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4/8/2015

Top Ten Lessons I Have Learned in Orthodontics

Richard McLaughlin, D.D.S.

AAO 2015San Francisco, CA

TOP TEN LESSONS I HAVE LEARNED IN ORTHODONTICS

1. Diagnosis and Treatment Planning

2. Importance of Staff

3. 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

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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

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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

• TMJ’S and Musculature

• Airway

• Perio Status-and Soft Tissue

• Habits

• Facial and Skeletal Pattern

• Dentition

CHECK LIST PROBLEM LIST

3

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7774__3

10

9

96

0

-4

-7

121

40

31

31

N.D.INITIAL12.8 yrs

102

82802

5      

2      

95   

‐1     

0      

‐4     

110    

32     

26

28     

SN-GoGn°

F-Mand°

Pal-Mand°

SNA°SNB°ANB°

A-Na Perp mm

Wits mm

Pg-Na Perp mmL1-Mand plane°

U1-Palatal plane°

U1 APO°

L1 APO°Occlusal Plane Angle

4

82802

5      

2      

95   

‐1     

0      

‐4     

110    

32     

26

28     

SN-GoGn°

F-Mand°

Pal-Mand°

SNA°SNB°ANB°

A-Na Perp mm

Wits mm

Pg-Na Perp mmL1-Mand plane°

U1-Palatal plane°

U1 APO°

L1 APO°

5

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Airway

TMJsAnd

Muscles

Perio Status

Facial &Skeletal Pattern

Habits

Dental Status

Edward H. Angle

MolarRelationship

Charles Tweed

Lower IncisorPosition

90°

6

4/9/2015

83 SNA79 SNB4 ANB

Steiner Analysis

Michigan Growth Studies

NasionPerpendicular

90°

A point

Pogonion

Bruce Epker and Larry Wolford

90°

NasionPerpendicular

Subnasale

7

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Subnasale

Cephalometric X-ray inNatural Head Posture

William Arnett

7774__3

10

9

96

0

-4

-7

121

40

31

31

102

“ I DON’T USE CEPHALOMETRICS ANY MORE”

N.D.INITIAL12.8 yrs

2014 JCO Study of Orthodontic Diagnosis and Treatment Procedures-Part 1

Table 3Cephalometric Diagnostic Records

Percentage of the time a routine pre-treatment cephalometric X-ray taken

1986 - 90%

1996 - 90%

2008 - 74%

2014 - 64%

8

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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

