DIAGNOSIS IN ORTHODONTICS

Dr Arun K. Thakur
MDS 1st Year
CONTENTS

INTRODUCTION

HISTORY

DEFINITION

CASE HISTORY

CLINICAL EXAMINATIONS

FUNCTIONAL ANALYSIS
EXAMINATION OF OROFACIAL
DYSFUNCTIONS

DIAGNOSTIC RECORDS

ANALYSIS OF DIAGNOSTIC
RECORDS

NORMAL OCCLUSION &IDEAL

OCCLUSION

MALOCCLUSION

REFERENCES
 INTRODUCTION

 The process of identifying a disease and designating it with

accepted medical terminology— that is, making a diagnosis.

 The science of the methods of making a diagnosis is called

diagnostics

 A diagnosis, can be regarded as an attempt at classification

of an individual's condition into separate and distinct
categories that allow medical decisions about treatment
and prognosis to be made. Subsequently, a diagnostic
opinion is often described in terms of a disease or other
condition
 HISTORY

 The history of medical diagnosis began in earnest from the days

of Imhotep in ancient Egypt and Hippocrates in ancient Greece

 An Egyptian medical textbook, the Edwin Smith Papyrus written

by Imhotep (fl. 2630-2611 BC), was the first to apply the
method of diagnosis to the treatment of disease

 A Babylonian medical textbook, the Diagnostic Handbook

written by Esagil-kin-apli (fl. 1069-1046 BC), introduced the use
of empiricism, logic and rationality in the diagnosis of an illness
or disease

 Over two thousand years ago, Hippocrates recorded the

association between disease and heredity
 In the first half of the 19th century, the well-known British
physiologist Marshall Hall wrote On diagnosis (1817) and The
Principles of Diagnosis (1834).

 The ideals of William Osler, who transformed the practice of

medicine in the early 1900s, were based on the principles of
the diagnosis and treatment of disease
 DEFINITIONS

the art or act of identifying a disease from its signs and

symptoms

Investigation or analysis of the cause or nature of a condition,

situation, or problem and getting conclusion from such an
analysis

https://www.merriam-webster.com/dictionary/diagnosis

The recognition and systematic designation of anomalies;

the practical synthesis of the findings, permitting therapy to
be planned and indication to be determined ,there by
enabling the doctor to act
Recognizing Formulating
the problem the problem

Interpretation Necessary
of results examinations

Diagnosis
 SOURCE OF DATA

Three major sources:

(1) interview data from questions (written and oral)

(2) clinical examination

(3) evaluation of diagnostic records, including

Dental casts

Radiographs

Photographs
 CASE HISTORY
Case history is usually assessed with the help of questionnaire

The goals

Chief concern

To obtain further information about three major areas

(1) Medical and dental history

(2) Physical growth status

(3) Motivation, expectations and other social and behavioral

factors
Ouestions related to case history is divided into two parts

FAMILY HISTORY

PATIENT HISTORY
 FAMILY HISTORY

Important to learn about certain malocclusions present in members of

same family

Deep bite in deciduous dentition

 Mandibular prognathism

Class II,div 2 malocclusion

Skeletal malocclusion

Bimaxillary Protrusion
 PATIENT HISTORY
NAME
 Communication
 identification
 Psychological benefits

AGE
 Diagnosis and treatment planning
 Growth modification procedures
 Developmental disorder
 Surgical consideration
SEX
 Timing of growth events

ADDRESS AND OCCUPATION

 Evaluation of socioeconomic status

 Selection of appropriate appliance
 Future correspondence
PATIENT HISTORY

• Nutritional disorders,diseases and accidents

Prenatal to mother during prgnancy

• Time of birth,fetal position at birth,

Natal

• Manner of feeding,nutritional disturbances

• Eruption of teeth,development of bad
POST NATAL habits
 IMPORTANCE OF PRENATAL HISTORY

Ionising radiation -
Microcephaly , Skeletal defects, Mental retardation
Hydrocephaly, Microphthalmia, Optic atrophy and cataracts
Mutations of germ cells

Cigarette smoking
Intrauterine growth retardation ,Perinatal mortality and
morbidity ,Cardiac defects, Chromosomal anomalies
Central nervous system defects

Warfarin
Nasal hypoplasia ,Spontaneous abortion, Distal limb
hypoplasia ,Central nervous system defects and
neurological abnormalities
 Thalidomide
Phocomelia ,and amelia

Phenytoin
Fetal antiepileptic drug syndrome , Distal phalanges hypoplasia
,Spina bifida, Abnormal nasal bridge and ears

Teratogenicity: A mechanism based short review on common teratogenic

agents,Prasad Govindrao Jamkhande et al.Asian Pacific Journal of Tropical Disease · December
2014

Fetal alcohol syndrome [FAS]

Indistinct philtrum, thin upper lip, depressed nasal bridge,short nose,
and flat midface
Cleft lip and Palate
anti-seizure/anticonvulsant drugs, acne drugs containing Accutane,
and methotrexate, a drug commonly used for treating cancer,
arthritis, and psoriasis.
 Rubella is known to cause abnormalities of the eye, internal
ear, heart, and sometimes the teeth

 A lack of folic acid, a B vitamin, in the diet of a mother can

cause cellular neural tube deformities that result in spina
bifida

 Folic acid, or vitamin B9, aids the development of the foetal

nervous system
 NATAL HISTORY

 A sudden traumatic insult due to the use of forceps at birth could

have long-term effects which could detrimentally influence
growth and development.

 Results showed no statistically significant difference between

delivery method and TMJ problems, posterior crossbites,
bruxism, or molar arch width.
 However the forceps-delivered group had a higher percentage of
bruxism and TM] pain and noise.

The effects of forceps delivery on facial growth ,Nicholas Germane,PEDIATRIC DENTISTRY

1989,The American Academy of Pediatric Dentistry,Volume 11, Number 3
Molar incisor hypomineralisation
It was observed that the patients undergoing low
birthweight, preterm delivery, high fever, and
asthma/bronchitis were more severely affected by MIH.
Prevalence, aetiology, and treatment of molar incisor hypomineralization in
children
Kılınç,nt J Paediatr Dent. 2019 Nov;29(6):775-782. doi: 10.1111/ipd.12508.
Epub 2019 May 29
POST NATAL HISTORY

 Breast feeding is important for overall growth of neonates

 History of any habits are properly recorded

 Any history of trauma especially in cervicofacial region is

properly recorded
 Interpretation of case history

 Clues regarding the cause of the malocclusion

 Help in planning the necessary therapy

 The course of orthodontic therapy and stability of treatment

results may be affected if causative factors of the malocclusion
have not been recognised
Clinical Evaluation
 Evaluate and document dental status,oral health, jaw function,
facial proportions, and smile characteristics and

 Decide which diagnostic records are required.

 Determination of Dental Age

 Evaluation of the dental status is of great importance for the

prognostic assessment of dental development

 In normal patient chronological age and dental age are

synchronous

 A child is labeled as an early or late developer if there is

difference of ±2 years from the average value
CHROLOGY OF PRIMARY TEETH
 Acceleration in dental development and eruption timing

TRUE

Endocrine disturbance
Diabetes mellitus

FALSE
Early loss of deciduous teeth
Inflammatory processes of alveolar bone
 Retardation in dental development and eruption timing

TRUE

Severe organic disease

Prolonged periods of deficiency
Endocrine disturbances
Bone disease
Environmental influence

FALSE
Post traumatic situation
Alveolar bone hyperplasia
Fibrous gingival hyperplasia
 Dental age estimation in children and adolescents is based on
the time of emergence of the tooth in the oral cavity and the tooth
calcification

 Schour and Masseler method

 Moorees, Fanning and Hunt method

 Nolla Method

 Age estimation using open apices (Cameriere method)

 Demirjian Method

 Willem Method
Schour and Masseler method (1941)
Schour and Masseler studied the development of deciduous and
permanent teeth, describing 21 chronological steps from 4
months to 21 years of age and published the numerical
development charts for them. These charts do not have
separate surveys for males and females

Moorees, Fanning and Hunt method (1963)

In this method, the dental development was studied in the 14
stages of mineralization for developing single and multirooted.
Permanent teeth and the mean age for the corresponding stage
was determined
Cameriere method
 Dental age is assessed with the help of of open apices in teeth

 The seven left permanent mandibular teeth were valued

 The number of teeth with root development completed with apical ends
completely closed was calculated (N0)

 For the teeth with incomplete root development, that is, with open apices,
the distance between inner sides of the open apex was measured (A)

