Introduction

Orthodontic diagnosis
Formulation of a problem list
Setting priorities for the orthodontic
problem
list
Planning space requirements

INTRODUCTION
Treatment planning is the second step in the
treatment of any patient; the first step being
diagnosis of the problem. Treatment planning can
commence once a diagnosis has been arrived at. It
entails the formulation of a detailed problem list,
setting up of treatment objectives, and finalizing the
treatment plan after discussing it with the patient
or the patients guardians. It also involves, planning
space require- ments, choice of appliance and the
retention regimen. Putting it simply, it involves
producing a road map of each step to be executed
sequentially for a particular case so as to achieve the
desired results.
ORTHODONTIC DIAGNOSIS
Orthodontic diagnosis involves three stepscollection
of data, processing of the collected data and finally
drawing conclusions. Step one is generally the
simplest. It basically involves the taking of case
history, intraoral and extra-oral examination of the
patient, making of study models and taking the
relevant radiographs or other diagnostic records.
The second step involves the processing of all this
collected information into understandable and
coherent data. This will involve undertaking cephalogram and study model analyses. The resulting

Treatment possibilities
Choice of mechanotherapy
Planning retention
Factors in the choice of a specific treatment
plan
Discussion with the patient and patient consent

information should be able to give a concise and

exact location of the malocclusion. A statement of
diagnosis should include the exact problem as
perceived by the clinician and why and/or what is
(etiology) causing the problem. For example, for
example: a 12-year-old male patient, suffering from
mild crowding of the upper and lower anterior teeth,
with a Class II skeletal and dental malocclusion due
to a short and retro-posi- tioned mandible with
proclined upper anteriors and an open bite of 2 mm
due to persistent thumb sucking habit. Another
important aspect, which the diagnosis should reflect
upon, is the growth potential. The diag- nosis
should comment on the amount of growth
potential available and this may involve the use of
additional radiographs (hand-wrist radiograph) or
other supplemental diagnostic aids. Treatment can
vary considerably for growing and non-growing
indi- viduals.
FORMULATION OF A PROBLEM LIST
Formulation of a problem list is an important step
and should be done in consultation with the parents
and patients. For most patients, esthetics may be the
most potent factor for demanding orthodontic
treatment. But on examination, the orthodontist has
to take into consideration the general health of the
patient, especially the oral health.

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Treatment
of Orthodontics
Planning
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RETRACTION OF PROTRUDED TEETH
The problem list should include comments on the
periodontal condition of the patient, his/her status For every millimeter of retraction required, 2 mm of space
of caries/restorations and vitality of teeth. Only is required.
then should the clinician formulate the orthodontic Protruded teeth are the most frequent reason for
problem list. Due importance should be given to the patients to approach the orthodontist. Unless the
patients desires, however, the clinician should also retraction required is very less or/and the dental
weigh options and possibilities from the arches are spaced, extraction of certain teeth might
standpoint of treatment.
be required to create space for retraction of proclined
teeth.
SETTING PRIORITIES FOR THE
CORRECTION OF CROWDING
ORTHODONTIC PROBLEM LIST
2

Setting priorities for orthodontic problems is important, as the space requirements are limited in most
cases. If the case requires a lot of space for the retraction of teeth and there is some amount of crowding
also present, then a compromise might need to be
arrived at, decrowding along with limited retraction
or retraction to desired limit and limited decrowding.
Similarly, priorities will have to be made regarding
correction of molar relations, derotations and
uprightenting of certain teeth.
It is always important to remember the goals of
orthodontic treatmentthe Jacksons triad of functional effi ciency, structural balance and esthetic
harmony, should always be the hallmark of all
corrections planned.

For every millimeter of decrowding, the same amount of

space is required for aligning the teeth.
Crowded teeth are as unsightly as proclined teeth
but maybe more harmful for the gums. The
correction of crowding requires calculating the exact
mesiodistal dimensions of the teeth to be aligned and
accordingly space can be created for alignment. Use
of Kesslings diagnostic setup can be of additional
help.
ALIGNMENT OF ROTATED ANTERIOR TEETH

