02 - Concepts of Orthodontic Treatment Planning

Treatment Planning Scheme

Diagnostic/Treatment Planning Process

Diagnosis and treatment planning in modern orthodontics is built around the problem-oriented approach. The question in diagnosis is: “What are the problems?” The answer is a description of the problems and their cause. The question in treatment planning, of course, is what to do about the problem(s) (image 1).

The diagnostic process is summarized in image 2 (see the module Essentials of Orthodontic Diagnosis for details). The diagnosis is a list of problems that represent the truth about this individual patient. The list is derived from an objective and scientific evaluation of the patient.

This module focuses on a structured approach to treatment planning based on the problem list. As in the previous module, we will use Anna as our illustrative patient.

It is important to understand that treatment planning is fundamentally different from diagnosis. Its goal is to establish what a wise and prudent clinician would do to maximize benefit to this particular patient. That requires the application of judgment. The goal of diagnosis is truth—the goal of treatment planning is wisdom. So diagnosis is a scientific procedure; treatment planning is not and cannot be. But, it can and must be carried out in a systematic manner (image 3) so that snap judgments do not compromise the quality of patient care.

Image 1, questions: Anna, diagnosis/treatment planning questions.	Image 2, diagnostic process: Steps in orthodontic diagnosis.
Image 3, tx planning process: Steps in orthodontic treatment planning.

Treatment Planning Method

The first step in treatment planning is to separate out the patient’s pathologic problems, which will require other types of treatment, from the developmental problems that are treated with orthodontics (image 1). The guideline is that pathologic problems are treated first, not because they are more important, but because they must be brought under control before orthodontic treatment begins. If they are not under control, they can—and quite likely will—become worse while the relatively prolonged orthodontic treatment is carried out.

Then the developmental problems are placed in priority order, and the treatment plan is developed by evaluating the possible treatment procedures relative to the patient’s prioritized problem list (image 2).

Image 1, pathologic problems: Pathologic problems must be brought under control before orthodontic treatment starts.	Image 2, tx planning process: The other steps in planning orthodontic treatment must wait for control of pathology.

Treatment Planning Process

Let’s examine the treatment planning approach to developmental problems in more detail, starting with prioritization of the developmental problem list.

It is at that point that judgment must be introduced, and pure science is left behind. If the patient has multiple problems, which is the most important? That depends…on some combination of what the patient thinks is most important and what the doctor might think is most important based on his or her training and experience.

What’s the importance of prioritizing the problem list? Very simply, the same problem list prioritized differently will result in different treatment plans.

Then the approach is to:

• consider the possible solutions to each problem, starting with the most important one
• examine the “practical considerations” of interactions among the possible solutions, cost-benefit, necessary compromises, and other factors
• and meet with the patient/parent to review alternative treatment possibilities, seek their input, and obtain informed consent

Treatment Planning Process (cont.)

The process of obtaining informed consent to treatment starts with being sure that the patient/parent understand the prioritization of the problem list. This requires presenting them with the probable outcome of no treatment and alternative treatment possibilities if they exist.

With the patient’s/parents’ informed consent, a treatment plan concept is developed and reviewed with them to be sure they understand. It should be presented in language that they can understand.

Based on the treatment concept, a detailed treatment plan for the doctor(s) is produced that specifies more precisely:

• exactly what will be done,
• by whom,
• and when.

Almost always there are multiple ways to do things. The doctors must consider the effectiveness and efficiency of the possible procedures as the detailed plan is developed:

• Does it work?
• How well does it work?
• What is its cost-effectiveness, with cost considered broadly?

Anna: Treatment Plan

Anna, Diagnostic Summary

Let’s continue with Anna, the 12-year-old girl whose diagnostic evaluation was illustrated in the previous module, Essentials of Orthodontic Diagnosis.

Her key diagnostic records are shown in those images. She had no skeletal problems, but a rather severe problem of dental development. The detailed evaluation is in the other module.

Her problem list:

• missing lower right 2nd premolar, severely delayed lower left 2nd premolar
• mildly crowded mandibular incisors

Image 1, facial photos, panoramic radiograph: Normal facial proportions, missing/delayed lower 2nd premolars.	Image 2, intraoral photos: Normal occlusion, mild mandibular incisor crowding, retained 2nd primary molars.

