Na Perp mm U1 APO 5 0 Wits 2 L1 APO mm L1-Mand plane 95 4 Pg-Na Perp mm 5
6 4/9/2015 TMJs And Muscles Airway Perio Status Habits Facial & Skeletal Pattern Dental Status Edward H. Angle Molar Relationship Charles Tweed Lower Incisor Position 90 6
7 4/9/2015 Steiner Analysis 8 SNA 79 SNB 4 ANB Michigan Growth Studies 90 Nasion Perpendicular A point Pogonion Bruce Epker and Larry Wolford Nasion Perpendicular 90 Subnasale 7
8 4/9/2015 William Arnett Cephalometric X-ray in Natural Head Posture Subnasale N.D. INITIAL 12.8 yrs I DON T USE CEPHALOMETRICS ANY MORE JCO Study of Orthodontic Diagnosis and Treatment Procedures-Part 1 Table Cephalometric Diagnostic Records Percentage of the time a routine pre-treatment cephalometric X-ray taken % % % % 8
9 4/9/2015 Why is this occuring and is there a solution? Cephalometrics should provide objective back-up to subjective observations Conventional Cranial Based Cephalometrics- Five Plane Evaluation SN Plane Frankfort Horizontal Plane Palatal Plane Occlusal Plane Mandibular Plane 9
10 4/9/2015 F.T. BEGINNING yrs SNA 89 SNB F.T. BEGINNING yrs SNA 82 SNB S.S. BEGINNING 0.2 yrs 77 SNA 69 SNB
11 4/9/2015 S.S. BEGINNING 0.2 yrs SNA 7 SNB S.Z. BEGINNING yrs 8 SNA 79 SNB 4 ANB The Wits appraisal of jaw disharmony Alex Jacobson, MDS, MS, PhD AJO-DO November Volume 124 Issue 5 Pages or 11
12 4/9/2015 A.B. BEGINNING 14.1 yrs ANB WITS OCCLUSAL PLANE ANGLE = G.B. BEGINNING 52.8 yrs ANB WITS OCCLUSAL PLANE ANGLE = 86 With Class I occlusions, the occlusal plane can vary from 80 to 110, or a total 0 This can effect the position of pogonion by 1.5 to 2 cm 12
13 4/9/2015 N.S. BEGINNING 17.0 yrs POSITIONALLY SENSITIVE 1 - DENTALLY SENSITIVE 8 Po can vary 1.5 to 2 cm Conventional Cranial Based Cephalometrics- Five Plane Evaluation SN Plane Frankfort Horizontal Plane Palatal Plane Occlusal Plane Mandibular Plane D.L. BEGINNING 5.5 yrs
14 4/9/2015 G.E. BEGINNING 9. yrs S.Z. BEGINNING yrs Conventional Cranial Based Cephalometrics- Five Plane Evaluation SN Plane Frankfort Horizontal Plane Palatal Plane Occlusal Plane Mandibular Plane 14
15 4/9/2015 Orthodontists need to dentally compensate incisors in many cases There is often a tension in orthodontics between stability and esthetics Larry Andrews S.Z. BEGINNING yrs
16 4/9/2015 Tetragon: A Visual Cephalometric Analysis Jorge Fastlicht, DDS, MS Journal of Clinical Orthodontics Vol 2000 Number 6 Pages 5-60 or Tetragon: A Visual Cephalometric Analysis Jorge Fastlicht, DDS, MS Mx 1 Occlusal Plane WITS Md 1 16
17 4/9/ POP OMP Mx1-PP Mx1-OP Wits Md1-MP Md1-OP CLASS I POP OMP Mx1-PP Mx1-OP Wits Md1-MP Md1-OP CLASS I J.C High Angle 17
18 4/9/2015 J.C Low Angle Low Angle S.W. BEGINNING 2.6 yrs POP OMP Mx1-PP Mx1-OP Wits Md1-MP Md1-OP CLASS II 18
19 4/9/2015 Z.D Class II POP OMP Mx1-PP Mx1-OP Wits Md1-MP Md1-OP CLASS III J.P Class III 19
20 4/9/2015 S.Z. BEGINNING yrs ) Cranial Base as a Reference ) Soft Tissue S.Z. BEGINNING yrs Bruce Epker and Larry Wolford 90 Subnasale ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS -NATURAL HEAD POSITION -WAX BITE IN CR -RELAXED LIPS True Vertical Line SUBNASALE - AJO, SEPT
21 4/9/2015 NATURAL HEAD POSTURE LITERATURE Moorrees-Am J Phys Anthropol, 1958 Cooke-AJO, March 1988 Lundstrom and Lundstrom-AJO, March 1992 Arnett and Bergman-AJO, April and May 199 LUNDSTROM AND LUNDSTROM - NATURAL HEAD POSTURE AS BASIS FOR CEPHALOMETRIC ANALYSIS, AJO, MARCH 1992 Sella-Nasion Basion-Nasion Porion-Orbitale Natural Head Position 5. sd 4.7 sd 5.0 sd 1.8 sd NHP is the most reproducible and accurate 21
22 4/9/ ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS 22
