TREATMENT DECISION EXTRACTION VERSUS NON EXTRACTION.

On of the most important decision that we make daily in our orthdontic practice is whether to extract teeth or not in our patients.
Do not extract teeth unless you know that , that is the best way to treat the case.


TREATMENT GOALS.
· BALANCED SOFT TISSUE PROFILE.
· NON - EXTRACTION WHEN POSSIBLE.
· MANDIBULAR INCISORS UPRIGHT ON BASAL BONE.
· GOOD INTERINCISAL ANGLE.
· ROOT ARTISTIC POSITIONING.
· MANDIBULAR MOLARS UPRIGHT.
· CUSPIDS NOT EXPANDED.
· NORMAL OB, OJ.
· CLASS L CUSPIDS. FUNCTIONAL OCCLUSSION BALANCED OCCLUSSION.

TREATMENT DECISIONS.

Soft tissue profile.
· Convex ......................................extract
· class ll.
· normal.
· concave.......................................non extraction.

Periodontal condition.
· Normal ....................................non extraction
· compromised.
· Poor .......................................extraction.

Mandibular incisor position.
· Proclined. ........................................extraction
· Upright. ..
· Retroclined.. ......................................non extraction.

Arch length discrepancy.
· Mild.... .........................................non extraction.
· Moderate.
Severe..........................................extract.

Growth potential.
· Present
direction......low angle non extraction .....high angle extraction.
amount
· Border line.
· Past.

Co-operation and growth makes border line case non extraction.

THE PRINCIPLES OF THE ALEXANDER DISCIPLINE.

PRINCIPLE # 1 = Kiss. (Keep It Simple ,Sir).

PRINCIPLE # 2 = Increase bracket space and rotational control with unique bracket design.

· Increased interbracket space.
· wings for rotation correction then control.
· precision pre torqued slot.
· Precision base variation.

PRINCIPLE # 3 = Build treatment into bracket placement.

Precision bracket placement.
· Height. (Measure with gauge).
· Angle
· Mesio-distal position.

PRINCIPLE # 4 = Utilize a systematic approach to treatment.
· Step -by- step sequence.
· Anticipate future appointment.

PRINCIPLE # 5 = Obtain predictable orthopedic correction using facebow or facemask.
· Facebow.
· Facemask.

PRINCIPLE # 6 = In non extraction treatment, initiate treatment in the maxillary arch.
· Consolidate with power chains.

PRINCIPLE # 7 = In non extraction treatment, Control Lower Incisors by utilizing:
· 5 degrees torque - incisors,
· 6 degrees - 1st molars,
· flexible, rectangular arch wires.



PRINCIPLE # 8 = In extraction treatment, initiate treatment in the maxillary arch.
· Retract cuspids on .016 S.S. wire


PRINCIPLE # 9 = In extraction treatment, delay treatment in the mandibular arch
· “Driftodontics.


PRINCIPLE # 10 = In extraction treatment, initiate treatment in the mandibular arch.
· When cuspids are in class I relationship.

PRINCIPLE # 11 = When in doubt, tie back.
· Use omega loop.


PRINCIPLE # 12 = Consolidate arches early in treatment.
· In extraction case use closing loop.
· In non extraction case use power chain.

PRINCIPLE # 13 = Level arch and open bite with accentuated curve of Spee and reverse curve of spee.

PRINCIPLE # 14 = Get into finishing arch wire quickly and “let it cook”.

PRINCIPLE # 15 = Be in finishing archwires before initiating:
· Class II
· Midline elastics.

PRINCIPLE # 16 = Obtain complete bracket engagement.
Ligate finishing archwires with steel ligatures.
· .010
· .012
· .014

PRINCIPLE # 17 = Utilize specific retention plan incorporating.
· Retainer design.
· Time sequence.
· Resolution of wisdom teeth.

PRINCIPLE # 18 = “There are no little things”.


PRINCIPLE # 19 = Motivation.
· Love
· Firmness.
· From vertical to horizontal relationship.

Effort vs result.