 For the teeth with two roots, the sum of the distances between inner sides of
two open apices was evaluated

 To nullify the magnification, the measurement of open apex or apices (if

multirooted) was divided by the tooth length (L) for each tooth
The dental maturity was calculated as the sum of
normalized open apices (s) and the numbers of teeth with
root development complete (N0)

The values are substituted in the following regression formula

for age estimation

Age = 8.971 + 0.375 g + 1.631 × 5 + 0.674 N0 – 1.034 s –

0.176 s

Nowhere g is a variable equal to 1 for boys and 0 for girls

Stages established by Nolla.
The advantages of NOLLA method are that it can be applied to
an individual with or without the third molar and that girls and
boys are dealt with separately.
DEMIRJIAN A NEW SYSTEM OF DENTAL AGE ASSESSMENT
 Demirjian’s method is the most widely accepted
and utilized method of dental age estimations

 This method has reported overestimation of age

in some native population samples
 OTHER METHODS TO STUDY DENTAL AGE

Willems method:
 Revised version of Demirjian method, based on modified
dental maturity scores to estimate age of children in years for
both sexes

 Willems method of dental age estimation gives comparatively

lesser overestimations of age than other methods reported in
the available literature and is thus, accurate and reliable enough
to be utilized for forensic purpose
Sehrawat JS, Singh M, Willems method of dental age estimation in children:
A systematic review and meta-analysis, Journal of Forensic and Legal Medicine (2017),
doi: 10.1016/ j.jflm.2017.08.017.
 DETERMINATION OF BIOLOGICAL AGE

Chronological age is not sufficient for assessing the

developmental stage so biological age has to be determined

 Skeletal age

Dental age

Onset of puberty
ASSESSMENT OF SKELETAL AGE

Made with Hand wrist

radiograph

The cervical vertebral

maturation (CVM)

Medial clavicle epiphyseal

fusion
Assessment of Skeletal Age Using Hand-Wrist Radiographs
Bjork System (1967)

Width of epiphysis as wide as diaphysis located :

 Proximal phalanx of the second finger (PP2)

 Middle phalanx of the third finger (MP3)

Ossification of adductor sesamoid located at the thumb

Capping of epiphysis located at middle phalanx of the third
finger (MP3 Cap)
Fusion of epiphysis and diaphysis located at

 Distal phalanx third finger fusion (DP3F)

 Proximal phalanx third finger fusion (PP3F)

 Middle phalanx of third finger fusion (MP3F)

 Radius (R),
Epiphysis equal to diaphysis Indicates the onset of
prepubertal growth velocity

Appearance of adductor sesmoid of thumb indicates very

rapid growth velocity

Capping of epiphysis over diaphysis indicates peak height

velocity

Fusion of epiphysis over diaphysis indicates decelerating

growth rate and growth potential
Evaluation of hand radiographs is indicated in the following cases

Prior to rapid maxillary expansion

When maxillomandibular changes are indicated in the treatment

of class III cases,skeletal class II cses or skeleal open bites

In patients with marked discrepancy between dental and

chronological age

Orthodontic patients requiring orthognathic surgery if undertaken

between the ages of 16 and 20 years
 Relationship of Hand wrist and panoramic radiographs

 The purpose of this study was to investigate the relationship

between the stage of calcification of various teeth and skeletal
maturity stage among Indians individuals

 The study subjects consisted of 23 male subjects and 22 female

subjects ranging inage from 8 to 20 years

 A total of 85 hand-wrist, panaromic radiographs were obtained

and analyzed

 Skeletal age and skeletalmaturity stages were determined form

hand-wrist radiographs by using the method outlined in the atlas
of Fishman's system.
.
  The tooth development of mandibular canines, first and second
premolars and second molars were assessed according to
theDemirjian system

 The second molar was the tooth showing the highest correlation

 This suggested that tooth calcification stages from panaromic

radiographs might be clinical useful as a maturity indicator after
pubertal growth period

B Rai, S Anand. Relationship of Hand wrist and panoramic radiographs. The Internet
Journal of Forensic Science. 2007Volume 3 Number 1
 The cervical vertebral maturation method

Ref:The cervical vertebral maturation method:A user’s guideJames A. McNamara,Angle

Orthod.2018;88:133–143.

 The cervical vertebral maturation (CVM) method is used to

determine the craniofacial skeletal maturational stage of an
individual at a specific time point during the growth process

 This diagnostic approach uses data derived from the second (C2),
third (C3), and fourth (C4) cervical vertebrae, as visualized in a
two-dimensional lateral cephalogram

 Six maturational stages of those three cervical vertebrae can be

determined, based on the morphology of their bodies.
 Cervical Stage 1
 The first step is to evaluate the inferior border
of these vertebral bodies, determining whether
they are flat or concave
(ie, presence of a visible notch).

 Inferior borders ofC2, C3, and C4 -Flat

 Morphology of C3 and C4 - Traphezoidal
Clinical implication-

CS 1 has strong clinical implications

research has shown that the ideal time to intervene with facial
mask therapy combined with rapidmaxillary expansion (RME)
is at CS 1

Franchi L, Baccetti T, McNamara JA Jr. Post-pubertalassessment of treatment timing

for maxillary expansionand protraction therapy followed by fixed appliances.Am
JOrthod Dentofacial Orthop. 2004;126:555–568
 CERVICAL STAGE 2
 Characterized by a visible notch along the
inferior border of the second cervical
vertebra (odon-toid process)

 The lower borders of the third and fourth

vertebral bodies remain flat

 Both C3 and C4 retain a trapezoidal shape

(wedge of cheese)

 CLINICAL IMPLICATION
CS 2can be considered the ‘‘get-ready’’ stage
because the peak interval of mandibular
growth should begin within a year after this
stage is evident
 Cervical Stage 3
 CS 3 is characterized by visible notching of the inferior
borders of C2 and C3; the inferior border of C4 remains flat

 Morphology of C3 - Traphezoidal C4 -Rectangular Horizontal

 Clinical implication-Circumpubertal (At this stage,maximum

craniofacial growth velocity is anticipated.
 Cervical Stage 4
 All three bodies have
obvious concavities along
their inferior surfaces

 so the more
importantfactor now is
the shape of C3 and C4

 At CS4, both vertebral

bodies have a rectangular
horizontal rather than a
trapezoidal shape

 Clinical implication-
Circumpubertal
 Cervical Stage 5

 CS 5 can be differentiated from CS 4 on

the basis of the shapes of C3 and C4,
with these bodies becoming square

 At least one of the bodies of C3 and C4

is square If not square, the body of the
other cervical vertebra is rectangular
horizontal

 All three cervical bodies have notches, so

the presence of notching no longer is
important in the differential diagnosis

-Postpubertal
 Cervical Stage 6

 Most difficult stage to determine is CS 6,requiring measurement

of the length of the posterior and inferior borders of C3and C4

 At least one of the third and fourth cervical bodies has assumed
a rectangular vertical morphology with the length of the
posterior border being longer than the inferior border
 Clinical Implications - Postpubertal stage

 At this stage, a patient can be evaluated for corrective jaw

surgery or the placement of endosseous implants in the
esthetic region
Is the cervical vertebral maturation (CVM) method effective enough
to replace the hand-wrist maturation (HWM) method in
determining skeletal maturation?

 The CVM method shows a high level of correlation with the

HWM method.
 The assessment of the skeletal age with the CVM is done on a
cephalometric radiograph, routinely used in orthodontic
practice, which makes it easy to apply
 The determination of features of only C2, C3 and C4 vertebrae is
possible even if the patient wears an X-ray protective thyroid
collar. Therefore, the radiation dose is minimize

-A systematic reviewAgnieszka Szemraj⁎, Anna Wojtaszek-Słomińska, Bogna

Racka-Pilszak,Eur J Radiol. 2018 May;102:125-128
SPECIAL CLINICAL EXMINATION

CEPHALIC EXMINATION

FACIAL EXAMINATION

SOFT TISSUE EXMINATION

Clinical examination of the dentition

 CEPHALIC EXMINATION

The cephalic index or cranial index is the ratio of the maximum

width (bi parietal diameter or BPD, side to side) of the head
multiplied by 100 divided by its maximum length (occipito frontal
diameter or OFD, front to back)
Martin and Saller (1957)

Williams et al (1995)
 FACIAL EXAMINATION

FACIAL INDEX = FACIAL LENGTH ×100

FACIAL WIDTH

Nasion: The intersection of the

nasofrontal suture with the midsagittal
plane. Nasion is the uppermost landmark
for the measure of facial height

Gnathion: The most anterior and lowest

median point on the border of mandible

Bizygomatic breadth: Farthest points on

zygomatic arches.
 SIGNIFICANCE OF CEPHALIC AND FACIAL INDEX IN
ORTHODONTICS

 Some studies conducted by Enlow et al are based on the

premise that face morphology can be de-termined by the
cranial base, which acts as a mold or “template.