Anna: Prioritization, Possible Solutions

For Anna, there were no pathologic problems, and there was no doubt that the missing teeth were more important than the mild crowding. So her prioritized problem list was the same as the initial one (which is often not the way it works out).

For her most important problem, the missing/delayed mandibular 2nd premolars, there were two possible solutions:

1. Maintain the 2nd primary molars as long as possible, hope the delayed premolar would eventually complete its formation and erupt, and replace the missing 2nd premolar with implants or bridges when the primary molars were lost.
2. Extract the 2nd primary molars and the delayed 2nd premolar, and close the space orthodontically by bringing the permanent molars mesially, hoping the 3rd molars would erupt into what would have been the space of the 2nd molars.

For the second problem, the mandibular incisor crowding, the solution would be orthodontic alignment, but alignment would require space. If the 2nd primary molars were retained, it would be difficult to align the incisors unless the width of the primary teeth was reduced. There would be plenty of space if the 2nd primary molars were removed.

For Anna, the choices involve the family dentist directly. Parents and patients often seek their dentist’s opinion about the choice between alternative treatment approaches. If you were the family dentist, they almost certainly would want to talk to you about a choice like this.

So who makes the decision? Remember, the doctor(s) advise, the patient decides.

Patient/Parent Consultation

At a meeting with the patient and parents, the doctor’s role is to evaluate the alternative treatment possibilities, and present them as clearly and objectively as possible (image 1). The goal is to get both the patient and the parents to understand the alternatives.

When the patient is an adolescent, it is a serious error to discuss treatment only with the parents. It’s the child, after all, who has to cooperate during treatment. She’s more likely to do that if she understands the plan and recognizes that treatment is being done for her, not to her.

The first thing to discuss is the probable fate of the mandibular premolar whose development is so severely delayed (image 2).

What’s the chance that it will develop into a normal tooth and erupt into the space of the primary molar? Not zero, but small. Orthodontics might be required to get it into the arch, some years in the future, if it did continue to develop. If it becomes hopelessly impacted, as it might, it would have to be extracted and replaced.

Image 1, patient-parent conference: The doctor’s role in the patient-parent conference is to evaluate the alternative treatment possibilities and help the patient and parents understand.	Image 2, panoramic radiograph: A severely delayed premolar like the mandibular left one has only a small chance of completing normal formation and erupting into the correct place in the dental arch.

Patient/Parent Conference (cont.)

What if nothing is done now? That amounts to selecting the plan to eventually replace the missing premolars.

What are the advantages of the “wait and eventually replace” plan?

• Perhaps only one side will need an implant or bridge.
• Some of the cost of treatment will be deferred.

What are the disadvantages?

• Orthodontic treatment to prepare for the implant(s) or bridge(s) eventually will be needed, and it will be more difficult for the patient to tolerate as an adult than now.
• If the primary molars are lost before growth is complete, temporary bonded bridges would be needed before implants could be placed—implants should be delayed until vertical growth is completed.
• The prosthetic replacements will require lifetime maintenance.
• Ultimately, costs are likely to be greater.

Patient/Parent Conference (cont.)

What are the advantages of the “extract and close the space now” plan?

• This is the ideal time for comprehensive orthodontics, which should provide excellent occlusion.
• There will be no need for prosthetic replacements requiring long-term maintenance.
• The lower third molars appear to be well formed, and bringing the second molars mesially should provide space for them to erupt.

What are the disadvantages?

• Comprehensive treatment over an 18- to 24-month period would be needed, with retainers afterward until growth was essentially completed.
• The space would have to be closed almost entirely by bringing the lower permanent molars forward, otherwise there is the risk of flattening the profile too much and adversely affecting facial esthetics, so good patient cooperation would be required.

Is orthodontic treatment to correct the mild malocclusion indicated now, even if the plan is to retain the second primary molars? Perhaps, but excellent occlusion will not be possible as long as the wide second primary molars are retained.

What do you think the patient and parents would choose?

Treatment Plan Concept, Details

Anna wanted to go ahead with orthodontic treatment now, and her parents felt that avoiding the long-term maintenance of replacement teeth was a positive factor.

