Diagnosis

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Diagnosis and Treatment planning In
Orthodontics
Ali A. Bahreman DDS, MS
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Orthodontic Treatment goal Is Accomplishment of
an occlusion which preserve Function
Esthetic Stability and Healthy
Oro-facial structure A health service dedicated
to Establishing both emotional and physical
wellness of the patients.
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To accomplish these goal
The first step toward cure Is to know

what
the disease is
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To understand the problem Careful examination
is necessary
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Patients Examinations
Consist two parts
Paraclinical Examination
Clinical Examination
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Clinical examination
Includes

• Reviewing patients Medical history
• Visual observation
• Digital Inspection
• Functional analysis

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Para clinical Examination
Includes

• Cast analysis
• Photographic analysis
• X-ray examinations
• Cephalometric analysis

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Diagnostic procedure
Steps in examination

• Medical history ( Family H. Case H. )
• Clinical examination
• Study cast analysis
• Photographic analysis
• Radiologic examination
• Cephalometric analysis

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I - Medical History
1. Family history 2. Condition of Siblings
A. Heredity B. Resemblance, susceptibility
is similar or increased or decreased .
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I - Medical History

• 3. Patients medical history
• a Condition of mother during pregnancy .
• b Length of term
• c Delivery
• d - General health ( diseases, nutrition,
  surgery, accident )
• e Personality and characters
• f - General body development ( height, weight
  )
• g General mental development ( mental
  attitude, cooperation, degree of
• responsibility and dependability )

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II - Clinical examination
Extra oral examination

• Posture
• Facial morphology ( Vertical , transverse ,
  Sagital )
• Facial type ( Dolicho, Meso , Brachy )
• Facial symmetry
• Development and tonicity of facial muscles
• Nose ( size and proportion )
• Chin ( size , shape , position and symmetry )
• Lips ( Size , relation to profile , position at
  rest, Tonicity
• Naso-labial angle,mento-labial sulcus,
  color )

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Profile
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Straight Convex
Concave
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Facial type ( Dolichocephalic, Mesocephalic, and
Brachycephalic)
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Dolichocephalic
Brachycephalic
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Clinical examination
Lips

• Position
• Texture
• Size
• Tonicity
• Function

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Normal lip posture
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Lateral view of Lip tooth relationship
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Relation to Chin and Nose
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Clinical examination
Intra oral examination

• Lips ( Position relative to incisors )
• Oral hygiene
• Caries susceptibility, filling
• Dental age ( Teeth eruption and sequence )
• Teeth size, forms, and number
• Gum and periodontal and oral mucosa conditions
• Tongue size and position and texture
• Frenum and oral mucosa
• Presence of adenoid and tonsils
• Type of occlusion ( Classification, overjet,over
  bite,
• midline, curve of Spee

A B
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Functional analysis

• Perioral musculature, Tonicity and function
  during mastication ,
• deglutition , respiration and speech .
• Lip competency tonicity and function during
  rest and swallowing and
• speech and respiration .
• Dental and facial Midline relationship at wide
  open , rest and occlusion
• and path of closure .
• Mandibular movements , protrusive retrusive
  and lateral excursion .
• Free way space .
• Examination of TMJ function and dysfunction
  and condylar movements .
• Evaluation of mode of breathing .

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Important considerations of functional
diagnosis

1. Assessment of the relationships between rest
position and occlusion to differentiate a
functionally true and a forced bite
Malocclusion . 2. Examination of functional
status of lip,tongue, cheeks and
possibility of any muscle adaptive
dysfunction .

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Important considerations of functional diagnosis
3. Examination of TMJ function and dysfunction
and condylar movements. 4. Evaluation mode of
breathing, disturbed nasal respiration may
unable the patient to retain the functional
appliance in the mouth.
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Postural rest position and Freeway space
Is the initial task of functional analysis

• Rest position is the result of myostatic
  antistretch reflex in
• responding to gravity .
• Rest position alter with the position of head .
• So natural head position must be determined for
  each
• patient .