CEPHALOMATRIC ANALYSIS

The introduction of radiographic cephalomatrics in 1934 by Hofrath in Germany and Broadbent in
the United States provided both a research and clinical tool for the study of malocclusion and the underlying skeletal disproportions.
Cephalomatric films could be used to evaluate dentofacial proportion and clarify the anatomic basis for a malocclusion. Any malocclusion is the result of an interaction between jaw position and dental compensation or adaptation. It is possible to have a normal occlusion in spite of an underlying jaw discrepancy through the mechanism of dental compensation. or to have a significant dental malocclusion within a normal skeletal pattern. Another possibility is additive rather than compensatory dental and skeletal deviations, so that a combination of moderate jaw discrepancy and moderate dental displacement adds up to a severe malocclusion. Two apparently similar malocclusion as evaluated from the dental casts can turn out to be quite different when evaluated more completely, using cephalomatric analysis to reveal difference in dentofacial proportions.



TECHNIQUE OF TRACING CEPHALOMATRIC RADIOGRAPHS.

It has been found that direct measurements on the headplates are often difficult. For this reason, a 'TRACING' is made. The tracing is a pencilled outline of the major and pertinent structures, made on a semi-transparent sheet of acetate, usually .003" thick, and superimposed on the headplate itself.


MOUNTING TRACING PAPER:

Place the cephalomatric radiograph on the tracing table, with the profile facing to the left. Place a piece of acetate paper on top of the reproduction of the radiograph so that the two edges on the top are even. The dull side of the acetate should be facing you. Now take two pieces of draftman's tape about one to one and one-half inches long and place one piece on the upper left of the acetate sheet and the other one on the upper right side. Leave about half the length extending beyond the upper edge. Bend the free ends of the tape down and seal them to the back of the radiograph. The acetate sheet and the radiograph are now sealed to each other at the top, and open at the bottom. This permits folding the tracing paper up frequently to check directly on structual details while tracing.

TRACING:

1. Trace the soft tissue outline with a sharp pencil. Draw accurately, without erasure if possible.

2. Draw the bony skeleton of the head.

3. Draw the Sella Turcia. This is the pituitary fossa of the sphenoid bone.

4. Draw the mandible and the condylar head.

5. Trace the molars and the central incisors.

6. Tace the porion.

7. Trace the palate and the pterygo-maxillary fissure.

8. Trace the orbit.


.LANDMARKS:

· SELLA TRUCICA (S).
The centre of the Pituitary Fossa of the Sphenoid Bone.

· NASION (N)
The intersection of the Internasal Suture with the Nasofrontal Suture in the midsagittal plane

· ORBITALE (OR)
The most inferior point on the External Border of the Orbital Cavity.

· PORION (PR)
The most surerior point of the External Auditory Meatus.

· IR POINT (IR)
The most convex point along the Inferior Border of the Mandible.

· MENTON (M)
The most Inferior Point of the Symphysis.

· POGONION (PO)
The most Anterior Point of the Mandibular Symphysis.

· GNATHION (GN)
The Point of intersection between the plane connectimg N and Po, and the plane connecting Me and Ir points.

· MOLAR POINT (MP)
The bisection of the over bite of the Upper and Lower Molars as seen on the Lateral Cephalogram.

· A POINT (A)
The deepest point of the curve of the Anterior Maxillary Border between Anterior Spine and the Alveolus. .

· B POINT (B)
The most Posterior Point in the Concavity along the Anterior Borber of the Symphysis as seen in the Lateral Cephalogram .

· A 1 INCISOR (A 1)
The Incisal tip of the Upper Central Incisor.

· AR POINT (AR)
The Root Apex of the Upper Central Incisor.

· B1 INCISOR (B1)
The Incisal tip of the Lower Central Incisor.

· BR POINT (BR)
The Root Apex of the Lower Central Incisor.

· UPPER LIP (UL)
The most Anterior Point on the Curve of the Upper lip.

· LOWER LIP (LI)
The most Anterior Point on the Curve of the Lower Lip.

· CHIN (DT)
The most Anterior Point on the Curve of the Soft Tissue Chin.



LANDMARKS - PLANES.

1. SELLA NASION: - SN

The plane connecting Sella Turcica and Nasion. Known as the Cranial Base, SN defines the Lower Border of the Cranium.

2. FRANKFORT HORIZONTAL PLANE: - FH.

The plane formed by connecting Porion and Orbitale. This plane is approximately parallel to the ground when the patient is looking straight ahead. This plane is often used as a superimposition line for cephalomatric tracing.

