Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-02-22, 14:08:19 | version 1.38.0
Dental Tribune Middle East & Africa Edition | 5/2016 10 mCME Seven Keys to Optimize Interdisciplinary Orthodontics CAPP designates this activity for 2 CE Credits mCMEarticlesinDentalTribunehavebeenapprovedby: HAADashavingeducationalcontentfor2CMECreditHours DHAawardedthisprogramfor2CPDCreditPoints ByDr.AshokKarad,India Orthodontics has always been the discipline that sets the stage for dento-facial esthetics. With the in- creasing demand for appeal and appearance, orthodontic treatment of adults has been the fastest grow- ing area in the field of orthodontics. In addition to aesthetics, increased awareness of malocclusion, func- tional benefits of orthodontic treat- ment,advancesinmaterials,aesthet- ically pleasing and biomechanically sound appliances, and interdiscipli- nary treatment philosophy have all played an important role in making orthodontic treatment popular in adultpopulation. However, in recent years, increased focus on simplified and rapid inter- vention has created compromises in treatment outcomes. Lack of funda- mental diagnosis and systematically sequencedtreatmentplansarebeing circumvented by technology and re- lianceonlaboratoryassistance.Diag- nostic process, essence of treatment planning and biologic basis seem to be diminishing in importance. Often orthodontic treatment can be of significant assistance in peri- odontally and restoratively compro- mised patients. The primary goal of orthodontic therapy in such clinical situations is to reduce or prevent ex- cessiveperiodontalsurgerybyestab- lishing a physiologic alveolar crestal topography and to establish better occlusalrelationshipsforpredictable long-term prosthesis by customized orthodontic tooth movements. This article explains the philosophy and treatment approach that brings to- gether a diverse group of profession- als into a cohesive interdisciplinary teamtoprovidetreatmentstrategies for adult patient. It explains existing and new orthodontic, periodontic, surgical and restorative techniques that provide the best possible solu- tion to complex dentofacial prob- lems. Inclinicalpractice,orthodontictreat- ment of adults may be somewhat different from that of most adoles- cents(1).Comparedwithadolescents, adults are more likely to have denti- tions that have undergone some degree of mutilation over a period of time and they may have other problemslikemissingteeth,restored teeth, periodontally compromised teeth, endodontically involved teeth etc., which demand some alterations intreatmentstrategy. In patients with periodontally com- promised dentition with significant bone and attachment loss, con- ventional approach to orthodontic tooth movement does not produce the desired results, as this may lead to increased tipping of teeth (2). Therefore, in such clinical situations, entirely different biomechanical strategies are required for efficient and desired tooth movement (3). Ab- sence of growth potential in adults as opposed to growing patients is another factor that influences the orthodontic treatment strategy to resolveadultmalocclusions. 1)Establishorganized approach to diagnostic and treatment planningprocess To formulate proper treatment plan, clarity in the final treatment and to prevent any complications and con- fusion, establishing accurate diagno- sis is the most important step. The goal of the diagnostic process in an interdisciplinary treatment is to pro- duce a comprehensive but concise list of patient’s problems and to in- corporate various treatment options into a plan that gives maximum benefit to the patient (4). The ortho- dontistshould: 1) recognize the various elements of malocclusion contributing to the development of a problem. This can be achieved by developing a com- prehensive but concise database of useful information derived from pa- tient’s history, clinical examination and analysis of diagnostic records (study models, full-mouth radio- graphs and facial and intraoral pho- tographs;(Fig.1) 2) have comprehensive knowledge of different disciplines of dentistry to generate the pertinent data other thanorthodontics, 3)andfinally,definethenatureofthe problem to design a treatment strat- egy based on the specific needs and desiresofthepatient. This database is then well organized in such a way that it gives a system- aticdescriptionofthepatient’sprob- lems. The team involved can eas- ily refer to this during the treatment planning process. While arranging the database of a complex dentofa- cialprobleminasystematicmanner, if the problem list becomes very ex- tensive, it is advisable to classify the problem list into various areas like orthodontic problem list, restorative problem list and periodontal prob- lemlist(Fig.2). 2)Definetreatment goals Inthemanagementofapatientwith multiple dental problems, it is ex- tremely important for a clinician to define finishing goals at the begin- ning of treatment and continue to focusonthemtillthefinishingstage, inordertoachievethemwithacom- bination of appropriate orthodontic treatment mechanics, restorations and periodontal procedures. The treatment goals are mainly focused on establishing optimal oral health, aesthetics, good stomatognathic functionandlong-termstability. The clinician should be able to visu- alize the end result before imple- menting the definitive treatment plan. This requires clearly defined treatmentgoalsthatsetthedirection to the proposed treatment plan. Ide- ally,interdisciplinarytreatmentplan should be the one that addresses maximum number of highest pri- ority problems including the chief complaint and optimizes the treat- mentresultswithmaximumbenefit tothepatientwithlessriskinvolved. Since complex dentofacial abnor- malities frequently present mul- tifaceted problem list involving Figure1:Diagnosticprocess. Figure3:Treatment execution. Figure2:Organizedapproach toafinal treatment plan. Figure4:11-point interdisciplinary treatment protocol. Figure5:Toothpositionandperiodontalhealth.(A)Gingivalimpingementduetodeepbitecausesdirectperiodontallesion,(B)Dental crowdingleadstoaccumulationofplaquethatcausesindirectperiodontallesion,(C)Orthodonticmovementofteethintobetterbone support,parallelismofrootsanddifferentialvertical toothmovement Figure 8: Lateral cephalometric superim- position to determine the status of facial growth Figure 9: Adequate space between the rootsforimplant placement Figure7:Biologicwidthanditsclinicalsignificance.(A)Pre-treatmentphotographshow- ing anterior restorations violating biologic width, which is seen clinically as gingival in- flammation and recession. (B) Illustration shows biologic width and its components. Total attachment of 2.04 mm is essential for the preservation of periodontal health. Its components include: mean gingival sulcus depth of 0.69 mm, junctional epithelium measuring 0.97 mm and mean supra-alveolar connective tissue attachment of 1.07 mm.(C)Orthodontictreatment tobringaboutdifferentialforcederuptionof11and12. (D)Restorationsarecontouredpalatallytocreateinterocclusalspacetofacilitatevertical movement ofincisors Figure 6: Dental arch crowding as a ‘ma- jor’ periodontal concern. (A) Labially po- sitioned mandibular right central incisor associated with gingival recession. (B) Teeth that are orthodontically moved into areas of better bone support show partialattachment gain. ÿPage 11 A B