They endorsed the treatment plan concept:

• extraction of primary second molars and delayed right second premolar
• comprehensive orthodontics with space closure
• oral health maintenance within the family practice

The doctors’ treatment plan required more details:

• oral surgery: consultation appointment, then extractions
• complete orthodontic appliance 2-3 weeks later
• space closure with NiTi springs and light Class II elastics to bring second molars mesially
• maxillary and mandibular removable retainers, full-time except eating for first 2-3 months, 12 hours/day another 3 months, just at night until growth completed

Anna: Treatment Outcome

Treatment Progress

As planned, Anna’s orthodontic appliance was placed 3 weeks after the teeth were extracted, the teeth were aligned, and space closure was accomplished with superelastic nickel-titanium springs (image 1). She wore light Class II elastics (lower molar to upper incisors) to further assist in closure of the lower extraction space without creating overjet.

The treatment was completed and the orthodontic appliances removed at age 14-7, with an active treatment time of 22 months.

She matured rapidly during treatment, and facial proportions were maintained reasonably well (images 2, 3). There was no esthetic problem from the extractions.

Forward movement of the lower molars created a Class III molar relationship (image 4), but normal overjet/overbite and good interdigitation and alignment of the teeth (image 5) were maintained.

Image 1, progress: Anna, age 13-1, during space closure.	Image 2, change in smile: Age 12-6 to age 14-7, change in treatment.
Image 3, change in profile: Age 12-6 to age 14-7, change in treatment.	Image 4, post-tx occlusion: Posttreatment occlusion—note the Class III molar relationship.
Image 5, post-tx alignment: Posttreatment alignment, space closure in the lower arch.

Treatment Outcome

The panoramic radiograph shows the extraction space closure, with the lower molars brought mesially (image 1).

Note the tendency of the upper second molars to elongate as their occlusal contact is removed by bringing the lower molars mesially. One of the goals of retention will be to control the vertical position of the upper 2nd molars until the lower 3rd molars erupt into function with them.

The posttreatment cephalometric radiograph (image 2) allows an evaluation of the changes produced by treatment. Note in the cranial base superimposition tracing (image 3) that Anna grew vertically during treatment. Her upper incisors were tipped lingually somewhat, and the lower extraction space was closed almost totally by bring her lower molars mesially.

The maxillary and mandibular superimpositions (image 4) show that the lower molars and upper incisors were slightly elongated, in addition to mild retraction of the upper incisors and considerable mesial movement of the lower molars. Both the retraction of the upper incisors and the changes in vertical tooth positions undoubtedly were created by the Class II elastics used to bring the lower molars forward.

Image 1, post-treatment pan: Panoramic radiograph, age 14-7.	Image 2, post-treatment ceph: Cephalometric radiograph, age 14-7.
Image 3, ceph superimposition, overall: Ceph superimposition on cranial base, 12-6 to 14-7.	Image 4, ceph superimposition, max/mand: Ceph superimposition on maxilla and mandible.

Two-Year Recall

At age 17-2, 2 1/2 years after the completion of treatment, Anna was entering her senior year in high school. Facial esthetics were entirely satisfactory (image 1). The extractions and space closure had no deleterious effects.

Despite the unusual molar relationship, her functional occlusion was good (image 2), and the extraction space remained closed (image 3). As planned, she was still wearing removable retainers at night.

On the panoramic radiograph (image 4), continued development of the mandibular third molars can be seen. There is a good chance that they will erupt in the previous position of the second molars and will function against the upper second molars.

Image 1, face on recall: Anna, age 17-2, 2 1/2-year recall.	Image 2, occlusion on recall: Anna, age 17-2, 2 1/2-year recall.
Image 3, alignment on recall: Anna, age 17-2, 2 1/2-year recall.	Image 4, pan, recall: Anna, age 17-2, 2 1/2-year recall.