3. OCCLUSAL PLANE: - OP

The bisection of points A1 and B1 is connected to the Molar Point to form this plane. Although the patient's actual Occlusal Plane is rarely completely flat, this constructed plane is a useful approximation

4. MANDIBULAR PLANE:- MP

The plane connecting Menton and the Ir Point. This plane defines the Base of the Mandible.

5. APo PLANE:- APo

This plane defines the Anterior Border of the Facial Skeleton. It is formed by connecting A point with Pogonion.

6. SOFT TISSUE LINE:-

A line connecting Dt (chin) and UL (upper lip). This line defines the Anterior Border of the Soft Tissue in the Lower Face.

LANDMARK - ANGLES.

1 SNA:-
The Angle between the SN Plane and a Plane connecting Nasion and A Point. The SNA angle defines the anteroposterior position of point A relative to the anterior cranial base. Its mean value , 81 degrees, indicates a normal relationship between maxilla and anterior cranial base. If the angle is less than normal, the maxilla lies more posterior in relation to the cranial base , if the angle is too large, the maxilla lies more anterior. The angle therefore defines the degree of prognathism for the maxilla. A large SNA angle (greater than 84 degrees ) makes the anteroposterior position of the maxilla prognathic, a small angle (less than 78 degrees) makes it retrognathic.

Variations due to age and sex are minimal with this angle (80.5 - 82 degrees).


2. SNB :-
The Angle between the SN Plane and a Plane connecting Nasion and B Point (NB). The SNB angle determines the anteroposterior position of the mandible in relation to the anterior cranial base, analogous to the SNA angle for the maxilla. This angle defines prognathism for the mandible, the mean value being 79 degrees. If it is greatewr than 82 degrees, the mandible is prognathic relative to the cranial base, if it is less than 77 degrees, the mandible is retrognathic. The mandible is described as orthognathic if the angle is between 77 and 82 degrees.

The size of this angle increases with age (from 76 degrees at 6 years to 79 degrees at 16 years of age). Retrognathism may thus be compensated in the course of growth, and it is often difficult to distinguish the effects of therapy from those of growth when Class II anomalies are treated.


3. ANB :-
SNA minus SNB. This represents the diffrence between the SNA and SNB angles and defines the mutal relationship, in the sagittal plane, of the maxillary and mandibular bases.The SNA is positive if point A lies anterior to NB. If NA and NB coincide, the angle will be zero. If, however, point A lies posterior to NB, ANB will be negative. Apart from establishing the relationship between the maxillary and mandibular bases, the angle also largely determines the position of the incisors. On average, the angle is 2 degrees. High positive occurs in Class II, negative in skeletal Class III.


Comparison of SNA, SNB and ANB
The three angles refered to above (SNA, SNB and ANB) define the relationship of the maxillary and mandibular bases to the anterior cranial base, and also the mutual relationship of the maxillary and mandibular bases. A number of combination are possible.

Normal SNA and SNB
This indicates a normal position of the maxillary and mandibular bases relative to the cranial base and also to each other.


Normal SNA.
Normal SNA angles indicate normal relations between maxilla and cranial base with:
(a) Small SNB angle = mandible retrognathic.
(b) Large SNB angle = mandible prognathic.


Normal SNB
Normal SNB angle indicates normal relationship between mandible and cranial base, with :

(a) Small SNA angle = maxilla retrognathic.
(b) Large SNA angle = maxillprognathic.


4. Angle of Convexity.
The angle defined by the intersection of the line connecting N and A , and the APo plane.


5. SN - MP (Mandibular Plane).
The Angle formed by the intersection of SN and the Mandibular Plane. This angle gives the inclination of the mandible to the anterior cranial base.


6. FMA (Frankfort - Mandibular Angle).
The angle formed by the intersection of the Frankfort Horizontal and the Mandibular Plane.


7. OM (Occulasal - Mandibular Angle).
The angle formed by the intersection of the Occlusal Plane and the Mandibular Plane.


8. Y - Axis Angle.
The Angle between SN and a line connecting Sella Turcica with Gnathion. This angle determines the position of the mandible relative to thr cranial base, as an additionall check. It has a mean value of 66 degrees. if it is greater than that, the mandible is in a posterior position, with growth predominantly vertical. If the angle is less than 66degrees, the mandible is in an anterior position relative to the cranial base, and growth is predominantly anterior.


