315-fall-1.pdf

Introduction to the Ortho Clinic Dr Julia Cohen-Lévy August 2022 2 HELLO! I am Julia Cohen-Lévy DDS, Msc Anatomy, Msc Medical Law, PhD (Neuroscience), Post-Doc Sleep Medicine Specialist Orthodontist in France Specialist Orthodontist in Canada Fellow of the RCDC Diplomate of the ABO Post Doc & DES...

Introduction to the Ortho Clinic Dr Julia Cohen-Lévy August 2022 2 HELLO! I am Julia Cohen-Lévy DDS, Msc Anatomy, Msc Medical Law, PhD (Neuroscience), Post-Doc Sleep Medicine Specialist Orthodontist in France Specialist Orthodontist in Canada Fellow of the RCDC Diplomate of the ABO Post Doc & DES in Orthodontics Université de Montréal You can find me at: [email protected] Office : 510 Upon request 3 1. ORTHO DENT 315 Overview 6 7 ORTHO DENT315 & 415 ▹ Course Outlines ▹ Descriptions & Detailed Content ▹ Pre-requisite for Courses ▹ Course availability ▹ Method of Evaluation 8 Welcome to you all (DENT315 2023-2024) Curriculum & Evaluations Some rules : ▹ ▹ ▹ ▹ ▹ Courses In Person, Recorded Pre-recorded Technical Notes (Ceph Analysis, Space Analysis, PVS impressions) Open to Questions ! No sharing of this content (Copyright) Maintain patient’s confidentiality at all times 9 Evaluations 10 11 12 Clinical Evaluations Patient’s Best Interest Ethics 13 It is Expected that each pair of students… ▹ Reviews patient’s history (medical, dental, orthodontic diagnosis & treatment) ▹ Is able to give a brief summary to the clinician ▹ Reviews and masters perfectly the theory on impression techniques & materials (alginate, PVS) cementing of bands, bonding of brackets ... before doing it on a patient 2. Objectives 1. Explain the clinic dynamics 2. Little sib-big sib concept 3. Present the different diagnosis procedures 4. Present the different clinical procedures 14 performed in the Clinic 2.1. Clinic Dynamics Patients distribution 15 16 Young patients Complex cases Removable Hawley type Screened patients Removable Essix type Contraindications New patients Active patients Retention patients Clinical Observation Records Case Analysis Interceptive treatment Limited Bracketing Clear Aligner Therapy Fixed, Bonded Retainer 2.2. Big sib-Little sib https://weheartit.com/entry/325848989 3rd & 4th year students work together in the clinic. 4th year student is responsible for the patient already in treatment Explain the rationale and evolution of treatment of active patient 3rd year will get a new patient (4th year is expected to assist) 17 18 First semester • At the beginning, 3d year student assists the 4th year student. • Slowly, the third year will perform more procedures. • Full patient transfer to the 3d year happens in March. • Make it a gradual transition 19 Screening Important Procedure ▹ Be there on time ▹ Rotation basis (See Schedule) ▹ Dr Madelaine Shildkraut 20 Ortho Rotation Schedule (Nila Aranjuez) Screening or … Not screening ▹ Screening students cannot book another patient ▹ When not screening, meet the other clinicians of the clinic 21 B races , Applia nc e s Braces, Applian ces Braces, Applian ces B races , Applia nc e s 22 What is screening ? ▹ A quick assessment of the patient’s malocclusion ▹ Diagnostic clues ▹ Differential diagnosis 23 Screening Procedure ▹ 14 to 18 patients per screening session ▹ A pair of students (3rd and 4th year students) will screen 2 to 3 patients during a session. 24 What is screening ? ▹ Refer or treat (communication with the dentist) ▹ Spend time to explain the orthodontic problem to the patient and/or parent ▹ Patient « compatible » with the clinic 25 26 Chief Complaint (Reason for visit) ▹ ▹ ▹ ▹ ▹ Crowding Overbite Dentist sent me… Don’t have a clue… Second opinion 27 28 34 35 Patient Examination (Medical & Dental History) ▹ Evaluation of the orthodontic condition ▹ Facial & Dental assessments as precise as possible ▹ Write down findings 36 Complete Clinical Examination & Records : Systematic Approach ▹ ▹ ▹ ▹ Extra-oral Intra-Oral Functional (4D) Radiological 37 Case Presentation to the Instructor (Template) Present the case following the order of the screening form Use Orthodontic Nomenclature You will be evaluated using a precise grid 38 Case Presentation: ▹ Third year students are paired with a fourth-year students for case presentations. Students are expected to present a minimum of 2 cases per year. ▹ Third year students will be evaluated on the following: ▹ Data collection, Quality of the presentation, Interpretation of photographs and radiographs (performing a ceph analysis and panoramic film exam), Study models and analysis ▹ 4th year students will be evaluated on the following: ▹ Summary of diagnosis / Problem list / treatment objectives / treatment plans / risks and benefits / consent form. Quality of the presentation (please refer to the dedicated evaluation grid annexed to this document). ▹ There is no remedial case presentation but case presentations may be rescheduled for a valid reason. 