Summary, Diagnosis & Treatment Planning

The approach to problem-oriented orthodontic diagnosis and treatment planning is outlined in the attached image. It looks complex, but it is an organized and time-efficient way to meet three important criteria:

• gather the necessary diagnostic information as objectively as possible
• introduce judgment at the appropriate point, as treatment planning begins
• produce the treatment plan with the best chance of maximizing benefit to the patient

Consider it the equivalent of the pilot’s checklist at the end of the runway before beginning take-off. Going through the list of prescribed procedures, no matter how many times you have done it, is the best way to be sure that something important was not overlooked.

Self-Test Referral

The self-test section of this program is designed to help you be sure you have understood the material. Do the reading in Contemporary Orthodontics (5th ed., pages 220-250 and 395-403; 4th ed., pages 234-267). Then take the test, and use it as a guide for further study and review.

Copyright 2013, UNC Dept. of Orthodontics

Self-Test

Question 1

Which of the following must be taken into account in planning orthodontic treatment?

a. Dental alignment

b. Dental occlusion

c. Facial proportions

d. Patient attitude toward dental condition

1. a and b
2. a and c
3. a, b, and c
4. a, b, and d
5. all of the above ✓

Correct

That’s right, all must be evaluated during the diagnostic evaluation that must precede treatment planning. The first step in planning treatment is to place the items on the problem list in priority order. To do that, it is necessary to take the patient’s attitudes into consideration.

Incorrect

That’s wrong. All these factors must be evaluated during the diagnostic evaluation that must precede treatment planning. The first step in planning treatment is to place the items on the problem list in priority order. To do that, it is necessary to take the patient’s attitudes into consideration.

Question 2

(A) Diagnosis is a scientific procedure, while treatment planning cannot be because (B) the goal of treatment planning is truth, not wisdom.

1. A true, B true, A and B related
2. A true, B true, A and B not related
3. A true, B false ✓
4. A false, B true
5. A and B false

Correct

That’s correct, the first statement is true, but the second is false. The goal of treatment planning is wisdom, which requires judgment. Diagnosis is a matter of gathering the facts—its goal is truth, so it is a scientific procedure, but treatment planning cannot be.

Incorrect

No, that’s wrong. The first statement is true, but the second is false. The goal of treatment planning is wisdom, which requires judgment. Diagnosis is a matter of gathering the facts—its goal is truth, so it is a scientific procedure, but treatment planning cannot be.

Question 3

(A) Pathologic problems are separated from developmental problems and given priority for treatment because (B) pathologic problems are inherently different from developmental problems.

1. A true, B true, A and B related
2. A true, B true, A and B not related ✓
3. A true, B false
4. A false, B true
5. A and B false

Correct

That’s right, both statements are true, but they are not related, i.e., the second statement isn’t the reason for separating out pathologic problems. Pathologic problems receive priority for treatment, not because they are inherently different (although that’s true) but because they must be brought under control to protect the patient’s health during treatment of the developmental problems.

Incorrect

That’s wrong. Both statements are true, but they are not related, i.e., the second statement isn’t the reason for separating out pathologic problems. Pathologic problems receive priority for treatment, not because they are inherently different (although that’s true) but because they must be brought under control to protect the patient’s health during treatment of the developmental problems.

Question 4

(A) Prioritizing the orthodontic problem list is a critically important step in treatment planning because (B) the same problem list prioritized differently will produce a different plan.

1. A true, B true, A and B related ✓
2. A true, B true, A and B not related
3. A true, B false
4. A false, B true
5. A and B false

Correct

That’s right, these statements are true and related. If you don’t prioritize the problem list correctly, you won’t end up with the correct treatment plan for that patient. A key to informed consent in planning treatment is to be sure that the patient agrees with the prioritization of the problem list. Informed consent problems are particularly likely to arise when the doctor places the emphasis on a problem that was not a high-priority item to the patient and failed to correct something that was important to the patient.

Incorrect

No, that’s wrong. These statements are true and related. If you don’t prioritize the problem list correctly, you won’t end up with the correct treatment plan for that patient. A key to informed consent in planning treatment is to be sure that the patient agrees with the prioritization of the problem list. Informed consent problems are particularly likely to arise when the doctor places the emphasis on a problem that was not a high-priority item to the patient and failed to correct something that was important to the patient.