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-6

1

10

88

-5

-14

9

123

23

23

22

83 SNA89 SNB

0°

F.T.BEGINNING21.11 yrs

-6

1

10

88

-5

-14

9

123

30

23

22

76 SNA82 SNB

7°

F.T.BEGINNING21.11 yrs

8

9

3

101

1

2

-12

117

40

29

28

77 SNA69 SNB

11°

S.S.BEGINNING30.2 yrs

10

4/9/2015

8

9

3

101

1

2

-12

117

36

29

28

81 SNA73 SNB

7°

S.S.BEGINNING30.2 yrs

83 SNA

79 SNB

4 ANB

S.Z.BEGINNING10.11 yrs

The “Wits” appraisal ofjaw disharmony

Alex Jacobson, MDS, MS, PhD

AJO-DO

November 2003 - Volume 124 Issue 5

Pages 470-479

or www.ajodo.org

11

4/9/2015

8479__

5 ANB

6

1

94

-1

3 WITS

-12

112

30

27

27

OCCLUSAL PLANE ANGLE = 101

101

A.B.BEGINNING14.1 yrs

8786__

1 ANB

5

4

94

6

5 WITS

+8

111

20

14

23

OCCLUSAL PLANE ANGLE = 86

86

G.B.BEGINNING52.8 yrs

With Class I occlusions,the occlusal plane can vary

from 80° to 110°, or a total 30°

This can effect the position of pogonion

by 1.5 to 2 cm

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N.S.BEGINNING17.0 yrs

7366__7

13

8

94

-3

3

-22

104

50

42

49POSITIONALLY SENSITIVE

DENTALLY SENSITIVEPo 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

7567__8

10

‐3

83

‐1

10

‐16

112

43

32

33

D.L. BEGINNING53.5 yrs

13

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8176__5

8

‐0

87

‐1

2

‐11

112

34

30

30

G.E.BEGINNING9.3 yrs

8479__

5

4

-0

80

5

-2

2

98

35

29

38

S.Z.BEGINNING10.11 yrs

Conventional Cranial Based Cephalometrics- Five Plane Evaluation

• SN Plane

• Frankfort Horizontal Plane

• Palatal Plane

• Occlusal Plane

• Mandibular Plane

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Orthodontists need to

dentally compensate incisors

in many cases

“There is often a tension

in orthodontics between

stability and esthetics”

Larry Andrews

8379__4

4

0

81

4

-2

1

98

35

29

38

S.Z.BEGINNING10.11 yrs

15

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Tetragon: A Visual Cephalometric Analysis

Jorge Fastlicht, DDS, MS

Journal of Clinical Orthodontics

Vol 33 2000 Number 6

Pages 353-360

or www.jco-online.com

Tetragon: A Visual Cephalometric Analysis

Jorge Fastlicht, DDS, MS

Mx 1

Md 1

Occlusal Plane WITS

16

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115

57 65

95

20

8 0

POP

OMP

Mx1-PP

Mx1-OP

Wits

Md1-MP

Md1-OP

CLASS I

110-115

57 65

90-95

20

8 0

POP

OMP

Mx1-PP

Mx1-OP

Wits

Md1-MP

Md1-OP

CLASS I

J.C.7575__0

8

3

72

-4

-3

-8

113

43

35

38

-3

11356

8072

2711

High Angle

17

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J.C.

8178__

3

6

3

100

-0

3

-6

117

27

21

21

3

1175865

100

165

Low Angle

8684__2

1

-2

105

62

10

106

11

3

-4

2

1066872

105

36

Low Angle

S.W.BEGINNING32.6 yrs

100

72 60

100

20

8 5

POP

OMP

Mx1-PP

Mx1-OP

Wits

Md1-MP

Md1-OP

CLASS II

18

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Z.D.

7975__

4

6

3

101

-2

4

-11

104

24

20

21

4

1046966

101

138

Class II

120

52 80

80

20

8 -5

POP

OMP

Mx1-PP

Mx1-OP

Wits

Md1-MP

Md1-OP

CLASS III

J.P.

7882__-4

3

2

82

-6

-8

-1

120

26

24

23

-8

1205481

82

176

Class III

19

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8379__4

4

0

81

4

-2

1

98

35

29

38

-2

9864

80

81

1919

1) Cranial Baseas a Reference

2) Soft Tissue

S.Z.BEGINNING10.11 yrs

Bruce Epker and Larry Wolford

90°Subnasale

S.Z.BEGINNING10.11 yrs

-

ARNETT SOFT TISSUE

CEPHALOMETRIC ANALYSIS

AJO, SEPT. 1999

-NATURAL HEAD POSITION

-WAX BITE IN CR

-RELAXED LIPS

SUBNASALE

True Vertical Line

20

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NATURAL HEAD POSTURELITERATURE

• Moorrees-Am J Phys Anthropol, 1958

• Cooke-AJO, March 1988

• Lundstrom and Lundstrom-AJO, March 1992

• Arnett and Bergman-AJO, April and May 1993

LUNDSTROM AND LUNDSTROM- NATURAL HEAD POSTURE AS BASIS FOR

CEPHALOMETRIC ANALYSIS, AJO, MARCH 1992

• Sella-Nasion 5.3 sd

• Basion-Nasion 4.7 sd

• Porion-Orbitale 5.0 sd

• Natural Head Position 1.8 sd

• NHP is the most reproducible and accurate

21

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100

96 57

65

7

8

125

21

2

47

73

5

26

5112

-8

-19

-22-15

-1315

-1

3-9

1

-5

-3

17

17075

12

133

3

15

343

842

59

2

1155765

95

208 0

ARNETT SOFT TISSUE

CEPHALOMETRIC ANALYSIS

22

ARNETT NORMS AND STANDARD DEVIATIONS

UPPER ANTERIOR SEGMENT-HORIZONTAL Female STCA research values and (means)