 According to these studies, individuals with a dolichocephalic

head shape have a brain that is long in the anteroposterior
direction and narrow in the trans-verse direction, which
results in a longer, flatter skull base, i.e., the angle
formed by the floor of the skull is wider. As a result, the
entire nasomaxillary complex assumes a lower, more
protrusive position, inducing an inferior and posterior
rotation of the mandible.
  Thus, a dolichocephalic head would favor the development
of a predominantly long morphology of the face, with a
tendency toward a retrognathic mandible and a Class II
molar relationship compatible with a leptoprosopic fa-
cial type.

 The same reasoning may be applied to patients with a

brachycephalic head shape. Their brains would be wider
and more rounded, with a shorter, more angular cranial
base, causing a relative retrusion of the naso-maxillary
complex and anterior rotation of the mandi-ble. Therefore,
these individuals would exhibit features that are closer to a
euryprosopic facial pattern

Franco FCM, Araujo TM, Vogel CJ, Quintão CCA. Brachycephalic, dolichocephalic
and mesocephalic: Is it appropriate to describe the face using skull patterns? Dental
Press J Orthod. 2013 May-June;18(3):159-63.
 Bhat and Enlow investigated the relationship between
facial types and head shape in in-dividuals with Class I and
Class II malocclusions that had not been treated
orthodontically.

 They noted that the lep-toprosopic facial type and a

tendency toward developing a Class II are characteristic of
mesocephalic and dolichoce-phalic skulls; whereas the
tendency to develop a protruded mandible is related to
brachycephalic skulls.


As a general rule ,in borderline crowding cases of a broad
facial type, an expansion treatment should be carried out

Extraction therapy should be considered with long face

types
 Examination of soft tissues

EXTRAORAL
Forehead
Nose
Lips
Chin

INTRAORAL
Lip and cheek frenal attachments
Gingiva
Palatal and oral mucosa
FOREHEAD
 LATERAL FOREHEAD CONTOUR

In cases of steep forehead the dental bases are

more prognathic than in cases with flat forehead
 NOSE

Size, shape and position of nose determine the esthetic

appearance of the face

The shape of the nose is not only determined by hereditary

or ethnic factors but may be the result of trauma in childhood

Assessment of size,shape and width of nostrils as well as

nasal septum is also important

Width of nostrils is approximately 70% of the length of the

nose

It should be stressed that nasal profile is not improved by

orthodontic procedures,rhinoplasty may be necessary later on
 SIZE OF NOSE
Left- normal,normal vertical to horizontal
length of the nose is 2:1
Middle-Microrhinic type with high root
of nose,short nasal bridge
Right-large nasal profile with long nasal
bridge and protruding tip

NASAL CONTOUR
Left Straight nose
Convex nasal bridge
Right Crooked nose from previous
trauma

Nostrils
Left The nostrils are usually oval and
symmetrical
Middle-slight nasal anomaly
right- Disturbed nasal breathing due to
stenosis of right nostril combined with
septal deviation
 LIPS

Lip length ,width and

curvature should be
assessed

In a balanced
situation length of
upper lip measures
one third to the lower
facial height whereas
lower lip and chin
measures two third
 Nasolabial angle

Angle formed by the labial

surface of the upper lip at the
midline and the inferior border of
the nose

 It is a measure of the relative

protrusion of the upper lip

Enlarged nasolabial angle is a

sign of the retrusive position of
upper lip to the nose
 LIP STEP ACCORDING TO KORKHAUS

Marked negative lip

Positive lip step Slight negative lip step
step
 CHIN

Configuration of the soft tissue chin is not only

determined by the bone structure but also by the thickness
and tone of mentalis muscle

PROTRUDING NORMAL Negative

CHIN CHIN chin
Apart from chin width ,chin
height (distance from the
mentolabial sulcus to menton) is
also important

Overdevelopment of the chin

height alters the position of the
lower lip and interfere with the lip
closure
Facial and Dental Appearance
Systematic Examination of Facial and Dental Appearance
1.Facial proportions in all three planes of space (macro-esthetics)

Asymmetry, excessive or deficient face height,

mandibular or maxillary deficiency or excess

2.The dentition in relation to the face (mini-esthetics). This

includes the display of the teeth at rest, during speech, and on
smiling.

3.The teeth in relation to one another (micro-esthetics). This

includes assessment of tooth proportions in height and width,
gingival shape and contour, connectors and embrasures, black
triangular holes, and tooth shade
 Frontal Examination.
In the frontal view, one looks for bilateral symmetry in the
fifths of the face and for proportionality of the widths of the
eyes, nose, and mouth

 An ideally proportional face can be divided into

central, medial, and lateral equal fifths

 The separation of the eyes and the width of the

eyes, which should be equal, determine the
central and medial fifths.

 The nose and chin should be centered within

the central fifth, with the width of the nose the
same as or slightly wider than the central fifth.
 The interpupillary distance (dashed line) should
equal the width of the mouth.
A small degree of bilateral facial asymmetry exists in essentially
all normal individuals. This can be appreciated most readily by
comparing the real full-face photograph with composites
consisting of two right or two left sides

Composite of right side True Photograph Composite of Left side

Data from Farkas LG. Anthropometry of the Head and Face in Medicine. New York:
Elsevier Science; 1991.
Bow calipers Straight calipers
Profile Analysis

Establishing whether the jaws are proportionately

positioned in the anteroposterior (AP) plane of space

Evaluation of lip posture and incisor

prominence

Reevaluation of vertical facial proportions and

evaluation of mandibular plane angle
Establishing whether the jaws are proportionately
positioned in the anteroposterior (AP) plane of
space
This step requires placing the patient in the physiologic natural
head position (NHP)

Convex Straight Concave

Evaluation of lip posture and incisor prominence

 Excessive protrusion of the incisors is revealed by prominent

lips that are separated when they are relaxed, so that the patient
must strain to bring the lips together over the protruding teeth
For such a patient, retracting the teeth tends to improve both lip
function and facial esthetics

 If the lips are prominent but close over the teeth without
strain, the lip posture is largely independent of tooth position.
For that individual, retracting the incisor teeth would have little
effect on lip function or prominence.
 Lip posture and incisor
prominence should be evaluated
by viewing the profile with the
patient’s lips relaxed.

 This is done by relating the upper

lip to a true vertical line passing
soft tissue point A and by relating
the lower lip to a similar true
vertical line through the soft
tissue point B

 If the lip is significantly forward of

this line, it can be judged to be
prominent; if the lip falls behind
the line, it is retrusive.
In evaluating lip protrusion, it is important to keep in mind
that everything is relative

 lip relationships with the nose and chin affect the perception
of lip fullness.

The larger the nose, the more prominent the chin must be to
balance it, and the greater the amount of lip prominence that
will be esthetically acceptable.
 Reevaluation of vertical facial proportions and
evaluation of mandibular plane angle
The mandibular plane is visualized
readily by placing a finger or mirror
handle along the lower border

 A steep mandibular plane angle

usually accompanies long anterior
facial vertical dimensions and a
skeletal open bite tendency

 A flat mandibular plane angle

often correlates with short anterior
facial height and deep bite
malocclusion.
EVALUATION OF THROAT FORM
Throat form is evaluated in terms of the contour of the
submental tissues

 Straight is better, chin–throat angle (closer to 90 degrees

is better),

 Throat length (longer is better, up to a point).