Question 5

Which of the following are “practical considerations” to be reviewed as treatment possibilities are evaluated?

a. Compromises related to treatment priorities

b. Interactions among the treatment possibilities

c. Relative cost of treatment possibilities

d. The amount of patient cooperation necessary

1. a and b
2. b and c
3. c and d
4. a, b, and c
5. all of the above ✓

Correct

That’s right, all these are important practical considerations, and all must be reviewed as treatment possibilities are evaluated. Compromises, interactions, and costs always must be considered. Remember that cooperation is part of the “burden of treatment” that is also a cost consideration.

Incorrect

No, that’s wrong. All these are important practical considerations, and all must be reviewed as treatment possibilities are evaluated. Compromises, interactions, and costs always must be considered. Remember that cooperation is part of the “burden of treatment” that is also a cost consideration.

Question 6

Which of the following are not appropriate in the consultation appointment for a 14-year-old?

a. Presentation to the parents only

b. Review of computer-generated image predictions

c. Recommendation of implants as immediate replacements for missing premolars

d. Questions as to what the family want as a result of treatment

1. a and b
2. b and c
3. a and c ✓
4. b and d
5. none of the above

Correct

That’s right, it’s an error to leave a 14-year-old out of the consultation appointment, and implants should not be placed for at least another 4-5 years, so both are inappropriate. It’s highly appropriate to review computer image predictions of alternative treatment approaches if these are available and important to be sure what the patient and parents want as a result of treatment.

Incorrect

No, that’s wrong. It’s an error to leave a 14-year-old out of the consultation appointment, and implants should not be placed for at least another 4-5 years, so both are inappropriate. It’s highly appropriate to review computer image predictions of alternative treatment approaches if these are available and important to be sure what the patient and parents want as a result of treatment.

Question 7

What is the chance that a severely delayed premolar will eventually complete its root formation and erupt normally?

1. 5-10% ✓
2. 20-25%
3. 50%
4. 60-75%
5. Impossible to predict, could be anything

Correct

That’s right. It is possible (but quite unlikely) that a severely delayed premolar will eventually complete normal root formation and erupt into the correct position. It is rarely good treatment planning to wait for years to see what such a tooth will eventually do, because the chance of a good outcome is so low.

Incorrect

No, that’s wrong. It is possible (but quite unlikely) that a severely delayed premolar will eventually complete normal root formation and erupt into the correct position. It is rarely good treatment planning to wait for years to see what such a tooth will eventually do, because the chance of a good outcome is so low.

Question 8

Which of the following are advantages of orthodontic treatment to close the space of a congenitally missing tooth?

a. Short-term prosthodontic cost avoided

b. Long-term prosthodontic cost avoided

c. Better facial esthetics

d. Treatment completed at an earlier age

1. a, b, and c
2. b, c, and d
3. a, b, and d ✓
4. all of the above

Correct

That’s correct. Closing the space avoids both short- and long-term prosthodontic costs, and the treatment is completed at an earlier age because it is not necessary to wait until vertical growth is completed—but space closure must be done very carefully to keep from making facial esthetics worse and is unlikely to make the facial appearance better. Closing spaces bilaterally tends to retract the incisors and decrease lip support. Closing a unilateral space tends to create an asymmetry within the arch and a midline discrepancy. Both can affect facial esthetics unfavorably unless the treatment is done very carefully.

Incorrect

No, that’s wrong. Closing the space avoids both short- and long-term prosthodontic costs, and the treatment is completed at an earlier age because it is not necessary to wait until vertical growth is completed—but space closure must be done very carefully to keep from making facial esthetics worse and is unlikely to make the facial appearance better. Closing spaces bilaterally tends to retract the incisors and decrease lip support. Closing a unilateral space tends to create an asymmetry within the arch and a midline discrepancy. Both can affect facial esthetics unfavorably unless the treatment is done very carefully.

Question 9

When lower molars are moved mesially to close the space of missing second premolars, what is the effect on the maxillary second molars? These teeth

1. must also be moved mesially.
2. tend to extrude. ✓
3. usually end up in lingual crossbite.
4. often end up in a Class II relationship.
5. no effect, they’re in the other dental arch.