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Functional analysis continued
Abnormal pattern of sliding
May be caused by
1 - Neuromuscular abnormalities . 2 -
Disturbances in dental interrelationships . 3 -
Compensation of skeletal discrepancies . 4 -
Combination of the above .
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Evaluation of path of closure
In transverse plane
Cross bites
1 - Mandibular midline shift in closing but not
in Rest position . This is called
Laterocclusion or Pseudo - cross bite or
functional cross bite , treatment plan is
expansion , prognosis is good . 2 - Mand .
Midline is shifted in both occlusal and postural
position ( A true asymmetric facial skeleton ,
is referred to as Laterognathy ). In severe and
skeletal asymmetry Surgery is the only
alternative .
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Assessment of the Postural rest position
1- -Phonetic exercises ( repeating words, e.g.
Mississippi ) . 2 - Command methods ( lick the
lips then swallow, then apart the lips .
3 - Patient having no idea , and careful
observation during speech and swallowing
.
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Study cast

• One of the most useful tools in Orthodontic
  treatments is a set of good impression of the
  occlusion.
• A good set of impression must comprise the
  followings
• Maximum displacement of soft tissue, created by
  maximum
• extension of the impression.
• 2. A good wax bite of the patients usual
  interdigitation ( centric
• occlusion ) .
• 3. Proper pouring for bauble free cast and
  impression of all
• 4. miniature details.
• 5. Proper trimming and polishing and having
  all necessary
• patients information's ( name, date, age,
  and No. ) recorded on
• the cast.

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Benefit of a good study cast

• Is a good record of patients original occlusion.
• Is good tool for parents / patients
  demonstration.
• Is an important part of case record for patients
  transfer.
• Is a useful references for treatment progress
• evaluation.
• 5. Is a very useful tool in different cast
  analysises.

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Study cast analysis

• Arch form
• Arch symmetry
• Space anlysis
• Type of occlusion

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Transparent ruled grid
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Space analysis
Size prediction of unerupted Cuspids and Bicuspids

• Nance analysis
• Moyers analysis
• Nakata analysis

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Photograph analysis

• Facial form ( a Fontal . B - Lateral )
• a Meso, Dolicho, Brachy
• b Straight, Convex, Concave
• Facial symmetry ( Frontal and lateral view )
• Facial proportions

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Facial proportion
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Convex profile
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Straight profile
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Concave profile
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Radiographic examination

• Periapical X-ray
• Bite wings
• O P G
• Occlusal
• Wrist X-ray

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Radiographic examination

• Careful examination of Intra-oral and
  Extra-oral
• X- ray before any treatment plan is a must
  in
• orthodontic treatment.
• Careful evaluation of different X Rays is not
  only
• very useful in treatment planning but also
  can
• show many factors that can be harmful to
  teeth
• and other occlusal structures during or
  after
• treatment.

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What is the problem here ?
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2
3
What happened ?
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1
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2
1
3
3
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Wrist radiograph And Skeletal maturation
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skeletal age

• The best result in growth modification type of
  treatment
• in orthodontics, happens during the fastest
  rate of general
• skeletal growth.
• Too often treatment planning and initiation of
  Orthodontic
• treatment is determined by chronological age
  and the stage
• of dental development.
• While neither of these two factors is very
  reliable in
• growth modification type of treatment .

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Chronological versus skeletal age

• It has been distinguished that individuals
• chronological age does not necessarily
  correlate
• well with his maturational age.
• Various degree of retardation or advanced
• growth can be present within a population .

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Chronological versus skeletal age

• Studies have shown a positive correlation between
  general
• skeletal growth and facial growth, specially
  in the
• mandible .
• It has also been observed that the maximum rate
  of facial
• growth occurs slightly after the peak growth
  in statural
• height .
• Osseous changes seen in hand and wrist, are good
• indicators of general skeletal changes.

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Chronological versus skeletal age

• According to this concept, hand-wrist
• radiograph have been used in many ways
• by many investigators for evaluation of
• general skeletal growth.

