Atlas college of health science

School of dentistry

ORTHODONTIC – II by
Dr abduselam k
DMD, MPH,BSC in radiology, Public Health specialist
 CHAPTER- 1

ORTHODONTIC DIAGNOSIS
&
TREATMENT PLANNING
 Course contents
CHAPTER –I –Orthodontic Diagnosis
and treatment Planning
CHAPTER - II- Orthodontic Treatment
- Based on Removable Orthodontic
Appliances
CHAPTER III- Orthodontic Treatment -
Based on Fixed Orthodontic Appliances
 References
 Text Book of Orthodontics, Samir E. Bishara,
2001W.B Saunders Company.
 Contemporary Orthodontics; William R. Proffit with
Henry W. Fields, JR, 2000 3rd edition, Mosby Inc.
 Text Book of Orthodontics; M.S.Rani, 2001 3 rd
Edition, All Indian publisher and Distributors Regd.
 Orthodontics the Art and Science; S.I Bahlajhi, 1997
Aray (medi) publishing House.
 An Introduction to orthodontics; Mitchell, Laura,
2001, 2nd edition, Oxford university press.
 Orthodontics and pediatric Dentistry; Declan Millett,
Richard Wilbur, 2000 Churchill Livingston.
 A text book of orthodontics; T. D. Foster , third
edition, Blackwell Scientific Publications Oxford
London , 1990
 Tip-Edge orthodontics ; Richard Parkhouse
 ORTHODONTIC DIAGNOSIS
AND
TREATMENT PLANNING
 Orthodontic diagnosis:
 As in other disciplines of dentistry and medicine,
Orthodontic diagnosis :
1.Requires the collection of an adequate database of
information about the patient
 pertinent data is Collected in a systemic manner to help
in identifying the nature and cause of the problem.
2.Requires distillation from that database a
comprehensive but clearly stated list of the patient’s
problem.
3.Formulating the patients problem list
 Requires sound scientific knowledge combined with
clinical experience and common sense (practical
judgment).
 Requires recognition of the various characteristics of
the malocclusion.
 Cont…
 Both the patient’s perceptions and the
doctor’s observations are needed in
formulating the problem list.
 Diagnosis must be done scientifically; for all
practical purposes.
4.Treatment planning
 Then the task of treatment planning is to
synthesize the possible solution to the specific
problems into a specific treatment strategy
that would provide maximum benefit for this
particular patient.
 Treatment planning cannot be science alone,
judgment by the clinician is required to:
• Prioritized the problems
 Cont…
 There are a series of logical steps in carrying out diagnosis
and treatment planning.
1. Collection of an adequate diagnosis database (organized
information).
2. Formulation of a problem list - the diagnosis from the
database.
Both pathological and developmental problems may be
present
3. Planning of treatment based on a problem list.
 Pathologic problems should be separated from the
developmental ones so that they can receive priority for
treatment not because they are more important but because
pathologic processes must be under control before treatment
of developmental problems begins.
 Cont…
 Orthodontic diagnosis involves development
of a comprehensive data base of pertinent
information derived from three major
sources.
1. Patient questioning
2. Clinical examination of the patient includes:
 Extra oral examinations.
 Intra oral examinations.
3. Evaluation of diagnostic records including:
 Dental Casts
 Radiographs
 Photographs
Cont…
Obtaining Patients
database
 Two types of Data
1. Subjective data
 Information given by the patient , the
family or close relatives who accompany
the patient
2. Objective data
 Information derived from physical
examination and laboratory tests/
diagnostic records
 I. Patient questioning