9. Upper 1 to SN.
The Angle between SN and a line connecting A1 (upper incisor tip) to AR (upper incisor root apex). The posterior angle is measured. It has a mean of 102 degrees +- 2 degrees. Up to the 7th year, it is only 94-100 degrees, with 1o2 angulation achieved only 1 or 2 years after eruption. Large angles usually indicate maxillary incisor protrusion, smaller angles very upright incisors.


10. IMPA.
The Angle between the Mandibular Plane and the line connecting B 1 and BR. It has a mean value of 90 +- 3 degrees. From the 6th to the 12th year the angle increases from 88 to 94 degrees. A wide angle denotes protrusion of the mandibular incisors, a smaller than normal angle, very upright incisors. Treatment planning, even for simple forms of treatment, always calls for diagnostic analysis of lower incisor angulation.


11. Interincisal Angle.
The intersection of the two lines A 1 - AR and B1 - BR. It has a mean value of 135 degrees. A good incisal angle on conclusion of treatment is a major factor in denture stability and prevention of relapse.

LANDMARKS - LINEAR MEASUREMENTS.

1. Lower Incisor to APo.
The linear distance from Point B1 to the APo Plane, measured perpendicular to APo. Apart from determining the angles, linear measurements are also used to assess incisor position. The distance of the lower incisal edges from the APo plane is determined. The average distance being i mm. This figure is of considerable importance in treatment planning. The aim of treatment, at least with the permanent dentition is to achieve those normal relations to the APo plane This particular measurement therefore, is frequently the key factor in deciding:

(a) whether extraction is indicated.
(b) whether the lower incisors can be moved forward.
(c) whether anchorage is critical.

Until the 9th year, the metric relations in the mandible are not sufficent to stabilised to serve as the basis for major diagnostic decisions, In the mixed dentition period, interpretation must consider the phases of active growth still to come.


2. Holdaway Ratio.
The Ratio of the following two distances.
1). The perpendicular distance from Po to the line connecting Points N and B (NB).
2). The perpendicular distance from B1 to the line connecting N and B.


3. Lower Lip to Harmony Line.
The Hormony Line connects DT (Soft Tissue Chin) with UL ( Upper Lip).
The distance from the most anterior point on the lower lip (LT) to the Harmony Line
is measured parallel to FH


4. Wit's appraisal.
The 'Wit's (Univ. of Witwatersrand) appraisal of jaw disharmony, which is a measure of the extent to which jaws are related to each other anteroposteriorly. Perpendiculars lines are drawn on the lateral cephalometric head flim tracing from point A and B on the maxilla and mandible respectively, onto the occlusal plane which is drawn through the region of maximum cuspal interdigitation. The points of contact on the occlusal plane from A and B are labelled AO and BO respectively. It was found that with normal occlusion, point BO was approximately 1mm anterior to point AO. In skeletal Class II jaw dysplasias, point BO would be located well behind point AO, whereas in skeletal Class III jaw disharmonies, point BO will be forward of point AO.

Clinical Examination.

Extra oral : Profile / Frontal view

The profile is an important aspect of the patient's external appearance and give an indication of the underlying orthodontic situation. The examination should be done with the Frankfort Horizontal Plane parallel to the floor. If the chin slopes back or the maxilla and the nose are set forward, the profile is convex. If all of the middle of the face retreats, then the profile is concave. In between convex and concave, the profile becomes straight. There are no set measurement that can be used when assessing the profile - experience is the key.
The profile view allows a lateral evaluation to be made which corresponds to the lateral cephalogram. The following aspects of the face should be viewed and noted in the treatment chart.