Correct

That’s right, when lower molars are moved mesially, the upper second molars can’t go with them (unless a space has been created in the upper arch), and they tend to extrude because they do not have an occlusal antagonist until the mandibular third molars erupt. For this reason, a retainer to control their vertical position is important after the type of space closure used in Anna’s case. What’s wrong with the other answers? Extracting teeth in the upper arch to allow the upper molars to be moved mesially rarely is indicated, the 2nd molars do not move lingually, and the eventual molar relationship is Class III, not Class II.

Incorrect

No, that’s wrong. When lower molars are moved mesially, the upper second molars can’t go with them (unless a space has been created in the upper arch), and they tend to extrude because they do not have an occlusal antagonist until the mandibular third molars erupt. For this reason, a retainer to control their vertical position is important after the type of space closure used in Anna’s case. What’s wrong with the other answers? Extracting teeth in the upper arch to allow the upper molars to be moved mesially rarely is indicated, the 2nd molars do not move lingually, and the eventual molar relationship is Class III, not Class II.

Question 10

Which of the following is not a goal of establishing a problem list with the problems placed in priority order?

1. Improve the chances of obtaining true informed consent
2. Facilitate treatment planning
3. Improve communication with other dentists
4. Increase the chance of insurance coverage for the necessary treatment ✓

Correct

That’s right, insurance companies are unlikely to base a decision as to coverage on whether a systematic approach to diagnosis and treatment planning was used, so that really isn’t a goal—but the other items certainly are.

Incorrect

That’s incorrect. Insurance companies are unlikely to base a decision as to coverage on whether a systematic approach to diagnosis and treatment planning was used, so that really isn’t a goal—but the other items certainly are.

Question 11

Which of the following are important to discuss at the planning conference with the patient and parents?

a. Consequences of no treatment

b. Alternative treatment approaches

c. Cost of alternatives

d. Chance that treatment will fail

1. a and b
2. b and c
3. a, b, and c
4. b, c, and d
5. all of the above ✓

Correct

That’s right, all of these things should be discussed at the planning conference. Doing nothing is always an alternative to treatment, and the patient should be informed as to the consequences of that choice as well as being told about the alternative treatment approaches and their cost-effectiveness.

Incorrect

That’s wrong. All of these things should be discussed at the planning conference. Doing nothing is always an alternative to treatment, and the patient should be informed as to the consequences of that choice as well as being told about the alternative treatment approaches and their cost-effectiveness.

Question 12

For a patient with congenitally missing teeth for whom space is to be closed, which of the following is the greatest advantage of doing it during the late mixed or early permanent dentition, as compared to doing it in the early mixed dentition?

1. Restorations can be placed at the ideal time
2. Jaw growth can be modified best at that time
3. Cooperation with treatment is best then
4. Second molars become available for additional anchorage
5. Growth tends to end as treatment does, making retention easier ✓

Correct

That’s right, if treatment starts in the late mixed or early permanent dentition, it usually ends about the time the adolescent growth spurt ends, and that makes retention easier and more successful. It is difficult to maintain the correction of a malocclusion if orthodontic appliances are removed before most adolescent growth has been completed, even if there was not a major skeletal problem initially.

Incorrect

No, that’s wrong. If treatment starts in the late mixed or early permanent dentition, it usually ends about the time the adolescent growth spurt ends, and that makes retention easier and more successful. It is difficult to maintain the correction of a malocclusion if orthodontic appliances are removed before most adolescent growth has been completed, even if there was not a major skeletal problem initially.

Question 13

Which of the following are different for the treatment plan concept and the treatment plan details?

a. Extent to which it is shared with the patient

b. Specifics of treatment procedures

c. Treatment methods used by various doctors

d. Language used

1. a and b
2. b and c
3. a, b, and c
4. b, c, and d
5. all of the above ✓

Correct

That’s right, all of these are different for the treatment plan concepts and details. The concept is in broad terms that the patient can understand, and its language reflects that. The details specify which doctor is to do what, when, and how, and are accessible in the chart to guide clinical activity.

Incorrect

No, that’s wrong. All of these are different for the treatment plan concepts and details. The concept is in broad terms that the patient can understand, and its language reflects that. The details specify which doctor is to do what, when, and how, and are accessible in the chart to guide clinical activity.