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Skeletal Maturation Assessment ( SMA)

• Is a system developed by Dr. Fishman, In 1982 ,
  for the
• evaluation of skeletal maturity from
  hand-wrist radiograph .
• This system is based on four stages of bone
  maturation, all
• located at six anatomical sites of hand and
  wrist

• Thumb
• Third finger
• Fifth finger
• Radius

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Dr. Fishmans growth indicators
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Skeletal Maturation Assessment ( SMA)

• The sequence of maturation of epiphysis of
  selected
• phalanges are evaluated in four distinguished
  stages

1 Widening of Epiphysis 2 Capping of
Epiphysis 3 Ossification of Epiphysis
4 Fusion of Epiphysis to
Diaphysis
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3
1
2
4
4 stages of bone maturation
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Epiphyseal widening

• Widening of the epiphysis is a progressive
• process.
• Epiphysis first appears as a small center of
• ossification located in center of its
  Diaphysis.
• This ossification extend laterally and reach to
• the width of diaphysis, then considered as
  SMI
• in this system.

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Capping stage

• Capping occurs in the transition between
  initial widening
• and fusion.
• In this stage the rounded lateral margins of
  the epiphysis
• begin to flatten and point up toward the
  diaphysis with an
• acute angle.
• The time of first appearance of cap is
  considered
• as a SMI.

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Fusion

• Fusion is the last stage of bone maturation
  which
• occur between epiphysis and diaphysis after
  the
• capping is completed.
• Fusion also start centrally and progress
  laterally
• until the two formerly separate bone became
  one.
• The time of completion of this fusion, with a
  smooth
• continuity of the surface at the junction
  area, is
• applicable as an SMI.
• A bony line may remain visible between two,
  even
• years after fusion is complete but are not
  relevant.

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Ossification of Adductor Sesamoid of the thumb

• It first appear as a small relatively round
  center of
• ossification medial to the junction of
  epiphysis and
• diaphysis of the proximal phalanx.
• It then become progressively larger and more
  dense, and
• then considered as a SMI.
• This occur after SMI, widening, and before
  Capping.

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5 - 8
2 6 - 10
7 - 3
1 - 9
4
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Skeletal Maturational Indicators ( S M I )
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2
3
1
4
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Eleven Skeletal Maturity Indicators SMI

• 3rd finger proximal phalanx Epiphyseal widening
• 3rd finger middle phalanx
  
• 5th finger middle phalanx
  
• Ossification of adductor sesamoid
• 3rd finger distal phalanx Capping
• 3rd finger middle phalanx
• 5th finger middle phalanx
• 3rd finger distal phalanx fusion
• 3rd finger proximal phalanx
• 3rd finger middle phalanx
• Radius bone fusion

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SMI 2
SMI 1
SMI 3
SMI 4
Ossification of sesamoid
Width of epiphysis as wide as diaphysis
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SMI 5
SMI 6
SMI 7
Capping of epiphysis
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SMI 8
SMI 10
SMI 9
SMI 11
Fusion of epiphysis and diaphysis
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2
3
1
4
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5-8
6
7
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10
9
11
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Cephalometric Analysis
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Four basic facial types ( two vertical,
two antero-posterior )
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Cephalometric Radiography

• The basic technique of Cephalometrics was
  introduced to
• Orthodontic specialty by Dr. B. Holly
  Broadbent in 1931.
• It is a radiographic technique for head
  measurement .
• This technique is a development of Craniometric
  technique
• which was used by Anthropologists by
  direct
• measurement of dried skull.
• The essence of cephalometric Radiography is
• standardization.
• Patients position and orientation of X-ray beam
  is
• established by mechanical devices in such a
  way that
• repeated exposure in other time is
  essentially with the
• same conditions.

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Cephalostat
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Sagittal Veiw
Frontal view
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Purpose of Cephalometrics

• Study craniofacial growth
• Diagnosis
• Planning orthodontic treatment
• Evaluation of treated cases
• Growth prediction

Cephalometric is a technique employing oriented
radiographs for the purpose of making head
measurements.
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Treatment planning

• Evaluate of Dento - skeletal relationship
• A - Teeth relation to each other
• B - To basal bones
• C - To Facio-skeletal structures
• D Relation, shape, position and
  proportion of each
• of these bony structures in general
• Evaluation of soft tissue profile
• Lips , tongue , chin , nose
• Assessment of other soft tissue e.g. Tonsils ,
  Adenoid

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Cephalometric Criteria
1- Analysis of Facial Skeleton . 2-
Analysis of Jaw bases . 3- Analysis of
Dentoalveolar relationship.