Both submental fat deposition and a low tongue posture

contribute to a stepped throat contour, which becomes a
“double chin” when extreme
For this boy who has a mild mandibular deficiency, throat
contour and the chin–throat angle are good, but throat length is short, as usually is
the case when the
mandible is short. (B) For this girl with more chin projection, throat contour is
affected by submental fat,
and the chin–throat angle is somewhat obtuse, but throat length is good.
Mini-Esthetics: Tooth–Lip Relationships and Smile Analysis

Examination of symmetry

Important to note the relationship of the dental midline of each

arch to the skeletal midline of that jaw

Incisor display

Important to note the vertical relationship of the teeth to

the lips at rest and on smile
An important relationship to note is whether an up–down
transverse rotation of the dentition is revealed when the patient
smiles or the lips are separated at rest

A cant to the occlusal plane can be seen in both frontal and

oblique views
The usual cause of excessive display of
maxillary gingiva is a long face due to
excessive downward growth of the
maxilla, which moves the maxilla down
below the upper lip and results in a
disproportionately long lower third of
the face
Gingival display due to a combination
of incomplete eruption and a short
upper lip
Lip height increases and the facial soft tissues move downward
relative to the teeth with increasing age

Whatever the cause of excessive display, this tends to

decrease with advancing age, so what looks like a problem
at a younger age may not be as the patient gets older
 Evaluation of smile
Posed or social smile
Reasonably reproducible and is the one that is presented to the
world routinely

Enjoyment smile (also called the Duchenne smile in the

research literature)
The enjoyment smile varies with the emotion being displayed

The social smile is the focus of orthodontic diagnosis

Amount of incisor and gingival display

Overlap by the lip of Display of all the maxillary

the cervical margin incisors and some gingiva on
of the tooth by 1 to 2 smiling is a youthful and
mm is ideal appealing characteristic.
No gingival display is Tooth coverage by the
less attractive, lip of 4 mm is
although it is not considered to be the
considered maximum acceptable
objectionable at this amount
level by lay persons.
Transverse dimensions of the smile relative to the upper
arch

Buccal corridor that is displayed on smile—that is, the

distance between the maxillary posterior teeth (especially the
premolars) and the inside of the cheek

 Minimal buccal corridors are favored by most observers

especially in females, the transverse width of
the dental arches can and should be related to
the width of the face
A broad smile is
appropriate for a face Narrower smile is
with relatively large preferred when the
width across the face width is narrow.
zygomatic arches
It must be remembered that buccal corridor evaluation is
subjective and that during clinical studies it has been shown to be
unreliable.
The smile arc
The smile arc is defined as the contour of the incisal edges of
the maxillary anterior teeth relative to the curvature of the lower
lip during a social smile

For best appearance, the contour of the incisal edges of these

teeth should parallel the curvature of the lower lip. If the lip and
dental contours match, they are said to be consonant.

A flattened (nonconsonant) smile arc can pose either or both of

two problems: It is less attractive, and it tends to make you look
older
The data indicate that the most important factor in smile
esthetics, the only one that by itself can change the rating of a
smile from acceptable to unesthetic, is the smile arc
Rosenstiel S, et al. Attractiveness of variations in the smile arc and buccal corridor
space as judged by orthodontists and laymen. Angle Orthod. 2006;76:612–618.

Another feature that draws negative attention to the smile is

excessive inclination of the upper teeth as they tip toward the
left or right

These maxillary central incisors are tipped

mesiodistally. If it exceeds a 2-mm
deviation from where you would expect
the normal then it would appear
objectionable to lay person
Ker AJ, Chan R, Fields HW, et al. J Am Dent Assoc. 2008;139:1318–1327, 2008; and
Springer NC, Chang C, Fields HW, et al. Am J Orthod Dentofac Orthop. 2011;140:e171–
e180
Micro-Esthetics
Tooth Proportions

Two aspects of proportional relationships are important

components of their appearance: the tooth widths in relation
to one another and the height–width proportions of the
individual teeth.
Golden Proportion

The apparent widths of the maxillary anterior teeth on

smile, and their actual mesiodistal width, differ because of
the curvature of the dental arch such that not all of the
lateral incisors and only a portion of the canine crowns can
be seen in a frontal view.

For best appearance, the apparent width of the lateral

incisor (as one would perceive it from a direct frontal
examination) should be 62% of the width of the central
incisor, the apparent width of the canine should be 62% of
that of the lateral incisor, and the apparent width of the
first premolar should be 62% of that of the canine
Ideal tooth width proportions when viewed from the front are one of many
illustrations of the “golden proportion”—1.0 : 0.62 : 0.38 : 0.24, and so on
Height–width proportions of the individual teeth.

width of the tooth

should be about 80% of
its height
Connectors and Embrasures.

The connector includes both the contact point and the

areas above and below that are so close together they
look as if they are touching.

The contact points of

the maxillary teeth
move progressively
gingivally from the
central incisors to
the premolars, so
there is a
progressively larger
incisal embrasure
Embrasures: Black Triangles
 Gingival Heights, Shape, and Contour

For ideal appearance, the contour of the gingiva over the maxillary central incisors and
canines is a horizontal half-ellipse—that is, flattened horizontally, with the zenith the
height of contour distal to the midline of the tooth. The maxillary lateral incisor, in
contrast, has a gingival contour of a half-circle, with the zenith at the midline of the
tooth. The canine gingival contour is a vertical half-ellipse, with the zenith just distal to
the midline.
Proportional gingival heights are needed to produce a normal
and attractive dental appearance

 In general, the central incisor has the highest gingival level,

the lateral incisor is approximately 1.5 mm lower, and the canine
gingival margin again is at the level of the central incisor

Maintaining these gingival relationships becomes particularly

important when canines are used to replace missing lateral
incisors or when other tooth substitutions are planned

Both laypersons and dentists readily recognize differences of

more than 2 mm.
The patient’s oral hygiene status should be recorded and
documented by clinical photographs

The general guideline is that before orthodontic treatment

begins, any disease or pathologic condition must be under
control
Bleeding on probing indicates inflammation that may extend
into the periodontal ligament, and this must be brought under
control before orthodontic treatment is undertaken.

Inadequate attached gingiva around crowded incisors may

lead to stripping of the gingiva away from the teeth when the
teeth are aligned, especially if the dental arch is expanded
 TONGUE

Shape,color and configuration are assessed at the first clinical

examination

A rough assessment of size in relation to the size of oral cavity

can be made by lateral cephalogram

Functional investigation is most important aspect of clinical

examination
 LIP AND CHEEK FRENA

Examination of maxillary
labial frenum in mixed
dentition is important

Mandibular labial frenum is

less often associated with mid
line diastema however it has
frequently broad insertion
which can result in gingival
recession
 FUNCTIONAL ANALYSIS

Determination of Postural Rest Position

Registration of the Rest Position

EVALUATION OF THE RELATIONSHIP BETWEEN REST POSITION AND

HABITUAL OCCLUSION
 Determination of Postural Rest Position

Postural rest position is the position of the mandible at which the

muscles that close the jaws and those that open them are, in a state
of minimal contraction, so as to maintain the posture of the
mandible. At the postural rest position, a space exists between the
upper and lower jaws

Patient’s orofacial musculature must be relaxed

Rest position should be determined with the patient completely

relaxed,sitting upright and looking straight ahead

When the mandible is in the postural rest position it is usually 2 -3

mm below and behind the centric occlusion (recorded in canine
area)
 Phonetic
method

Postural Non
Command
method Rest command
Position method

Combined
method
 Components Affecting Rest Position

Short term influences

Inconsistency in muscle Long term influences
tonicity Attrition of dentition
Respiration Premature loss of teeth
Body posture Disease of the
Stress situations neuromuscular system
Dysfunction of TMJ
 Registration of the Rest Position

Extraoral indirect
Intraoral Direct Method methods

Roentgenocephalometric Kinesiographic
registration registration
 Roentgenocephalometric registration

Two cephalograms are required either in lateral or

frontal projection

One in centric(habitual) and one with mandible in rest

position

Rest position and freeway space can be determined

by comparing the radiographs
 Kinesiographic registration

Given by Jankelson in 1984

Mandibular rest position is recorded three-

dimensionally

The position of mandible is recorded electronically by

A permanent magnet which is fixed with rapid setting

acrylic to the lower anterior teeth and a sensor system of
six magnetometers mounted on spectacle frames
EVALUATION OF THE RELATIONSHIP BETWEEN REST POSITION AND HABITUAL OCCLUSION

Closing movements of mandible can be divided into two phases

-
Mandibular path from the postural rest to the initial or
premature contact position

- Mandibular path from the initial contact position to centric or

habitual occlusion.