For every millimeter of derotation required, the same

amount of space is required for aligning the teeth.
The anterior teeth are broader mesiodistally and
occupy less space when they are rotated. Alignment
of such teeth requires additional space in the dental
PLANNING SPACE REQUIREMENTS
arch. Provision should be kept for overcorrection as
Space creation and utilization is important because of the tendency of such teeth to relapse is high.
the overall size of the oral cavity. Extraction of a premolar may create as less as 6 mm of space or as much ALIGNMENT OF ROTATED POSTERIOR TEETH
as 7.5 mm of space. The measure of error is very
small as we deal only in a few millimeters of space. If Space is created when rotated posterior teeth are aligned.
even a small amount of space is lost, the overall The space created depends upon the tooth and the amount
goals of treatment might not be achieved to of rotation present.
The posterior teeth are broad labiolingually and
perfection. Not achieving the treatment goal not only
compromises treatment results, but also functional can be compared to a parallelogram when viewed
efficiency and long-term stability of treatment from the occlusal aspect. When they are rotated,
they occupy more space; hence, space is actually
results.
Corrections required as part of treatment:
created by aligning such teeth.
1.
2.
3.
4.
5.
6.

Retraction of protruded teeth

Correction of crowding
Alignment of rotated anterior teeth
Alignment of rotated posterior teeth
Correction of molar relationship
Leveling the curve of Spee

is not stable and space might be required to bring the

maxillary or mandibular molar mesially to achieve
stability. The exact space required can be calculated
on the study models.
LEVELING THE CURVE OF SPEE

CORRECTION OF MOLAR RELATIONSHIP

The space required for mesial or distal movement of the
molars is as per the actual movement planned.
To achieve a stable molar relationship, it is
essential
to have
a full Class I, II or III relation. End-on relation

For every 1 mm of leveling, approximately 1 mm of space

is required.
Skeletal malocclusions are very commonly associated with an increase in the curve of Spee. No malocclusion can be fully corrected, especially involving
the camouflage of an underlying skeletal problem,
without leveling the curve of Spee. An excessive

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Treatment
of Orthodontics
Planning
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curve will not only limit the amount of retraction of If the patient is growing, the mandible can be
made to grow and the case can be finished with
the maxillary anteriors but can also aid in the relapse
of the condition.
the molars in Class I relationship.
The maxillary molar can be distalized to a full
ANCHORAGE
Class I relation and the space created can be used
to retract the maxillary anterior teeth.
All appliances generate tooth moving forces from
Another treatment option can be to defer
certain other intraoral anchor teeth. In trying to move
treatment till the patient has completed growth
the maligned teeth, certain amount of undesired
and then plan orthodontic correction with
movement has been noticed in the anchor teeth. This
surgical intervention.
anchorage loss or the forward movement of the
anchor teeth into the extraction space has been Finally, it is not always essential to treat a case;
calculated to be approximately between 30 and 40
however, it is the clinicians duty to enlighten the
percent of the total space created by the extractions.
patient regarding the consequences of not
The space lost is dependent upon the appliance
undertaking orthodontic correction.
used and the treatment mechanics involved.
Each treatment possibility has an advantage and a
If greater amount of space is required for the corresponding disadvantage. Compromises might
resolution of the malocclusion, additional means have to be made regarding extraction of teeth,
should be used to prevent anchorage loss. These may skeletal vs dental corrections, or amongst various
involve the use of extraoral or intraoral appliances dental corrections required.
(Nance palatal button, trans-palatal arches or lingual
Treatment possibilities should be listed and the
arches).
possibility, which best serves, the particular patient
at that particular age with maximum improvement
TREATMENT POSSIBILITIES
in esthetics and function should be chosen.
Correction of a particular malocclusion can be achieved in various different ways. For example; correcCHOICE OF MECHANOTHERAPY
tion of a mild skeletal and dental Class II
malocclusion can be achieved by:
Why treat a case using a particular appliance? Is it
Extraction of maxillary fi rst premolars and essential to treat each and every case using the
retraction of the maxillary anteriors and finishing Beggs appliance or the Straight wire appliance
with molars in Class II relation.
because the clinician has been trained in its use? All
With the extraction of all first premolars and appliances were designed to treat all kinds of
finishing with molars in Class I relationship.
malocclusions. Some manage to do them more
simply, others require more time and maybe still do
not give the desired results.
The appliance should be chosen so as to attain all
the possible treatment results within the least
possible
time with as little tissue irritation/damage as
possible. It is at times a compromise between the
patients
desires and the ability of the clinician.
3

PLANNING RETENTION
The malocclusion dictates the kind of retention that
is planned. Rotations and diastemas are more prone
to relapse and hence retentionthe type, kind and
duration should be planned accordingly. The most
frequently used Hawleys appliance still remains the

favorite of most clinicians today. Still as the number

of adult patients is increasing, so is the use of fixed
retainers.
The retention planned should be mentioned in
the treatment plan that is presented to the patient.
FACTORS IN THE CHOICE OF
A SPECIFIC TREATMENT PLAN

completion of treatment can result in relapse of the

treatment results. This is especially true for Class III
skeletal pattern cases. Sufficient planning and followup is advised in growing patients.
PATIENTS
HYGIENE