And their relation
To each other
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Cephalometric
continued
and
Treatment planning
2. Skeletal assessments

• Evaluation of jaws relation to each other,
• and to cranial base in different
  dimensions.
• Evaluation of jaws size to each other and to
• cranial base.
• 3. Evaluation of jaws shape.

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Cephalometric
and
Treatment planning

• Evaluate of Dentition
• A Upper and lower Teeth relation to each
  other.
• B Teeth Relation to basal bones.
• C Teeth Relation to Cranio-facial bony
  structures.
• D - Anterior teeth relation to profile.
• E Anterior teeth relation to lips.

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continued
Cephalometric
and
Treatment planning
3. Soft tissue evaluation A - Lips size,
position, proportion to each other
and to profile. B - Tongue size, position,
proportion. C - Tonsils and adenoid size, air
way passage. D - Nose Size, shape, relation to
profile. E - Chin Size, shape, relation to
profile

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Cephalometric Landmarks
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Cephalometric Points

• S, Sella - midpoint sella turcica
• N, nasion - most anterior point of the
  nasofrontal suture
• A, subspinal - deepest midline point below the
  anterior nasal spine
• B, Supramentale - most posterior point on the
  outer contour of the mandibular alveolar process

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Cephalometric Points

• ANS, anterior nasal spine - tip of the anterior
  nasal spine
• PNS, posterior nasal spine - tip of the posterior
  spine of the palate
• Pog, pogonion - most anterior point of the bony
  chin
• Gn, gnathion - midpoint between the most anterior
  and inferior points on the bony chin
• Me, menton - most inferior point on the outline
• of the symphysis

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Cephalometric Points

• Go, gonion - point midway between the most
  inferior and most posterior points in the angle
  of the mandible
• P, porion - uppermost point on the outline of the
  ear rods of the cephalostat
• Or, orbitale - lowermost point on the orbit

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Cephalometric Points

• PTM, pterygomaxillary fissure - the projected
  contour on the lateral film anterior wall
  represents maxillary tuberosity outline, and the
  posterior, the anterior curve of the pterygoid
  process.

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Nasion
Sella
A Point
B Point
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Nasion
Sella
A Point
B Point
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Orbitale
Porion
ANS
PNS
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Frequently Used Planes
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SN Plane
Frankfort Plane
Palatal Plane
Occlusal Plane
Mandibular Plane
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Landmarks
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Facial angle
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Facial angle
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AB to Facial Angle
A-B to Facial
Mean 4.6
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Angle of convexity
Mean 0
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Analysis of jaw bases
Sagittal
SNB
SNA
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Y- axis angle ( Downs )
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B Ideal position
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Inadequacy of of incisor tip
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N
L. Incisor to N-B
4 mm and 25 degree
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Tweed triangle
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Morphology of Mandible

• Orthognatic
• Ramus and body are fully developed
• Ramus width is equal to body height
• Condylar and Coronoid process are at the same
  level
• Symphysis is well developed

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Morphology of Mandible

• Prognathic
• Corpus is well developed and wide in molar
  region .
• Symphysis is wide in sagital plane .
• Ramus is wide and long .
• Gonial angle is acute .

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Morphology of Mandible

• Retrognathic
• Corpus is narrow and short .
• Coronoid process is shorter than Condylar
  process .
• Symphysis is narrow and long .
• Ramus is narrow and short .
• Gonial ange is obtuse or large .

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A toward mand. retro B Mand. Excess
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Steiners S - line
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A well balanced B Protrusive
C Retrusive
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Merrifields Z angle 80 degree - 9
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Ricketts E - line
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Adenoid and air way space
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Large Tonsils