In case of functional equillibrium the articular phase does not

occur(movement without tooth contact)
Movements of mandible from the rest position to habitual
occlusion can be differentiated into

 Pure rotational movements(hinge movements)

 Rotational movement with an anterior sliding component

 Rotational movement with a posterior sliding component

 Evaluation in sagittal plane
CLASS II MALOCCLUSION

Without sliding action(Functional true class II malocclusion)

 Neurumuscular and morphological relationships correspond

to each other
 There is no functional disturbances

 The mandible slides backwards and is guided into a

posterior occlusal position
 This reveals a functional class II malocclusion and not a true
class II malocclusion
 Movement with anterior sliding action

 Starting from the relatively posterior rest position ,the

mandible slides forward into habitual occlusion

 Class II malocclusion is more pronounced than can be

seen in habitual occlusion
 CLASS III MALOCCLUSION

Without sliding action(Functional true class III malocclusion)

 Neurumuscular and morphological relationships correspond

to each other
 There is no functional disturbances

 During articular phase the mandible shifts forwards into a

prognathic,forced bite
 Movement with posterior sliding action

In cases with pronounced mandibular prognathism,the

mandible may slide posteriorly into the position of
maximum intercuspation.This makes the true sagittal
dysplasia
 TRUE FORCED BITE AND PSEUDO-FORCED BITE

Pseudoforced bite includes those true skeletal class III

malocclusions where due to partial dentoalveolar compensation
in the anterior region ,the mandible occludes at the end of the
closing path by means of anterior sliding action

Unfavourable prognosis
Evaluation of the relationship between rest position and habitual
occlusion in the vertical plane

 According to Hotz and Muhlemann there is a need of differentiation

between True deep overbite and pseudo-deep-overbite
Prognosis of true deep bite
with functional methods is
favourable whereas
prognosis of treatment of
pseudooverbite with
functional method is
unfavourable
Evaluation of the relationship between rest position and habitual
occlusion in the transverse plane
EXAMINATION OF TEMPOROMANDIBULAR JOINT

AUSCULTATION
• Crepitus
• Clicking

Palpation
• TMJ and musculature
• note any palpatory pain

Functional analysis
• Mandibular excursions,occlusion,rest position,premature contacts
are checked
• Dislocation ,hypermobility,limitation,deviation, may present
PALPATION OF TEMPORALIS MUSCLE
 Examination of orofacial dysfunctiom

SWALLOWING

TONGUE

SPEECH

LIPS

RESPIRATION
 SWALLOWING

takes place without contracting the muscles of facial

expression.Teeth are momentarily contact and tongue remains
inside the mouth

caused by either tongue thrust simply or as tongue thrust

syndrome
 Visceral swallow

 Toungue between the teeth

 Also known as infantile swallow

 Tongue is pushed forward and placed between the gum

pads

 Tip of the tongue protrudes

 Mandible is stabilised by contraction of tongue and the

orofacial musculature
 Somatic swallow

 As deciduous dentition is completed the visceral

swallowing is gradually replaced by somatic swallowing

 As swallowing is triggered off by contraction of the

mandibular elevators(masseter)

 The teeth occludes momentarily during the swallowing

act and the tip of tongue is enclosed in the oral cavity
 Tongue thrust
is the common name of an oral myofunctional disorder, a
dysfunctional muscle pattern in which the tongue
protrudes anteriorly or laterally during swallowing, during
speech, and while the tongue is at rest
 Tongue thrusting can adversely affect the teeth and mouth

 A person swallows from 1,200 to 2,000 times every 24 hours with

about four pounds (1.8 kg) of pressure each time.

 If a person suffers from tongue thrusting, this continuous pressure

tends to force the teeth out of alignment.

 People who exhibit a tongue thrust often present with open bite
 Speech may be affected by a tongue thrust swallowing pattern

 Sounds such as /s/, /z/, /t/, /d/, /n/, and /l/ are produced by
placing the tongue on the upper alveolar ridge, and therefore a
tongue thrust may distort these sounds

 Chewing and swallowing with dysfunctional muscle patterning (as

in a tongue thrust) is not as effective
SIMPLE TONGUE THRUST Lateral Tongue Thrust
EVALUATION OF SPEECH
 LIP DYSFUNCTION

Lips which are in slight contact when musculature is relaxed

 Anatomically short lips which do not touch when the musculature

is relaxed

 Lip seal is only achieved by active contraction of the orbicularis

oris and the mentalis muscles
POTENTIALLY INCOMPETENT LIPS

The protruding upper incisors prevent the lip closure.Otherwise lip

are developed normally

EVERTED LIPS
Hypertrophied lips with redundant tissue but weak muscular tonicity
 LIP HABITS

LIP -SUCKING
Lower lip is positioned behind the upper incisors
in many patients it occurs with the hyperactivity of mentalis muscle

L
 HYPERACTIVITY OF MENTALIS MUSCLES

 Deep mentolabial
sulcus
 Impedes forward
development of the
anterior alveolar
process in the
mandible
 Often occurs with
Cases which occur in the same
lip thrust or lip
family are usually hereditary
sucking
 MOUTH BREATHING

Impeded nasal
breathing results in
ADENOID FACIES
High palate
Narrowning of upper
arch
poor oral hygiene and
hyperplasia of gingiva
The possibility of sleep apnea related to mandibular deficiency

 Obstructive sleep apnea (OSA) is the most common type of

sleep apnea and is characterised by repeated episodes of
complete or partial obstructions of the upper airway
during sleep, despite the effort to breathe, and is usually
associated with a reduction in blood oxygen saturation.

 Each pause can last for a few seconds to a few minutes

and they happen many times a night

 In the most common form, this follows loud snoring.

There may be a choking or snorting sound as breathing
resumes.
 The episodes of decreased breathing are called “hypopnea”
and its definition requires a ≥30% drop in flow for 10 seconds
or longer, associated with ≥3% oxygen desaturation.

 The episodes of breathing cessations are called “apneas”

(literally, “without breath”) and to be defined, a ≥90% drop in
flow for 10 seconds or longer must be assessed and associated
with ≥3% oxygen desaturation, or an arousal

 To define the severity of the condition, the Apnea-Hypopnea

Index (AHI) or the Respirratory Distrubance Index (RDI) are
used. AHI measures the mean number of apneas and
hypopneas per hour of sleep
The OSA syndrome is thus diagnosed if AHI > 5 episodes per
hour and results in daytime sleepiness and fatigue

Sleep apnea can be related to mandibular deficiency and

occasionally this functional problem is the reason for seeking
orthodontic consultation.

Both the diagnosis and management of sleep disorders requires

an interdisciplinary team and should not be attempted without
assessment, documentation, and referral from a qualified
physician
 Diagnostic Records

Orthodontic diagnostic records are taken for two purposes:

1. To document the starting point for treatment

(after all, if you do not know where you started, it is hard to tell
where you are going or how far you have come)

2. Add to the information gathered on clinical examination

 CATEGORIES OF DIAGNOSTIC RECORDS

Health of teeth and oral structure

Alignement and occlusion reationship of teeth

Facial and jaw proportion of teeth

 PHOTOGRAPHIC RECORDS

 The word "photography" was coined by Sir John

Herschelin 1839

 Photography is the process of making pictures by means

of the action of light

 The major purpose of intra-oral photograph is to

enable the orthodontist

 To review the hard and soft tissue at clinical

examinations

 To record hard and soft tissue condition as they exist

before treatmen
American Board of Orthodontics Requirements for
Intra Oral Photographs

 Quality, standardized intra oral prints in color

 Patient dentition oriented accurately in all three plane of

space

 One frontal view in maximum intercuspation

 Two lateral view right and left

 Optional two occlusal view maxillary and

mandibular
 Free of distraction -check retractors, labels, and
fingers

 Quality lighting which reveals anatomical contours

and makes image free of shadows

 Tongue retracted

 Free of saliva and bubbles

 Clean dentition
 INTRAORAL PHOTOGRAPHS

Five standard intraoral photographs are suggested

center right left

maxillary and mandibular occlusal views

 GUIDELINES

 It is important to get permission from the patient before

taking photograph

 Patient should be seated, leaning back slightly in the chair

 Height of chair should be adjusted such that the patient’s

head is lower to that of photographer’s

 All standard views should be done in horizontal frame

 A stable position of photographer is mandatory (since

camera is handled and not placed on a tripod)
 The eye is not pressed against the eyecup but slightly in
back of it. The other eye to be open

 Photographer leg should be supported by outside

edge of the patient chair in order to find secure,
comfortable position

 Select magnification ratio according to the desired

frame and focus by moving camera back and forth

 The upper arm held against upper part of body

with the left hand supporting front of lens
 Extra-Oral Photographs
As For The American Board Of Orthodontics
Requirement Are

 Quality, standardized facial photographs either in black

and white or col

 Patient head oriented accurately in all three planes of space

and in Frankfort horizontal plane

 One lateral view, facing to the right; serious

expression lips closed tightly to reveal muscle
imbalance and disharmony

 One anterior view serious expression

 Optional one lateral view and or one anterior view
with lips apart

 Optional one anterior view, smiling

 Background free of distractionsEar exposed for purpose

of orientation
 Eyes open and looking straight ahead, glasses
removed

 Quality lighting revealing no shadows in the

background
 Profile View

 Usually only one profile (right profile matching up with lateral

cephalogram) is taken

 For a patient with facial asymmetries both right and left profile should be
taken

