functional treatment planning - spear education · ortho if there is adequate root length since the...

FUNCTIONAL TREATMENT PLANNING

TREATMENT IMAGES

LEARNING OBJECTIVES

•Understand what to evaluate to make functional planning decisions

•Understand when and how occlusal alterations should be considered

•Treatment options available

•How to choose among the options

Esthetics

Function

Structure

Biology

Tooth PositionGingival Levels

Contour & Color

TMJMuscle

Occlusion

RestorationReplacement

EndoPerio

Oral Surgery

DiagnosisExam

History

TMJ

Muscles

Dental

Perio

Photography

Treatment Planning

No treatment

Mounted Models

Equilibration

Restoration

Develop the

Occlusion

Intercuspal position

End to End

Joint

Muscle

Dental

Splint therapy

Pathways

Developing the Occlusion

1.Evaluate the TMJ’s

2.Evaluate muscles

3.Evaluate the teeth

4.Mount Models

5.Develop the occlusion

Step 1: Examine the joints, muscles, and

teeth to determine if the existing occlusion is

physiologic or pathologic

Step 2: Following the examination make a

diagnosis of the current occlusion

Physiologic Pathologic

If the patient’s current occlusion is

physiologic

Are you going to alter it?

If so, where are you going to alter it?

If the patient’s current occlusion is

pathologic

How are you going to alter it?

Occlusal Positions

1) The position of maximum intercuspation MIP

Male 45 years old

• Desires esthetic

improvement of maxillary

teeth with veneers

• Has cracked maxillary right

first and second molars

• No joint or muscle symptoms

Relationship between the

occlusion and muscles

The lateral pterygoid pulls the

condyle in an anterior direction

producing translation

Relationship between the

occlusion and muscles

The lateral pterygoid pulls is

programmed by the posterior teeth

to hold the mandible so that when

we close we close into MIP

Relationship between the

occlusion and muscles

The lateral pterygoid pulls is

programmed by the posterior teeth

to hold the mandible so that when

we close we close into MIP

Intercuspal Position Options

• Use the patient’s existing intercuspal position

Useful when the existing position is asymptomatic, and your treatment plan won’t destabilize the occlusion

Intercuspal Position Options

• Create a new intercuspal position

Useful if your treatment plan will destabilize or remove the existing occlusion, or when the existing occlusion is

pathologic

Occlusal Positions

1) The position of maximum intercuspation

2) Excursive pathways anterior or lateral to MIP

Male 55 years old

• Fractured left lateral incisor

• No esthetic complaints

• No room for a restoration

• No joint or muscle symptoms

Pathway wear End to end wear Crossover

X

The goal in pathway wear patients is to

increase the overjet!

Occlusal Positions

1) The position of maximum intercuspation

2) Excursive pathways anterior or lateral to MIP

3) End to end and crossover occlusion

Male 20 years old

• Fractured left lateral incisor

• No esthetic complaints

• No room for a restoration

• No joint or muscle symptoms

Pathway wear End to end wear Crossover

X

The edge to edge treatment plan will be created on models first

Protrusive

Right lateral

Left lateral

1. Establish maxillary tooth position

2. Transfer desired esthetic changes to the

models

3. Move the articulator end-to-end and correct lower

anteriors

The goal in edge to edge wear patients is broad smooth contacts

The goal in edge to edge wear patients is broad smooth contacts

3. Move the articulator end-to-end and correct lower

anteriors

Left lateral

The goal in edge to edge wear patients is broad smooth contacts

Right lateral

The goal in edge to edge wear patients is broad smooth contacts

4. Evaluate centric contacts in anterior

Equilibrate posteriors Add palatal compositeOR

Female 50 years old

• Unhappy with the esthetics

of her maxillary anterior

teeth

• Concerned about the wear

on her mandibular anterior

teeth

• No joint of muscle symptoms

Pathway wear facets, only on the facial surfaces

Pathway wear End to end wear Crossover

X

There is some evidence of erosion as well as attrition

The radiograph shows the lower anteriors occluding at the palatal

aspect of the uppers

The facets show the depth of the overbite

Her intercuspal position is not Class I, but is acceptable

Not missing any teeth

The model shows a combination of attrition and erosion

Correction by intruding and proclining the upper incisors and

intruding the lower incisors

The gingival levels and occlusal plane illustrate the mandibular

anterior over-eruption

Esthetics

Function

Structure

Biology

Treatment Alternatives

1. Procline upper incisors

2. Retract lower incisors

3. Intrude upper incisors

4. Intrude lower incisors

5. Orthognathic surgery

lip

Diagnosis

1. Upper incisal edge position

Diagnosis

1. Upper incisal edge position

2. Upper incisor inclination

Diagnosis

1. Upper incisal edge position

2. Upper incisor inclination

3. Gingival levels

Diagnosis

1. Upper incisal edge position

2. Upper incisor inclination

3. Gingival levels

4. Lower incisor position

Resting lip levellower incisor level

4mm of lower incisor display at rest and they are worn

Treatment Alternatives

1. Procline upper incisors

Treatment Alternatives

1. Procline upper incisors

2. Retract lower incisors

95% 95%

Treatment Alternatives

1. Procline upper incisors

2. Retract lower incisors

3. Intrude upper incisors

77% 77%

Treatment Alternatives

1. Procline upper incisors

2. Retract lower incisors

3. Intrude upper incisors

Treatment Alternatives

1. Procline upper incisors

2. Retract lower incisors

3. Intrude upper incisors

4. Intrude lower incisors

Treatment Alternatives

1. Procline upper incisors

2. Retract lower incisors

3. Intrude upper incisors

4. Intrude lower incisors

5. Orthognathic surgery

Ortho set up simulating tooth movements and restoration

Note: no changes are being made to the posteriors

Maxillary anteriors proclined

Mandibular anteriors intruded and restored

Mandibular anteriors intruded and restored

Ortho vs Crown Lengthening

Crown lengthening could be

done on the lower instead of

ortho if there is adequate root

length since the tooth position

is good, just over-erupted

Ortho vs Crown Lengthening

Crown lengthening is not a

good option for the upper due

to the retroclined position of

the teeth, the subsequent

tooth preparation would leave

no tooth structure

Composite bonded to allow for bracket placement

Composite bonded to allow for bracket placement

Composite bonded to molars to hold open the vertical

Composite bonded to molars to hold open the vertical

Maxillary proclination and intrusion, mandibular anterior intrusion

Brackets removed for composite bonding

Incisor length corrected with composite prior to re-bracketing

Pencil line represents previous tooth length

Brackets replaced ideally for ortho finishing

Veneers

Concluding Thoughts

Intercuspal position

Pathways

End to End