1.The lip posture : This is viewed with the patient seated upright in a relaxed position with the lips parted. If the teeth are exposed this reflects that the dentition are positioned forward in the jaws.This could possibly mean need for retraction of the anterior dentition, with an indication for bicuspid extraction. It is also important to note the extent to which the lips are separated when they are relaxed and whether the patient must strain to bring the lips together. When the lips are protrusive and separated at rest by more than 3 to 4 mm, it can be concluded that the lip protrusion results from protrusion of incisors, and that both lip function and facial esthetics would improve if the protruding teeth were retracted. If the lips are protrusive but close over the teeth without strain, on the other hand, retraction of the incisor teeth will result in minimal changes in lip prominence.
Detecting protrusion of incisors (which is relatively common) or retrusion of incisors (which is rare) is important because of the effect of this on space within the dental arches. If the incisors protrude, they align themselves on the arc of a larger circle as they lean forward, whereas if the incisors are retrusive, less space is available to accommodate the canines and premolars. In extreme cases, incisor protrusion in what might have been a patient with severe crowding can produce ideal alignment of the dental arches, at the expense of lips that protrude and are difficult to bring into function over the protruding incisor teeth. This condition can be termed bimaxillary dentoalveolar protrusion, meaning simply that in both jaws the teeth protrude. The condition is often referred to as just bimaxillary protrusion, a simpler term but a misnomer since it is not the jaws but the teeth that protrude.


2. Lip thickness: In patients with very thin lips, the orbicularis oris muscle contract and pull the lips together. In such patients caution must be applied if the anterior teeth are to be retracted. Retraction of the anterior teeth in such cases will cause the lips to retract at approximately a one to one ratio with the dentition. This could result in excessive flattening of the profile, creating a "dished - in" look.
Excessive advancement of the anterior dentition in a tight-lipped should also be handled with caution. In such patients change will initially make the profile more aesthetically pleasing. But , the tight musculature will often cause these teeth to relapse to their original position. In such situation it is wiser to warn the patient prior to the treatment and indicate that lenghty retention procedure will be essential.
When anterior teeth are retracted in the thick lipped patient, for every two millimeters of dental retraction, the lips move distally only one millimeter. Hence, it is more difficult to alter this type of profile dramatically. These patients will usually exhibit tittle lips strain. and the orbicularis oris muscles are more flaccid. Advancement of the incisors in these patients is quite easy, because there is less muscle strain. This also minimizes the chances of relapse.


3. Shape of nose and the naso - labial angle : The naso labial angle is too actue, the upper lip should be retracted. If the angle is too obtuse, the upper lip may need to be advanced.


4. Upper lip lower lip relationship: The anteroposterior relationship between the most anterior surfaces of the upper and lower lip have a great effect on facial esthetics. The relationship of the lips could reflect the skeletal pattern of the patient. When the upper lip is advanced the patient could be a skeletal class II. Retruded upper lip could mean a skeletal class III.This could be confirmed by looking at the cephalomatric readings.


5. Soft tissue pogonion: This indicates whether the lower face is protruded, retruded or in normal relationship to the other facial bones.



6. Facial type: The shape of the face indicates whether the patient has a round , long , short or balanced face.


7. Facial heights: Here it is noted whether the face is equally balanced or unbalanced. Vertical proportions can be seen more clearly in profile. The face is divided into vertical thirds. The inclination of the mandibular plane to a true horizontal line is visualized readily by placing a ruler along the lower border of the mandible. A steep mandibular plane angle correlates with long anterior facial vertical dimensions. A flat mandibular plane angle correlates with short anterior facial height.
There is also an interaction between face height and the anteroposterior position of the mandible. A long face predisposes the patient to Class ll malocclusion, a short face to Class lll.


8. Smile line: The smile line reveals whether the patient has a gummy smile or much more of the mandibular teeth is seen than that should be.With a relatively short upper lip and/or long maxillary alveolar process, a disfiguring amount of gingival tissue is exposed in laughing. This feature can influence the type of treatment and its prognosis. The height of the visible gingivae when laughing is measured from the cervical margin of the maxillary incisors to the inferior margin
of the upper lips .
Intra oral examination:

The routine intra oral examination is conducted with a through examination of the hard and soft tissues of the oral cavity. The presence of caries, hypocalcified teeth , fractured or discoloured teeth are noted. Presence of anomalies and non vital teeth are also looked for.
The soft tissues are examined , the periodontal condition should be evaluated and also look for the presence of abnormal labial , buccal and lingual frenal attachments. The health of the soft tissue and the presence of any soft tissue lesions must be checked
At this juncture it is good to evaluate the various habits such as tongue thrust, lip sucking , thumb sucking or any other oral habits.