Incisor torque to occl. plane 54.3° to 59.3° (57°)Incisor tip to TVL -11.4 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 (3)

UPPER ANTERIOR SEGMENT-VERTICAL Female STCA research values and (means)

Max. anterior height 23.6 mm to 27.8 mm (26)Lip length 19.1 mm to 22.9 mm (21)Incisor exposure 3.1 mm to 6.3 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 93.8° to 97.4° (96°)

Incisor torque to occl. plane 61.1° to 67.5° (65°)Lip thickness 12.2 to 15.0 mm (13)Lip to TVL -0.5 mm to 3.3 mm (1)

Soft tissue ‘B’ point -6.8 mm to -3.8 mm (-5)Soft tissue pogonion -4.5 mm to -0.7 mm (-3)

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 -13.9 mm to -10.3 mm (-12)Lip thickness 13.4 to 16.2 mm (14)Lip to TVL 1.6 mm to 5.0 mm (3)

UPPER ANTERIOR SEGMENT-VERTICAL Male STCA research values and (means) Max. anterior height 25.2 mm to 31.6 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 1.3 mm to 3.5 mm (2)

LOWER ANTERIOR SEGMENT Male STCA research values and (means)Occlusal plane to TVL 93.6° to 96.4° (95°)

Incisor torque to occl. plane 60.0° to 68.0° (64)Lip thickness 13.4 to 16.2 mm (15)Lip to TVL -1.6 mm to 3.2 mm (1)

Soft tissue ‘B’ point -8.7 mm to -5.5 mm (-7)Soft tissue pogonion -5.3 mm to -1.7 mm (-3)

23

57 3‐9‐

12

Upper Incisor InclinationMx1 – Mx OP

Upper Incisor Tip ProjectionMx 1 ‐ TVL

Upper Lip ThicknessMx1 Labial ‐ ULA

Upper Lip AnteriorULA ‐ TVL

Upper Anterior Segment – Horizontal Numbers

24

21

25

26

‐

Mx Anterior HeightSn’ – Mx1 Tip

Upper Lip LengthSn’ – ULI

Upper Incisor ExposureUL1 – Mx 1 Tip

Inner Labial GapUL1 – LLS

Upper Anterior Segment – Vertical Numbers

25

9665 1

‐5

‐3

13Mx Occlusal PlaneMx OP ‐ TVL

Lower Incisor InclinationMd1 – Md OP

Lower  Lip ThicknessLL Inside – LLOutside

Lower  Lip AnteriorLLA

Soft Tissue B PointB’

Soft Tissue PogonionPog’ ‐ TVL

Lower Anterior Segment Numbers

26

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISAnterior Segment – Numbers

AJO, SEPT. 1999

9665 1

‐5

‐3

13Mx Occlusal Plane

Lower Incisor inclination

Lower  Lip Thickness

Lower  Lip Anterior

Soft Tissue Pogonion

21

25

26

Mx Anterior Height

Upper Lip Length

Upper Incisor Exposure

Inner Labial Gap

Soft Tissue B Point

12

Upper Lip Thickness

3

Upper Lip Anterior

57

Upper Incisor Inclination

‐9

Upper Incisor Tip Projection

27

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Airway

TMJsAnd

Muscles

Perio Status

Facial &Skeletal Pattern

Habits

Dental Status

Soft Tissue&Incisors-AnteriorSegments

Remaining Dentition-Canines,

Premolars,Molars

Transverse Dimension

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Horizontal Numbers

57-

Upper Incisor Inclination

AJO, SEPT. 1999

115

57 65

95

20

8 0

POP

OMP

Mx1-PP

Mx1-OP

Wits

Md1-MP

Md1-OP

28

4/8/2015

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Horizontal Numbers

57 -9-

Upper Incisor Inclination

Upper Incisor Tip Projection

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Horizontal Numbers

57 -9-

12

Upper Incisor Inclination

Upper Incisor Tip Projection

Upper Lip Thickness

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Horizontal Numbers

57 3-9-

12

Upper Incisor Inclination

Upper Incisor Tip Projection

Upper Lip Thickness

Upper Lip Anterior

AJO, SEPT. 1999

29

4/8/2015

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Vertical Numbers

AJO, SEPT. 1999

26

Mx Anterior Height

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Vertical Numbers

AJO, SEPT. 1999

2126

Mx Anterior Height

Upper Lip Length

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Vertical Numbers

AJO, SEPT. 1999

21

5

26

Mx Anterior Height

Upper Lip Length

Upper Incisor Exposure

30

4/8/2015

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISUpper Anterior Segment – Vertical Numbers