23 ARNETT NORMS AND STANDARD DEVIATIONS UPPER ANTERIOR SEGMENT-HORIZONTAL Female STCA research values and (means) Incisor torque to occl. plane 54. to 59. (57 ) Incisor tip to TVL mm to -7.0 mm (-9) Lip thickness 10.8 to 14.4 mm (12) Lip to TVL 2.5 mm to 4.9 mm () UPPER ANTERIOR SEGMENT-VERTICAL Female STCA research values and (means) Max. anterior height 2.6 mm to 27.8 mm (26) Lip length 19.1 mm to 22.9 mm (21) Incisor exposure.1 mm to 6. mm mean (5) Inter-labial gap 2.0 mm to 4.0 mm (2) LOWER ANTERIOR SEGMENT Female STCA research values and (means) Occlusal plane to TVL 9.8 to 97.4 (96 ) Incisor torque to occl. plane 61.1 to 67.5 (65 ) Lip thickness 12.2 to 15.0 mm (1) Lip to TVL -0.5 mm to. mm (1) Soft tissue B point -6.8 mm to -.8 mm (-5) Soft tissue pogonion -4.5 mm to -0.7 mm (-) UPPER ANTERIOR SEGMENT-HORIZONTAL Male STCA research values and (means) Incisor torque to occl. plane 54.8 to 60.8 (57 ) Incisor tip to TVL -1.9 mm to -10. mm (-12) Lip thickness 1.4 to 16.2 mm (14) Lip to TVL 1.6 mm to 5.0 mm () UPPER ANTERIOR SEGMENT-VERTICAL Male STCA research values and (means) Max. anterior height 25.2 mm to 1.6 mm (28) Lip length 21.9 mm to 26.9 mm (24) Incisor exposure 2.7 to 5.1 mm mean (4) Inter-labial gap 1. mm to.5 mm (2) LOWER ANTERIOR SEGMENT Male STCA research values and (means) Occlusal plane to TVL 9.6 to 96.4 (95 ) Incisor torque to occl. plane 60.0 to 68.0 (64) Lip thickness 1.4 to 16.2 mm (15) Lip to TVL -1.6 mm to.2 mm (1) Soft tissue B point -8.7 mm to -5.5 mm (-7) Soft tissue pogonion -5. mm to -1.7 mm (-) 2
24 Upper Anterior Segment Horizontal Numbers Upper Incisor Inclination Mx1 Mx OP Upper Incisor Tip Projection Mx 1 TVL Upper Lip Thickness Mx1 Labial ULA Upper Lip Anterior ULA TVL 24
25 Upper Anterior Segment Vertical Numbers Mx Anterior Height Sn Mx1 Tip Upper Lip Length Sn ULI Upper Incisor Exposure UL1 Mx 1 Tip 2 Inner Labial Gap UL1 LLS 25
26 Lower Anterior Segment Numbers Mx Occlusal Plane Mx OP TVL 96 Lower Incisor Inclination Md1 Md OP Lower Lip Thickness LL Inside LLOutside Lower Lip Anterior LLA Soft Tissue B Point B Soft Tissue Pogonion Pog TVL 26
27 ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Anterior Segment Numbers Mx Occlusal Plane Mx Anterior Height Upper Incisor Inclination Upper Lip Length Upper Incisor Tip Projection 96 Lower Incisor inclination Upper Lip Thickness Upper Lip Anterior Upper Incisor Exposure Inner Labial Gap 2 Lower Lip Anterior Lower Lip Thickness 5 21 Soft Tissue B Point AJO, SEPT Soft Tissue Pogonion 27
28 4/8/2015 TMJs And Muscles Airway Soft Tissue & Incisors- Anterior Segments Perio Status Habits Transverse Dimension Facial & Skeletal Pattern Dental Status Remaining Dentition- Canines, Premolars, Molars ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Horizontal Numbers Upper Incisor Inclination 57 - AJO, SEPT POP OMP 8 20 Mx1-PP 115 Mx1-OP Md1-OP Wits 95 Md1-MP 28
29 4/8/2015 ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Horizontal Numbers Upper Incisor Tip Projection Upper Incisor Inclination AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Horizontal Numbers Upper Incisor Tip Projection Upper Incisor Inclination Upper Lip Thickness AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Horizontal Numbers Upper Incisor Tip Projection Upper Incisor Inclination Upper Lip Thickness Upper Lip Anterior AJO, SEPT
30 4/8/2015 ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Vertical Numbers Mx Anterior Height 26 AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Vertical Numbers Mx Anterior Height Upper Lip Length AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Vertical Numbers Mx Anterior Height Upper Lip Length Upper Incisor Exposure AJO, SEPT
31 4/8/2015 ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Upper Anterior Segment Vertical Numbers Mx Anterior Height Upper Lip Length Upper Incisor Exposure 2 Inner Labial Gap AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment Numbers Mx Occlusal Plane 96 AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment Numbers Mx Occlusal Plane Lower Incisor inclination AJO, SEPT