Finally the general oral hygiene of the patient is evaluated. The need for oral prophylysis and oral hygiene instructions is noted. Care in oral hygiene, wearing of appliance and keeping to the treatment regime all call for strong motivation, and so it is wise to assess patient cooperation before starting active treatment, particularly when a long-lasting treatment is anticipated.

DIAGNOSIS AND TREATMENT PLANNING

Introduction.

If the patient attends his family general practitioner for orthodontic advice, the dentist because he knows the patient's dental background - will already be acquainted with a number of relevant matters such as dental mindedness, cooperation, family relations and financial circumstances.
On the other hand if the general practitioner is being consulted by a patient he has never seen before the consultation is divided into three visits. A first consultation is when the patient presents himself at the office, during which such matters that the family dentist normally knows are discussed. A separate visit is arranged for a full examination such as the collection of administration data, taking a history the external and intra - oral examination, diagnostic aids such as taking impressions and request for panaromic and cephalomatric radiographs. A through study of all the facts collected is done and a third visit is planned to present the case to the patient and parent and a decision is taken whether to treat or not to treat the patient.


DIAGNOSTIC TREATMENT CHART

A good comprehensive examination is carried out by having a check list of points that may need investigation. Relevant finds should be recorded and all information obtained from the various diagnostic aids be collected before a decision is made. A Diagnostic treatment chart serves as a record into which all the diagnostic data are entered. This aids in the diagnosis, treatment planning and presentation of the particular case. Notations are made in the record as the treatment is carried through. At the completion of the treatment the Diagnostic treatment chart is filed complete with all the finishing data recorded along with initial and final photographs and cephalomatric tracings.
(The Diagnostic treatment chart used for the patient is the one used by the members of The Alexander Discipline Study Club of Malaysia.) For the convenience of the reader, a loose-leaf version is added which can be perused in conjunction with the text that follows in the remainder of this book.

ADMINISTRATIVE DATA.

Administrative data are generally entered by the dentist's chair side assistant. Most of the points are self explanatory.


Informed Consent: The purpose of this section is to enlighten the practitioner with a basic understanding of the concept of informed consent and why this must become an essential part of the orthodontic records. At the end of this section a sample of customized document entitled, “Information and Informed Consent", is added.

Definition of Informed Consent: This is consents obtained after disclosure of all information which are sufficiently complete and accurate so that a reasonable, competent person can make an intelligent decision on their future treatment The patient must be given sufficient information to make a informed decision regarding his treatment No treatment should commence without the patient's or parent's total agreement and cooperation.


Criteria for informed consent

Following are some of the information that must be given to the orthodontic patient in order for him to make an intelligent decision regarding the giving of consent of treatment.

1. The diagnosis and treatment plan must be thoroughly explained.
2. Discuss the benefits of the treatment.
3. Inform the risks involved.
4. Alternate treatment plan if any
5. The prognosis of the case if no treatment is done.
6. Information must be presented in an organized, systematic manner and easily understood by the patient.
7. Document must be signed by the patient or parent.


Diagnosis and treatment plan

Orthodontic is a time consuming treatment which can take several years or months. All details of the diagnosis, prognosis and the treatment plan must be explained to the patient. It is also important to discuss with the patient the different phases of the treatment and what the practitioner intents to accomplish at the end of each phase. It is also essential to discuss the treatment charges for each phase


Benefits of treatment

A pleasing smile, straight teeth, less TMJ symptoms, improved nasal breathing, improved profile, pleasing appearance, improved self esteem etc. are some of the benefits of treatment. These should be conveyed to the patient.


Risk of Orthodontic Treatment.

Possible risk associated with orthodontic treatment to be discussed with the patient is one of the essential parts of the informed consent procedure. Some of the associated risks are:-

1. Increase incidence of caries.
2. Periodontal diseases.
3. Decalcification due to poor oral hygiene.
4. Loss of tooth vitality especially when the tooth has been previously traumatized.
5. Occurrence of TMJ problems.
6. Relapse.
7. Need for further treatment such as orthognathic surgery.
8. Difficulty in the management of functional problems such as persistent anterior tongue which could result in anterior open bite.


Limitation of treatment.