AJO, SEPT. 1999

21

25

26

Mx Anterior Height

Upper Lip Length

Upper Incisor Exposure

Inner Labial Gap

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISLower Anterior Segment – Numbers

AJO, SEPT. 1999

96Mx Occlusal Plane

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISLower Anterior Segment – Numbers

AJO, SEPT. 1999

96Mx Occlusal Plane

Lower Incisor inclination

65

31

4/8/2015

115   

57 65

95     

20    

8       0   

POP

OMP

Mx1‐PP

Mx1‐OP

Wits

Md1‐MP

Md1‐OP

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISLower Anterior Segment – Numbers

AJO, SEPT. 1999

9665 13Mx Occlusal Plane

Lower Incisor inclination

Lower Lip Thickness

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISLower Anterior Segment – Numbers

AJO, SEPT. 1999

9665 113Mx Occlusal Plane

Lower Incisor inclination

Lower Lip Thickness

Lower Lip Anterior

32

4/8/2015

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISLower Anterior Segment – Numbers

AJO, SEPT. 1999

9665 13Mx Occlusal Plane

Lower Incisor inclination

Lower Lip Thickness

-5 Soft Tissue B Point

1Lower Lip Anterior

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSISLower Anterior Segment – Numbers

AJO, SEPT. 1999

9665

-3

13Mx Occlusal Plane

Lower Incisor inclination

Lower Lip Thickness

Soft Tissue Pogonion

-5 Soft Tissue B Point

Lower Lip Anterior1

N.D.INITIAL12.8 yrs

7774__3

10

9

96

0

-5

-7

121

40

31

31

-5

1214766

96

1912

33

4/8/2015

N.D.INITIAL12.8 yrs

10247

29

-4 13

7

-4

-6

25

15

3 566

9

N.D. BEG/PREDICTIONSN AT S

PALATAL PLANE AND PALATAL CURVATURE

MAND SYMPHYSIS AND MAND PLANE

N.D. BEG/PRED

34

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, 1993

Fig 3.20

The transverse dimensions is about

four factors:

Midline, Cant, Yaw and Widths

35

4/8/2015

N.D.

N.D.

N.D.

36

Patient: N.D. 

 37

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

.019 x .025 rectangularheat activated

.019 x.025 & .017 x.025rectangular ss heat treated

.016 x .022 rectangularheat activated

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

.019 x .025 rectangularheat activated

.019 x .025 & .017 x .025rectangular ss heat treated

.016 x .022 rectangularheat activated

NON EXT.

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

.019 x .025 rectangularheat activated

.019 x.025 & .017 x .025rectangular ss heat treated

.016 x .022 rectangularheat activated

1st BICUSPID EXT.

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

.019 x .025 rectangularheat activated

.019 x.025 & .017 x.025rectangular ss heat treated

.016 x .022 rectangularheat activated

1ST BICUSPID EXT.

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

.019 x .025 rectangularheat activated

.019 x.025 & .017 x.025rectangular ss heat treated

.016 x .022 rectangularheat activated

2nd BICUSPID EXT.

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

.019 x .025 rectangularheat activated

.019 x.025 & .017 x.025rectangular ss heat treated

.016 x .022 rectangularheat activated

2nd BICUSPID EXT.

39

ORTHODONTIC VTO Name: _____________________

MIDLINE MOLAR POSITION

Right 1st molar Midline Left 1st molar

Overjet ____mm Overbite____mm Crossbite

LOWER ARCH DISCREPANCY

3 x 3 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 1st Midline Left 1st

molar molar ( ) cuspid cuspid ( )

( ) ( )

40