32 4/8/2015 POP OMP 8 20 Mx1 PP 115 Mx1 OP Md1 OP Wits 95 Md1 MP ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment Numbers Lower Lip Thickness Mx Occlusal Plane Lower Incisor inclination AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment Numbers Lower Lip Thickness Mx Occlusal Plane Lower Lip Anterior Lower Incisor inclination AJO, SEPT
33 4/8/2015 ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment Numbers Lower Lip Thickness Mx Occlusal Plane Lower Lip Anterior Lower Incisor inclination -5 Soft Tissue B Point AJO, SEPT ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS Lower Anterior Segment Numbers Lower Lip Thickness Mx Occlusal Plane Lower Lip Anterior Lower Incisor inclination -5 Soft Tissue B Point AJO, SEPT Soft Tissue Pogonion N.D. INITIAL 12.8 yrs
34 4/8/2015 N.D. INITIAL 12.8 yrs N.D. BEG/PREDICTION SN AT S N.D. BEG/PRED PALATAL PLANE AND PALATAL CURVATURE MAND SYMPHYSIS AND MAND PLANE 4
35 4/8/2015 Facial Keys to Orthodontic Diagnosis and Treatment Planning -Part I & II Arnett, G. W. & Bergman, R. T. American Journal of Orthodontics April & May, 199 Fig.20 The transverse dimensions is about four factors: Midline, Cant, Yaw and Widths 5
36 4/8/2015 N.D. N.D. N.D. 6
37 Patient: N.D. 7
38 4/8/2015 ARCHWIRE SEQUENCE.015 multistrand.0175 multistrand.014 round stainless steel.016 round stainless steel.018 round stainless steel.020 round ss heat treated.019 x.025 &.017 x.025 rectangular ss heat treated.016 round heat activated.016 x.022 rectangular heat activated.019 x.025 rectangular heat activated.019 x.025 &.017 x.025 rectangular ss heat treated ARCHWIRE SEQUENCE.015 multistrand.0175 multistrand.014 round stainless steel.016 round stainless steel.018 round stainless steel.020 round ss heat treated.019 x.025 &.017 x.025 rectangular ss heat treated NON EXT..016 round heat activated.016 x.022 rectangular heat activated.019 x.025 rectangular heat activated.019 x.025 &.017 x.025 rectangular ss heat treated ARCHWIRE SEQUENCE.015 multistrand.0175 multistrand.014 round stainless steel.016 round stainless steel.018 round stainless steel.020 round ss heat treated.019 x.025 &.017 x.025 rectangular ss heat treated 1 st BICUSPID EXT..016 round heat activated.016 x.022 rectangular heat activated.019 x.025 rectangular heat activated.019 x.025 &.017 x.025 rectangular ss heat treated 8
39 4/8/2015 ARCHWIRE SEQUENCE.015 multistrand.0175 multistrand.014 round stainless steel.016 round stainless steel.018 round stainless steel.020 round ss heat treated.019 x.025 &.017 x.025 rectangular ss heat treated 1 ST BICUSPID EXT..016 round heat activated.016 x.022 rectangular heat activated.019 x.025 rectangular heat activated.019 x.025 &.017 x.025 rectangular ss heat treated ARCHWIRE SEQUENCE.015 multistrand.0175 multistrand.014 round stainless steel.016 round stainless steel.018 round stainless steel.020 round ss heat treated.019 x.025 &.017 x.025 rectangular ss heat treated 2nd BICUSPID EXT..016 round heat activated.016 x.022 rectangular heat activated.019 x.025 rectangular heat activated.019 x.025 &.017 x.025 rectangular ss heat treated ARCHWIRE SEQUENCE.015 multistrand.0175 multistrand.014 round stainless steel.016 round stainless steel.018 round stainless steel.020 round ss heat treated.019 x.025 &.017 x.025 rectangular ss heat treated 2nd BICUSPID EXT..016 round heat activated.016 x.022 rectangular heat activated.019 x.025 rectangular heat activated.019 x.025 &.017 x.025 rectangular ss heat treated 9
40 Name: ORTHODONTIC VTO MIDLINE MOLAR POSITION Right 1 st molar Midline Left 1 st molar Overjet mm Overbite mm Crossbite LOWER ARCH DISCREPANCY x 7 x 7 Right Left Right Left Crowding/Spacing-Anteriors C/S-Bicuspids (E-L space) C/S-Molars Curve of Spee Midline Incisor Position Initial Discrepancy Stripping Expansion Distalizing 6 6 Extraction Remaining Discrepancy THE DENTAL VTO Right 1 st Midline Left 1 st molar molar ( ) cuspid cuspid ( ) ( ) ( ) 40
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