 Frame extending to above the top of the head in front of the nose and
below the chin

 Back of head is not necessarily required, the remaining free space should
be in front of profile

 Patient assumes a natural head position and look straight ahead in a

relaxed manner keeping jaws closed, and lips also relaxed

 Subjects with long hair should always be asked to tuck them behind the
ear, so that Frankfort horizontal line can be assessed accurately.
Frontal at rest Frontal smile
Right profile

Three quarter profile

 RADIOGRAPHIC EXAMINATION

From the American Dental Association/U.S. Food and Drug Administration. Guidelines
for/Prescribing Dental Radiographs, revised 2009.
PANORAMIC RADIOGRAPHS
The panoramic image has two significant advantages over a series of
intraoral radiographs:
 It yields a broader view and thus is more likely to show any
pathologic lesions and supernumerary or impacted teeth, and the
radiation exposure is much lower.
 It also gives a view of the mandibular condyles, which
can be helpful

 The panoramic radiograph should be supplemented with

periapicalor occlusal radiographs only when greater detail is
required

 In addition, for children and adolescents, periapical views of

incisors are indicated if there is evidence or suspicion of root
resorption or aggressive periodontal disease.
 CBCT scan

 A CBCT scan with a single revolution of the radiation source

is sufficient to scan the entire maxillofacial region (Sukovic
et al., 2001)

 CBCT technology is based on the use of a

cone-shaped X-ray beam that is directed through the patient
and the remnant beam is captured on a flat two-dimensional
(2D) detector (Scarfe et al., 2006)

 The X-ray source and detector are able to revolve about a

patient’s head, anda sequence of two-dimensional (2D)
images is generated. These 2D images are then converted
into a 3D image using computer software
Advantages of CBCT over conventional CT

1. It is less expensive and involves a smaller system

2. The X-ray beam is limited

3. Accurate images are obtained

4. The scan time is rapid

5. A lower radiation dose is used

6. The display modes are exclusive to dentofacial imaging

7. There are fewer imaging artifacts

Application in orthodontic diagnosis

 Assessment of skeletal and dental structures

 3D evaluation of impacted teeth

 Growth assessment

 Pharyngeal airway analysis

 Assessment of the temporomandibular joint (TMJ)

complex in three dimensions

 Cleft palate assessment

Applications of CBCT in treatment planning
Orthognathic surgical planning

 Planning for placement of temporary anchorage devices

(TADs)

 Accurate estimation of the space requirement for

unerupted/ impacted teeth

 Fabrication of custom orthodontic appliances

Application of CBCT in assessing treatment progress
and outcome

 Dentofacial orthopedics
 Orthognathic surgery superimposition

Application of CBCT in risk assessment

 Investigation of orthodontic-associated sensory disturbances

 Assessment of orthodontics-induced root resorption and

periodontal tissues

 Supplementary findings, overlooked findings, and medicolegal

implications
 CBCT is the preferred method for localizing canines

An impacted maxillary canine, seen in a

panoramic radiograph and in cone beam
computed tomography (CBCT) sections in
various planes of space

Note that it is impossible to evaluate the

extent of root resorption of the
lateral and central incisors from the
panoramic radiograph, and it is difficult
to determine whether the canine is facial
or lingual to the incisors

From the CBCT slices, it is apparent that

the lateral incisor root has been
damaged but the central incisor root is
intact, although it is very close to the
crown of the canine, and the canine is on
the palatal side.
Dental Records
 Evaluation of the occlusion requires two things impressions for
dental casts or digital scanning into computer memory, and a
record of the occlusion (either a wax bite or a buccal scan) so
that the casts or images can be related to each other

 Dental casts for orthodontic purposes were usually trimmed

so that the bases were symmetric and then are polished.

 Digital images often are used, they still are prepared to look like
trimmed and polished casts
PARTS OF STUDY MODELS
Alignment, Crowding, and Spacing: Space Analysis

It is important to quantify the amount of space available for

alignment of the teeth within the dental arches because
treatment varies depending on whether the space is adequate,
deficient, or excessive.

 In adolescents and adults, the amount of available space

and the amount required to align all the teeth can be
measured directly

 In the mixed dentition there is a difference between the

apparent crowding at one point in time and the true
ultimate crowding after the transition from the mixed to
permanent dentition.
Pont's Analysis

 Developed by Pont in 1909

 This analysis allows one to predict the width of the

maxillary arch at the premolar and molar region by
measure the mesio-distal widths of the four permanent
incisors

 The analysis helps to determine if the dental arch is narrow

or normal and if expansion is possible or not
 The width from Left Premolar to Right Premolar or
Measured Premolar Value (MPV) can be calculated by
using Sum of Incisal Widths (S.I) of incisors and
multiplying it by 100. The result can be divided by 80.

 The width from Left Molar to Right Molar or Measured

Molar Value (MMV) can be calculated by using the S.I of
incisors and multiplying by 100. The result is divided by
64.

 The widths are measured from occlusal grooves of both

premolars and molars.
Bolton Analysis
 Analysis developed by Wayne A

 Bolton to determine the discrepancy between

size of maxillary and mandibular teeth

 This analysis helps to determine the optimum

interarch relationship

 This analysis measures the Mesio-distal width of

each tooth and is divided into two analyses.
Moyer's mixed dentition analysis
 Created in 1971 by Robert Moyers

 This an analysis that is used in dentistry to predict the size of the

permanent teeth by measuring the size of the primary teeth

 The analysis usually requires a dental cast, Boley's gauge and a

Probability Chart

 Measure widths of each of four permanent incisors of the

upper jaw (maxillary central incisor and maxillary lateral incisor)
and lower jaw (mandibular central incisor and mandibular
lateral incisor)

 The total Mesio-Distal width of the incisors is calculated

 A prediction chart is used for space available in each arch, and
the value that matches closest to the sum of incisors is picked.
 DIGITAL MODELS

 Neatly trimmed and polished casts are more acceptable for presentation to
the patient, as will be necessary during any consultation about orthodontic
treatment. By convention, these trimmed and polished casts are then referred
to as models.
 Three ways generate digital casts

From laser scans of impressions

From scans of casts poured up from impressions

From direct intraoral scans

Virtual models have the great advantage that

 they eliminate the need for storage space

 and can be used for computer-assisted fabrication of

appliances.
Records for Dentofacial Proportions
Radiographs

 Like all radiographic records, cephalograms should be taken

only when they are indicated

 Lateral cephalometric radiographs are the standard for

comprehensive orthodontic treatment

 For treatment of minor problems in children or for adjunctive

treatment procedures in adults, cephalometric radiographs
usually are not required, simply
Facial Photographs
A series of facial photographs has been a standard part of
orthodontic diagnostic records for many years.
The minimum set is three photographs, frontal at rest, frontal
smile, and profile at rest, but it can be valuable to have a
record of tooth–lip relationships in other views
With the advent of digital records, it is easy now to obtain a
short segment of digital video as the patient smiles and
turns from a frontal to a profile view.

It is important to keep in mind that even the best photographs

or videos are never a substitute for careful clinical evaluation—
they
 are just a record of what was observed clinically, or what
should have been observed and recorded—and

 the current view of digital video is that the gain in diagnostic

information over careful clinical analysis simply is not worth
the time and effort to obtain and analyze it.
 Cephalometric Analysis

 The introduction of radiographic cephalometrics in 1934

by Hofrath in Germany and Broadbent in the United States
provided both a research and a clinical tool for the study of
malocclusion and underlying skeletal disproportions

 Most important clinical use of radiographic cephalometrics

is in recognizing and evaluating changes brought about
by orthodontic treatment

 Superimpositions taken from serial cephalometric

radiographs before, during, and after treatment can be
superimposed to study changes in jaw and tooth positions
retrospectively
 American standard cephalometric arrangement. By convention, the distance from
the x-ray source to the subject’s midsagittal plane is 5 feet. The distance from the
midsagittal plane to the cassette can vary but must be the same for any one
patient every time
Cephalometric landmarks

Are represented as a series of points, which are usually defined as

locations on a physical structure (e.g., the junction of the nasal
and frontal bones) but often as an extreme point (e.g., the most
anterior point on the bony chin), or occasionally

as constructed points such as the intersection of two planes

(e.g., the intersection of the mandibular plane and a plane along
the posterior margin of the ramus
Horizontal (Cranial) Reference Line
In any technique for cephalometric analysis, it is necessary to
establish a reference area or reference line