39 Re-assessment , Progress Records 40 Instructor’s role 1. 2. 3. 4. Validate observations Correct any mistakes Listen to your proposed treatment plans Final decision regarding the acceptation of the patient in the Clinic Diagnosis Evaluation Grid (3d years) /100 ▹ 5 Chief Complaint ▹ 5 Review of Medical/Dental history ▹ 15 ExtraOral Examination (Face, Profile, Smile Analysis) /25 ▹ 5 Dental Clinical Exam ▹ 5 Periodontal Clinical Exam ▹ 15 Occlusion (AP, T & V) /25 ▹ 5 Functionnal Exam ▹ 5 Qualitative Radiological Exam (Pan Ceph) ▹ 15 measurement interpretation (skelettal AP, V and Dental, 5 each) /25 ▹ 10 quality of casts ▹ 5 cast exam (Intra) archform, , symetry, Spee, (Inter) Occlusion ▹ 10 Space Analysis, Bolton calculation & interpretation /25 Quality of oral presentation/ interaction +/- 10% notion + CC 5 RMH 5 CE Face Profile 10 CE smile 5 CE dental 5 CE perio 5 Occlusion AP 5 Occlusion T 5 Occlusion V 5 E Fonctionnel 5 Pan 3 Ceph qual 2 Ceph interpretation 15 Quality of casts 10 Cast exam 5 Space/ Bolton analyses 5 notion Treatment Plan Evaluation Grid (4th years) /100 ▹ /20 Problem list/ Summary of diagnosis (esth, skel, dent, funct) ▹ /20 Treatment objectives (esth, skel, dent, funct) ▹ Treatment plans /20 ideal /20 alter /10 No teatment For each plan, specify when to start therapeutic means (advantages / disadvantages) + retention Associated and individualized anticipated Risks / Possible referrals to specialists ▹ Consent form and Individualized treatment plan to be filled Quality of oral presentation/ interaction +/- 10% Pb list • est • Sq • Dent • Funct 20 Objectives • est • Sq • Dent • Funct 20 PTT ideal 20 When, How Prognosis Retention Benefit/Risks PTT alt 20 When, How Prognosis Retention Benefit/Risks No treatment 10 Individualized Consent Form 10 43 Then… ▹ a provisional grade will be assigned to you on the same day of the ▹ presentation Send the corrected ppt to Nila and myself on the following week (+ accepted or refused in the clinic) Delay = reduction of grade 10% ▹ If the case is accepted, Send a copy of signed treatment plan –name ▹ ▹ of clinician in charge- and consent form signed by patient/family. Final grades attributed when patient’s file is complete and all documents received by Nila and myself. Usually 2 to 3 case presentations per student a year. 44 45 46 47 49 Clinic & Laboratory procedures • 3d year student assists 4th year student for the first sessions • New patient examination • Get comfortable with orthodontic procedures • Case presentation 50 Active patients New patients (3d & 4th year students) (responsibility of 4th year student – transfer time March) Retention Patients 51 Clinical procedures for your new patient Complete Orthodontic records : • Orthodontic examination • Alginate impressions & Wax bite registration • Photographs • Panoramic radiograph • Cephalometric radiograph 2.3. Review of Diagnosis Procedures 52 53 Review patient’s chart Insure patient is caries free Review of hygiene techniques Are radiographs & photos current ? 54 2.3.1. Orthodontic examination 55 56 57 2.3.2. Alginate impressions Jarkas Manar. Alginate as impression material International Journal of Applied Dental Sciences 2018; 4(3): 300-303 https://www.kulzer.com 58 Example of a good impression 59 60 https://www.amjmed.com/article/S0002-9343(17)304941/fulltext https://evolutionorthodontics.co.uk/envira/mp56610sv-narrow-arch-forms-good/ 61 https://www.excelorthodontics.com/resources/education/impression-examples/ 62 63 Tray interfered with impression Impression collapsed when wrapped in paper towel Tray too small Not enough material to create a nice roll into the vestibule (too sharp) https://www.excelorthodontics.com/resources/education/impression-examples/ 64 Large bubble around distal of molars, Large buble in the anterior vestibule Tray is put too distally Not enough impression material Apply balanced pressure when taking the impression https://www.excelorthodontics.com/resources/education/impression-examples/ 65 5 mm clearance Extend posteriorly (wax, bioplastic material) 66 Protruding Plaster Bubbles 67 Bubbles ● ● ● How to avoid them ? Having the patient rinse with water and mouthwash mixture will eliminate mucin and lower the surface tension, thereby eliminating air bubbles. If repetitive impressions are made with alginate, the film over the teeth is lost and getting a satisfactory impression is prevented. While repeating impressions, the patient must be asked to rinse the mouth to re-hydrate and produce a new film over the teeth for accurate impressions 68 Preparing the mouth before impressions 69 Occlusal surfaces of teeth should be blown off with an air syringe to remove debris and saliva, in order to minimize air-blows. At the same time, the teeth should not be left to dry completely since alginate material sticks to dried teeth hence alginate tears upon removal. The mixed alginate should be rubbed onto the occlusal surfaces with a gloved finger to fill the occlusal grooves, allowing accurate reproduction of the occlusal tooth anatomy. Some alginate must be placed in the palatal vault; so wipe onto occlusal surfaces. 