ABILITY

TO

MAINTAIN

ORAL

Certain age groups or patients with compromised

The final treatment plan is the result of a discussion motor functions might not be able to maintain
between the patient and the orthodontist. It is adequate oral hygiene with fixed appliance therapy.
designed keeping in mind the priorities given to the Such patients can be treated using removable
various problems in the problem list. The choice of a appliances with compromised treatment results.
specific treatment plan is based upon:
THE COST OF THE TREATMENT
1. The type of tooth movements required
2. Patients expectations
Fixed orthodontic treatment is more costly as compa3. Growth potential of the patient
red to removable appliance therapy. Sometimes the
4. Patients ability to maintain oral hygiene
patient might not be able to afford costly yet ideal
5. The cost of the treatment
treat- ment plans. The financial implications of the
6. The skills of the treating clinician.
treatment should be considered and explained to the
patient at the time of deciding upon a particular
THE TYPE OF TOOTH MOVEMENTS REQUIRED
treatment plan.
Simple tipping movements can be achieved using
removable appliances. If multiple, complex tooth THE SKILLS OF THE TREATING CLINICIAN
movements are desired, it is advisable to use one of
It is always better to work within your means and to
the available fixed orthodontic appliances. Certain
fixed appliances provide three-dimensional control present treatment plans that can be achieved. It is not
over individual teeth and allow complex movements possible for every clinician to be good at everything
he/she does. Being truthful to the patient before
to be undertaken simultaneously.
treatment is better than being sorry for him/her
following treatment.
PATIENTS EXPECTATIONS
It is the duty of the clinician to choose an
Patients who have high expectations are expecting
appliance that is appropriate for the particular case
ideal finishes which might not be possible using
removable appliances. Such patients are concerned and not just appropriate for the clinician. If one has
about their esthetics to such an extent that the labial to continue to treat cases, the clinicians need to
upgrade their know- ledge and skills with the
change in developing technology.
appliances might not be an option. They might desire
the use of lingual appliances. A compromise might DISCUSSION WITH THE PATIENT
need to be arrived at regarding treatment results and AND PATIENT CONSENT
the patients expectations, it is advised to inform the Patient today act as co-decision makers. Hence, it is
patient exactly what is achievable with which the orthodontist legal and moral duty to discuss the
appliance, to the best of the clinicians ability before risk/benefit of the treatment and alternatives as well
commencing the treatment.
as the risks of no treatment at all.
Written consent is an adjunct to show willingness
to achieve informed consent in litigation cases.
Growing patients can be a boon as well as bane. Consent
Results achieved during growth are more stable yet is of two typesinformed and implied. Implied
sometimes the return of an abhorrent growth consent is generally required when undertaking
surgery. Informed consent can and should be taken
pattern following
GROWTH POTENTIAL OF THE PATIENT

after providing the patient with enough information

to have an understanding of the condition
(malocclusion), its severity and the proposed
treatmentits goals and objectives. He/she should
be made to understand the commitment required on
his/ her partboth regards to the time and
financial. Risks involved, of the treatment and of not
getting treatment, should also be explained.
FURTHER READING
1. Daugaard-Jensen I. Extraction of fi rst molars in
discrepancy cases 1973;64;115-36.
2. Enlow DH, Moyers RE, Hunter WS, McNamara JA. A
procedure for the analysis of intrinsic facial form and
growth, Am J Orthod 1969;56:6-14.

3. Horowitz SL, Hixon EH. The Nature of Orthodontic

Diagnosis, St Louis, CV Mosby, 1966.
4. KamedaA. Diagnosis and treatment planning in the
orthodontic practice, Tokeyo, 1978, Isyo Publishers Inc.
5. Proffi t SR, Ackerman JL. Diagnosis and treatment
planning in orthodontics, in Graber TM, Swain BF (eds),
Orthodontics, Current Principles and Technique, St
Louis, CV Mosby, 1985.
6. Ricketts RM. Planning treatment on the basis of the
facial pattern and an estimate of its growth. Angle
Orthod
1957;17:14-37.
7. Schwanniner B, Shaye R. Management of cases with
upper
incisors missing, Am J Orthod 1980;100(5):710-2.
8. Thampson FG. Second premolar extraction in Begg
technique, J Clin Orthod 1977;11:610-3.
9. Wagers LE. 8-tooth extraction cases using Begg technique,
J Clin Orthod 1977;11:526-38.