An international congress of anatomists and physical

anthropologists was held in Frankfort, Germany Germany, in
1882 the Frankfort plane, extending from the upper rim of the
external auditory meatus (porion) to the inferior border of the
orbital rim (orbitale), was adopted as the best representation of
the natural orientation of the skull because it was often parallel
to the true horizontal when people were standing in a relaxed
position.
In cephalometric use, however, the Frankfort plane has two
difficulties

 The first is that both its anterior and posterior landmarks,

particularly porion, can be difficult to locate reliably on a
cephalometric radiograph

 The second problem with the Frankfort plane is more

fundamental.It was chosen as the best anatomic indicator of the
true or physiologic horizontal line. Everyone orients his or her
head in a characteristic position, which is established
physiologically, not anatomically
 An alternative horizontal reference line, easily and reliably
detected on cephalometric radiographs, is the line from the sella
turcica to the junction between the nasal and frontal bones (SN)

 In the average individual the SN plane is oriented at 6 to 7

degrees upward anteriorly to the Frankfort plane
Steiner analysis
 The angles SNA and SNB are used to establish the
relationship of the maxilla and mandible to the cranial base

 the ANB angle shows the difference between the maxilla and
mandible

 the SN-MP (mandibular plane) angle is used to establish the

vertical position of the mandible.
 There were significant problems with the Steiner analysis,
however, that led to its replacement

 Its reliance on ANB is problematic

 The ANB angle is influenced by two factors other than the AP

difference in jaw position

 One is the vertical height of the face. As the vertical distance

between nasion and points A and B increases, the ANB angle
will decrease.
 The second is that if the AP position of the
nasion is abnormal, the size of the angle will
be affected.

 In addition, as SNA and SNB become larger

and the jaws are more protrusive, even if
their horizontal relationship is unchanged, it
will be registered as a larger ANB angle
Sassouni Analysis
 The Sassouni analysis was the first to emphasize vertical, as
well as horizontal, relationships and the interaction between
vertical and horizontal proportions

 Sassouni pointed out that the horizontal anatomic planes—

the inclination of the anterior cranial base, Frankfort plane,
palatal plane, occlusal plane, and mandibular plane—tend to
converge toward a single point in well-proportioned faces

The inclination of these planes to each other reflects the

vertical proportionality of the face
 Although the total arcial analysis described by
Sassouni is no longer widely used, his analysis of
vertical facial proportions has become an integral
part of the overall analysis of a patient

 In addition to any other measurements that might be

made, it is valuable in any patient to analyze the
divergence of the horizontal planes and to examine
whether one of the planes is clearly disproportionate
to the others.
Harvold and Wits Analyses
 Maxillary length is measured from the
temporomandibular joint (TMJ), the
posterior wall of the glenoid fossa, to
lower anterior nasal spine (ANS),
defined as the point on the lower
shadow of the ANS where the
projecting spine is 3 mm thick

 Mandibular length is measured from

TMJ to the gnathion, the most anterior
and inferior point on the chin in the
lateral views

 Lower face height is measured from the upper ANS, the similar point on
the upper contour of the spine where it is 3 mm thick, to menton.
Harvold Standard Values (Millimeters)
Wits analysis
 Was conceived primarily as a way to overcome
the limitations of ANB as an indicator of jaw discrepancy

 It is based on a projection of points A and B to the occlusal

plane,along which the linear difference between these points
is measured

 If the AP position of the jaws is normal, the projections from

points A and B will intersect the occlusal plane at very nearly
the same point.

 The magnitude of a discrepancy in the Class II direction

can be estimated by how many millimeters the point A
projection is in front of the point B projection, and vice versa for
Class III.
The Wits analysis, in contrast to the Harvold analysis, is influenced
by the teeth both horizontally and vertically—horizontally
because points A and B are somewhat influenced by the dentition
and vertically because the occlusal plane is determined by the
vertical position of the teeth.
 It is important for Wits analysis to use the functional
occlusal plane, drawn along the maximum intercuspation
of the posterior teeth, not the Downs analysis
functional plane influenced by the vertical position of the
incisors

LIMITATIONS

 Even so, this approach fails to distinguish skeletal

discrepancies from problems caused by displacement of
the dentition

 It does not specify which jaw is at fault if there is a

skeletal problem. If the Wits analysis is used, these
limitations must be kept in mind.
McNamara Analysis
 In this method, both the anatomic Frankfort plane and the
basion–nasion line are used as reference planes

 The AP position of the maxilla and mandible are evaluated

with regard to their position relative to the “nasion
perpendicular,” a vertical line extending downward from
nasion perpendicular to the Frankfort plane

 The maxilla should be on or slightly ahead of this line, the

mandible slightly behind
 The second step in the procedure is a comparison
of maxillary and mandibular length, using Harvold’s approach

 The mandible is positioned in space with the lower anterior

faceheight (ANS–menton).

 The upper incisor is related to the maxilla

with a line through point A perpendicular to the Frankfort
plane, similar to but slightly different from Steiner’s
relationship of the incisor to the NA line.

 The lower incisor is related as in the Ricketts analysis,

primarily by using the A-pogonion line.
 Counterpart Analysis
Enlow’s counterpart analysis emphasizes the way changes in proportions in one part
of the head and face can either add to increase a jaw discrepancy or compensate so
that the jaws fit correctly even though there are skeletal discrepancies

If the maxilla is long (measurement 6), there is no problem if the mandible (7)
also is long, but malocclusion will result if the mandibular body length is merely
normal.
The same would be true for anterior versus posterior vertical dimensions (1 to 3).
If these dimensions match each other, there is no problem, but if they do not,
whether short or long, malocclusion will result
 IDEAL OCCLUSION

 All 32 adult teeth in superb relationships in all three planes of

space

 The tip of the mesiobuccal cusp of the upper first molar fits
into the buccal groove of the lower first molar

 Tip of the upper canine crown fits into the embrasure

between the lower canine and first premolar (Class I ideal
occlusion)

 Overbite , the extent that the upper central incisors overlap

the lower central incisors in the vertical plane, is
approximately 20%.
 Overjet ,the distance along the anteroposterior plane between
the labial surfaces of the lower central incisors and the labial
surfaces of the upper central incisors, is approximately 1 to 2
mm

 Teeth, moreover, are normally angled in the mesiodistal plane,

normally inclined in the buccolingual plane, and aligned without
being spaced, rotated, or crowded along the crests of the
alveolar processes (Andrews 1972 ).
 NORMAL OCCLUSION

 Normal occlusion allows for minor variations

from the ideal which are aesthetically and functionally
satisfactory

 Thus normal occlusion includes slight irregularities of

tooth alignment and relationship

 Normal occlusions have minimal rotations, crowding,

and/or spacing of the teeth. More variability is observed
in overbite and overjet
 NORMAL OCCLUSION IN DECIDUOUS DENTITION
Arch Form and Alignment
The arches are regular in form and all
deciduous teeth must be present, of
normal form and in correct alignment

Spacings of two types may be present

(1) Spacings between the incisors.
(2) So-called 'primate' spacings mesial to
the
upper canine and distal to the lower
canine.
 Arch Relationship
 The upper arch is wider and longer
than the lowerThus the buccal cusps
of the upper molars should overlap
the lower molars and the
 upper incisors should overlap the
lower incisors establishing a normal
overjet relationship
 The overjet in the ideal deciduous dentition should be about
2 mm. and the overbite should be about one third of the
height of the lower incisor crowns.

 Each lower tooth (except for the lower central incisor),

should
 occlude both with the corresponding upper tooth and with
the upper tooth in front
 lower second deciduous molar is longer than the upper the
terminal surfaces of the deciduous arches should be flush.
Andrews the Six Keys to Normal Occlusion
Key I -Molar relationship
 The distal surface of the
distobuccal cusp of the upper
first permanent molar made
contact and occluded with the
mesial surface of the
mesiobuccal cusp of the lower
second molar

 The mesiodistal cusp of the

upper first permanent molar fell
within the groove between the
mesial and middle cusps of the
lower first permanent molar.
Key II- Crown angulation ( the
mesiodistal tip )
the term crown angulution refers to
angulation (or tip) of the long axis
of the crown, not to angulation of
the long axis of the entire tooth.
The gingival portion of the long axis
of each crown was distal to the
incisal portion, varying with
the individual tooth type.
Key III. Crown inclination (labiolingual or buccolingual inclination)

According to Andrews crown

angulation is formed by a line
which bears 90 degrees to the
occlusal plane and a line that
is tangent to the bracket site
(which is in the middle of the
labial or buccal long
axis of the clinical crown, as
viewed from the mesial or
distal).