70 Water to Powder Ratio 1/1 ▹ Adult mandibular impression : 2 scoops of powder/ 2 measures of water ▹ Adult maxillary impression : 3 scoops of powder/ 3 measures of water 71 Impression making https://pocketdentistry.com/8-impression-materials/ 72 Removal and Inspection of Impression 73 Treatment, Storage and Disinfection 74 2.3.3. Wax bite Wax bite 75 ▹ ▹ ▹ ▹ ▹ Practice centric relation with the patient Beware of dual bites Cut a piece of red/pink wax to the approwimate size of the patient’s upper arch Use the upper impression as a guide Roll the anterior part over itself (triple thickness of wax in the anterior) 76 Wax bite ▹ ▹ ▹ Try the wax in the mouth You want to barely cover the buccal cusps of the molars and premolars Roll the incisor portion to guide the patient’s condyles in position 77 Wax bite ▹ ▹ ▹ ▹ Warm with hot water Be sue to warm the wax evenly Place the bite on the upper teeth Press gently 78 Wax bite ▹ Guide patient in centric occlusion Have the patient bite down until the wax is almost perforated Wait 3 seconds Remove wax bite Identify and Store immediately ▹ DO NOT FORGET THE WAX BITE ! ▹ ▹ ▹ ▹ 79 Cast fabrication ▹ Impression Pouring ▹ Cast Trimming ▹ Properly Trimmed models are expected and will be marked during case presentations 80 ” 81 ” 82 Model Trimming ▹ Refer to Handout on Model Trimming ▹ Accurate ▹ Symmetrical ▹ Pleasing to the eye… Digital Impressions 83 84 How it works. ▹ A digital impression can be captured by a series of digital photographs ▹ Digital impressions eliminate some of the drawbacks of conventional elastomer impressions; however, proper soft-tissue management, the isolation of teeth and defined margins are still necessary ( i.e. preventing the cheeks and tongue from interfering) ▹ For some patients, the back side of the head (opposite the lens) of the handle can be sufficiently used to retract the cheek and tongue away ▹ One other option is to use lip and cheek retractors to hold the lips and cheeks away from the dentition while scanning 87 Common mistakes with digital impressions ▹ Common Mistake #1: Missing Scan Information ▹ Common Mistake #2: Distortion/missing info Caused by Moisture It is caused by the reaction of the intraoral scanner to anything that reflects back on it, such as saliva. The scanner can’t differentiate between that reflection and the rest of the image it’s capturing. Make sure the lens on the intraoral scanner wand is clean and dry, Suction excess saliva while air-drying the field. ▹ Common Mistake #3: Misalignment in the Buccal Scan Work with the patient to establish an accurate, natural bite before you begin the scan, and only activate the intraoral scanner once the bite is in place and the wand is positioned on the buccal. https://glidewelldental.com/company/blog/3-mistakes-you-dont-want-to-make-with-digital-impressions 88 Tutorial videos from Itero™ ▹ https://youtu.be/GqA6Y_i6Cnw https://youtu.be/a40pLVe3pVY 89 2.3.4. Photographs 90 Photographs ▹ Hygienists take intra & extra oral pictures ▹ Pictures are mandatory to new and finished patients and must be available for consultation ▹ Also necessary for Clear Aligner Patients ▹ A folder will be created for each patient in the clinic ▹ We will upload the photos & dental casts in Mipacs™ 91 92 93 94 Photographs ▹ We also encourage you to take pictures during treatment as they will be needed by you or somebody else presenting the case ▹ Interest in learning how to take pictures ? 96 98 99 2.3.5. Panoramic Radiograph 100 101 102 103 104 Panoramic radiograph ▹ You must take a panoramic radiograph every year for active patients ▹ If a problem (decay, periodontal issue,…) is suspected, add periapical & bitewings 2.3.6 Cephalometric Analysis 105 106 Cephalometric analysis ▹ We use Dolphin imaging system ▹ Instruction presentation to be uploaded ▹ 4th year is expected to assist 3rd year ▹ Make sure the cephalometric landmarks are in the right position (Porion is difficult) 107 2.4. Diagnosis Phase 108 109 Diagnostic phase ▹ Interpret Clinical Examination data ▹ Dental Cast analysis - Space analysis - Moyers analysis - Bolton discrepancy Analyze panoramic X-rays (Pas) Trace & Analyze Cephalometrix X-rays 110 Diagnostic phase Diagnose the malocclusion ▹ Treatment Objectives ▹ Treatment plan(s) ▹ 111 Treatment Objectives ▹ Formulate treatment objectives for your patient ▹ The sequence is important - As an example, it may be better to create space on the arch before starting to align the anterior dentition 112 113 THANKS! Any questions?