Patient must emphasized that orthodontic is not a perfect science and the result may not last a life time. Limitation to the success of treatment can be due to several factors such as.
1. Compliance problems.
2. Severe skeletal problem
3. Relapse problem.
4. Severity of malocclusion.


Alternate treatment plan.

There are always different options to treat an orthodontic case. It could be the conventional approach, functional approach, a combination, extraction or non extraction approach. Whichever approach is chosen. All treatment philosophies and treatment techniques must be discussed with the patient prior to the commencement of treatment.


Prognosis if no treatment is done.

The patient must be informed frankly and honestly the consequences of not undergoing treatment. This could depend on the severity of the malocclusions.


Patient asks questions.

At the end of the procedure the patient is encouraged to ask questions and communicate freely with the doctor regarding his future treatment. Hence it is ideal to set this appointment at the end of the day when there will be no interruptions.


Conclusion

The importance of informed consent is discussed. This procedure does not end with the patient signing the document Infect this is only the beginning of the Doctor patient relationship which must continue throughout the entire treatment. Dentist by training and by patient expectation, are primarily therapists and so they often launch into action before rendering a complete diagnosis. For many patients, the etiologies and remedies of problems are obvious, and the ensuring progress of treatment and management causes few problems. But whenever the diagnosis is obscure or difficult, patients will suffer from our haste and the practitioner is often baffled about ineffective regimens. The most grievous mistake one can make is that from misdiagnosis. One can easily overcome errors of mechanics, but have much more trouble correcting a wrong diagnosis. Nevertheless, a sound diagnosis remains the foundation of all successful therapy, and it remains the primary responsibility of conscientious clinicians


Patient History

Orthodontic treatment must only be iniciated on patients who are in good health. It is unwise to subject an unhealthy patient to the demands of the orthodontic treatment as there bound to be compliance problems broken appointments due to illness and at times neglected oral hygiene.

At this point it is also essential to note if the patient is on any medication or if he is undergoing any treatment. it ia appropiate to throughly discuss the situation with the patients parant and his physician


Medical History

In this section, the practitioner should note any existing medical condition such as allergies , tonsillitis or sinus related condition that may hinder orthodontic treatment. The severity of the condition should be noted and it is a good habit to consult the patient's physician before iniciating any treatment.


Dental History

A through dental history is essential for the success of the orthodontic treatment. It is important to look into the possibilities of existing habits such as mouth breathing, tongue thrust, thumb or finger sucking, lip sucking or biting , use of dummies abnormal lip position and activity and other habits.


TMJ Analysis.

Look for the existence of TMJ signs and symptoms. It is essential to note the presence of pain trigger spots clicking of the joints or the presence of crepidus. Deviation of the mandible on closing is noted and recorded. The maximum opening of the jaws is measured and noted.It is essential to inquire the presence of tension headache and whether the patient is under treatment or otherwise.


Panaromic Radiographs.

The applications of panaromic x - ray are as follows:
· Determination of the dentition present.
· Teeth that will be erupting.
· Missing teeth and supernumerary dentition noted.
· Impacted teeth usually upper cuspids or upper and lower third molars.
· The current status of the third molars is evaluated.
· The root apex of each tooth is examined in order to analyze possible potential for root resorption.
· Pre - treatment bone loss espcially in adult patients who might be having periodontal conditions.
· Any other patholigical conditions.

Introduction

The purpose of this Blog is to guide the General Practitioner in the management of their Orthodontic patients.

It is advisable for the General Practitioner to have the basic understanding of principles of Orthopedic and Orthodontic prior to introducing Orthodontics into their practice. In this Blog a great emphasis is placed on DIAGNOSIS AND TREATMENT PLANING. It is essential for every G.P doing Orthodontics to undergo courses on CEPHALOMATRIC ANALYSIS, DIAGNOSIS AND TREATMENT PLANNING, ORTHOPEDIC MANAGEMENT OF PATIENTS AND BASIC ORTHODONTIC.

The intent of this Blog is to lay the basic foundation of the understanding of Orthodontic Management in Private Practice. It is my hope that every G.P will up grade their knowledge by attending the various courses conducted, join a study club and subscribe to the various orthopedic / orthodontic journals.

Welcome to GPORTHO Blog and please give your comments to enable us to advance this Blog further