A plus reading is given if the gingival portion of the tangent line

(or of the crown is lingual to the incisal portion A minus reading is
recorded when the gingival portion of the tangent line (or of the
crown) is labial to the incisal portion, .
 A lingual crown inclination
generally occurs in normally
occluded upper posterior
crowns. The inclination is
constant and similar from the
canines through the second
premolars and slightly more
pronounced in the molars

 The lingual crown inclination

of normally occluded lower
posterior teeth progressively
increases from the canines
through the second molars.
 Key IV-Rotations

The fourth key to normal occlusion is

that the teeth should be free of
undesirable rotations

Rotated molar occupies more

mesiodistal space, creating a situation
unreceptive
to normal occlusion.
 Key V. Tight contacts

 Contact points should be tight (no spaces)

 Persons who have genuine tooth-size discrepancies pose

special problems, but in the absence of such abnormalities tight
contact should exist
 Key VI - Occlusal plane

 A flat plane should be a treatment goal as a form of

overtreatment. There is a natural tendency for the
curve of Spee to deepen with time

 For the lower jaw’s growth downward and forward

sometimes is faster and continues longer than that of
the upper jaw, and this causes the lower anterior
teeth, which are confined to the upper anterior teeth
and lips, to be forced back and up. resulting in
crowded lower anterior teeth and/or a deeper
overbite and deeper curve of Spee
A, A deep curve of
Spee results in a more
confined area for the
ups
creating spillage of the
upper teeth
progressively mesially
and distally.

B, A flat
occlusion is most
receptive to normal
occlusion.

C, A reverse curve of
Spee results in
excessive room for the
upper teeth.
 MALOCCLUSION

 The boundaries between normal occlusion and

malocclusion cannot be drawn precisely

 Malocclusion may be defined as those irregularities

of the teeth beyond the accepted range of normal

 However,the presence of a malocclusion is not in itself

justification for treatment

 Only if the patient would benefit aesthetically or

functionally should treatment be considered
 Angle’s classification of malocclusion
 The first useful orthodontic classification, still important now,
is given by Edward H. Angle in 1899
 Classification is based upon relationship between
mesiobuccal cusp of maxillary 1st molar and buccal groove of
mandible 1st molar
Normal occlusion
 Normal (Class I) molar relationship
 teeth on line of occlusion

Class I malocclusion
The mesiobuccal cusp of the upper first permanent molar
occludes with the mesiobuccal groove of the lower first molar
but line of occlusion is incorrect because of malposed
teeth,rotations or other discrepancies
 Class II malocclusion
 Lower molar distal to upper molar,
relationship of other teeth to line of
occlusion not specified

Class II Division 1
The molar relationships are like that of
Class II and the maxillary anterior teeth
are protruded. Teeth are proclaimed
and a large overjet is present.
 Class II Division 2
The molar relationships are Class II where the maxillary
central incisors are retroclined. The maxillary lateral
incisor teeth may be proclined or normally inclined.
Retroclined and a deep overbite exists.

CLASS II Sub-division
Class II molar relationship exists on one side and the other side
has a normal Class I molar relationship.
Class III malocclusion
Lower molar mesial to upper molar, relationship of other
teeth to line of occlusion not specified
Drawbacks of Angle's classification

 The first permanent molars may be missing They may have

drifted following early loss of deciduous teeth and have to be
mentally repositioned before classification—an obvious
source of error

 The molar relationship may differ between sides. Account is

taken only of sagittal arch relationships

 Skeleton malocclusion were not considered

 Not applicable to deciduous dentition

 Etiology of malocclusion were not elaborated

 MODIFICATIONS IN ANGLE'S CLASSIFICATION

Deway’s (1915 )
modified Angle’s Class I and III malocclusion by segregating
malposition of anterior and posterior segments

CLASS I
Type 1 (Crowd-ing of Max anterior teeth)
Type 2 (Proclined Max incisors)
Type 3 (Max incisors are in cross-bite)
Type 4 (Posterior cross-bite)
Type 5 (Mesial drift of molars)

CLASS II (no modifications)

CLASS III
Type 1: (Edge to edge bite)
Type 2: (Crowded Mandibular incisors and lingual to Max incisors)
Type 3: (Un-derdeveloped crowded Maxillary arch and a well
developed Mandibular arch)
 Lischer in 1933

CL I (Neutrocclu-sion)

CL II (Distocclusion)

CL III (Mesiocclusion)

Also proposed terms to designate individual tooth

malposition

Mesio-version (Mesial to normal position)

Disto-version (Distal to normal po-sition)

  Linguo-version (Crossbite)

 Labio-version (Increased Overjet)

 Infra-version (Submerged tooth)

 Supra-version (Super-erupted)

 Axio-version (Tipped tooth)

 Torsi-version (Rotated tooth)

 Trans-version (Transposed tooth)

SIMON'S CLASSIFICATION
 Ackerman and Proffit classification

In the 1960s, Ackerman and Proffit formalized the system of

informal additions to the Angle method by identifying five
major characteristics of malocclusion to be considered and
systematically described in classification

These five characteristics must be considered in a complete

diagnostic evaluation.
The approach overcame the
major weaknesses of the Angle scheme. Specifically, it

(1) incorporated an evaluation of crowding and asymmetry

within the
dental arches and included an evaluation of incisor protrusion,

(2) recognized the relationship between protrusion and

crowding

(3) included the transverse and vertical, as well as the AP,

planes of space

(4) incorporated information about skeletal jaw

proportions at the appropriate point, that is, in the description
of relationships in each of the planes of space.
 Additions to the Five-Characteristics Classification System

Two things particularly help this more thorough analysis

(1)Evaluating the orientation of the esthetic line of the

dentition, which is related to but different from Angle’s
functional line of occlusion,

(2) Rotational characteristics around each plane of space

 Esthetic line of the dentition

 Esthetic line of occlusion follows the facial

edges of the maxillary anterior and
posterior teeth

 The relationship of the teeth to Angle’s

line of occlusion (red) has long been the
basis for analysis of dental arch symmetry
and crowding.

 A curved green line along the incisal edges

and cusp tips of the maxillary teeth, the
esthetic line of the dentition, now is used
to incorporate tooth–lip relationships into
the diagnostic evaluation of tooth
positions
In addition to relationships in the transverse, anteroposterior, and vertical
planes of space used in traditional analysis, rotations around axes perpendicular
to these planes also must be evaluated. These rotations are pitch, viewed as
up–down deviations around the anteroposterior axis; roll, viewed as up–
down deviations around the transverse axis; and yaw, viewed as left–right
deviations around the vertical axis. The rotations should be evaluated for the
jaws and for the esthetic line of the dentition
Roll describes the vertical position of the teeth
when this is different on the right and left
sides

This image shows a downward roll of the

dentition on the right side relative to the
intercommissure line (yellow). Note that the
maxillary incisors tilt to the left. The chin
deviates to the left, reflecting asymmetric
mandibular growth with lengthening of the
mandibular body and ramus on the right side.
The
vertical position of the gonial angles can be
confirmed by palpation. In this case there is a
skeletal component to the roll
 Incisor Classification
By British standard classification(1983)

Class I
The lower incisor edges occlude with the middle part of
the palatal
surface of the upper incisors or lie directly below them
if the overbite is incomplete

Class II
The lower incisor edges lie posterior to the middle part
of the palatal surface of the upper incisors
Class II incisor relationship is divided into

Division 1: The upper central incisors

are proclined

Division 2: The upper central incisors

are retroclined

Class III
The lower incisor edges lie anterior to the middle
part of the palatal surface of the upper incisors
CANINE CLASSIFICATION
 The prevalence of malocclusion in India has been observed to be
ranging from 20% to 43% Class I malocclusion ranges from 66.7%
in the desert state of Rajasthan (North India) to 49.2% in
Bangalore (south India) 34 to 91.6% in 5-9 year age group and
27.7% in 10-13 years age group in New Delhi (Central India).

 The prevalence of Class II malocclusion in India varies from 1.9%

in Rajasthan 6 to 4.6% in Bangalore34 to 6% in 5-9 year age group
and 14.6% in 10-13 years age group in New Delhi.

 Similarly, Class III malocclusion ranges from 1.4% in

Rajasthan 6 to 0.3% in Bangalore 34 to 3.4% in 10-13 years age
group in New Delhi

Agarwal SS, Jayan B, Chopra SS. An overview of malocclusion in India. J

Dent Health Oral Disord Ther. 2015;3(3):319‒322.
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