 Recording of a comprehensive data base of

pertinent information from the patient or parents .
 Recording of a comprehensive and relevant
information’s from the patient or parents that
might be necessary to examine, diagnose and plan
the treatment is called case history/ Patient
history. = Subjective data
 Case history / Patient history should be recorded
in the patients or parents own words or sentences.
 It is important not to ask any leading questions.
 Case history should be a written record.= Legal
Document
 Case history usually made up of a medical history
and dental history.
 The essential elements of a
patient history/ Case history
1. Personal details/ information
2. Chief complaint
3. History of the present illness (HPI)-
Dental history
4. Past medical history
5. Family history
6. Personal, Social & Behavioral history
7. Review of systems
8. General Clinical Examination
 1. Personal details /
information
We should start the case history by recording:
 Name- For identification & communication
 Age
 To identify certain transient conditions that
occur during development that are considered as
normal for that age:
- For example the ugly duckling stage.
 To consider serial extraction procedures.
 To carry out palatal expansion.
 To apply growth modification procedures using
functional and orthopedic appliances during the
growth spurt/period .
 Surgical resective procedures are best carried
out after the cessation of growth.
 Cont…
 Sex
 Sex is important in planning orthodontic
treatment as growth spurts is different in
males and females.
 Females usually precede males in growth
spurt, puberty and termination of
growth.
 Address and occupation
 This helps in selection of an appropriate
appliance.
 Helps in evaluation of the socio-economic
status of the patient and parents.
 Chief complaints
 The chief complaint is the reason that the
patient seeks care, as described in the patient’s
own words.
 This helps the clinician in identifying the
priorities and desires of the patients.
 There are two logical reasons for patient
concern about the alignment and occlusion of
teeth:
A. Impaired dentofacial esthetic that can lead to
psychological problems. Aesthetic is the most
common reason or concern of the patient.
B. Impaired function that can lead to physiological
problems.
 Cont…
Occasionally patients might be referred
for reasons such as:
Correcting occlusal prematurities
To maintain the space of early lost
deciduous teeth
Re- alignment of tilted teeth
 3. History of the present
illness (HPI)- Dental
History
The HPI is a chronologic description
and elaboration of the patient’s
symptoms and should include
information about
 Onset of the problems
 Aggravating/exacerbating factors
 Alleviating/relieving factors -cold or hot things.
 Duration,
 Frequency : How often, how long what time
day or night.
 Location,
 Cont…
 character, and intensity: how would the pain
described.
 features of the occlusion that concerns the
patient.
 E.g. A child may be more concerned about
the mild rotation of an upper central incisor
than increased overjet, particularly if other
members of the family have Class II division
1 malocclusions.
 Elements that should be included in the
dental history are:
1. Past dental visits:
 The patient's past dental history should
include details of any previous appliance
therapy. Along with:
 The nature of previous orthodontic treatment
 Appliance type
 Details relating to Extractions, …
 complications
 The reason for present consultation.
 Cont…
 The nature, extent and frequency of previous
dental treatment together with the level of
patient cooperation should be recorded.
 If treatment was abandoned, the patient
must be questioned carefully for the reasons.
 A history of early loss of primary teeth or of
incisor trauma should be noted.
2. Oral hygiene practices - Regular dental care
and good oral health are an essential
prerequisite to orthodontic treatment.
 Cont…
3. Oral symptoms
- including tooth pain or
- sensitivity,
- gingival bleeding or pain,
- gum recession, alveolar bone loss
- tooth mobility,
- halitosis, and
- abscess formation
4. Past dental or maxillofacial trauma
 Cont…
5. Any history of temporomandibular joint
symptoms including pain, muscle
tenderness or difficulty with mouth
opening.
6. Habits related to oral disease, such as
 thumb sucking,
 tongue trusting, bruxing,
 clenching, and
 nail biting.
 4. Medical history
 Helps to identify the medical conditions of the
patient.
 Should also include information on drug usage.
 Elements that need to be included in the medical
history are:
1. Current status of the patient’s general health
2. History of hospitalizations
 Medications-The use of certain drugs like aspirin
may impede orthodontic tooth movement.
 Allergies
 Cont…
There are very few medical conditions which
preclude orthodontic treatment. These include:
 Patients suffering from debilitating diseases like
Mumps, Chicken pox, should be recovered fully
before undertaking orthodontic treatment.
 Pregnancy
 Patients with history of repeated colds, allergic
rhinitis, pneumonia, tonsillectomy,
adenoidectomy, Active Tb, jaundice and hepatitis.
 Patients with history of allergy to acrylic resin.
 Children with sever mental or physical handicap.
 Medical Conditions that may
impact on orthodontic
treatment.
I. Rheumatic fever/congenital cardiac defects
 If a patient is suspected of being at risk of
infective endocarditis it is advisable to
seek medical advice, preferably from a
cardiologist.
 Antibiotic cover will be required prior to
band placement and extractions in patients
with a history of rheumatic fever.
 For all congenital cardiac defects, it is wise
to consult the patient's cardiologist to
ascertain the need for antibiotic
prophylaxis.
 Cont…
II. Recurrent oral ulceration
 Appliance therapy should be avoided until
this condition has been investigated
thoroughly.
 Depending on the frequency and nature of
ulceration, limited appliance treatment
may be possible.
 Cont…
III. Epilepsy
 Risk of airway obstruction from appliance
parts fractured during an epileptic attack
 Difficulty with tooth movement in the
presence of gingival hyperplasia,
 Dental extractions are contraindicated in
uncontrolled epileptic patients
 Because of these orthodontic appliance
should be delayed until the epilepsy is
well controlled and the gingival condition
improved.
 Cont…
IV. Diabetes
 Diabetic patients are more prone to
periodontal breakdown, and active
appliance therapy should be withheld
until the periodontal condition is sound
and the diabetes is stabilized.
 Cont…
V. Hay fever
 Seasonal rhinitis resulting from an
allergic reaction to pollen
 Hay fever may interfere with the wearing
of functional appliances over the
summer months.
 An alternative approach to treating the
malocclusion may be sought.
 Cont…
VI. Nickel allergies
 Although rare, patients sensitized to nickel
are at risk of developing a severe allergic
reaction to appliance components that
contain nickel and these must be avoided.
 Cont…
VII.Bleeding diatheses / predisposition
 If extractions are necessary, special
medical arrangements will need to be in
place.
 Patients with history of blood dyscrasias
may need special management if
extractions are planned.
 Cont…
VIII. Severe physical/mental handicap
 In selected patients, extractions only may
produce an improvement in dental
aesthetics and facilitate tooth cleaning
measures.
 Children who are severely handicapped
either mentally or physically may require
special management.
 Appliance therapy is invariably not a viable
option.
 5. Family histories
Why is the family history of interest to the
dentist?
The family history often provides
information about diseases of genetic
origin or diseases that have a familial
tendency. Examples include
Hemophilia
Clotting disorders,
Atherosclerotic heart disease,
Psychiatric diseases, and
Diabetes mellitus.
 Cont…
 Any genetic family problem including type of
malocclusion or any other oro - facial
abnormalities present in the family members.
 A large number of class II and Class III
malocclusion are inherited through a
dominant gene.
 Congenital deformities like cleft lip / cleft
palate are transmitted through a recessive
gene.
 The family history will help us in establishing
any familial tendencies towards the
development of a particular type of
malocclusion and to take necessary preventive
 6. Personal , Social &
Behavioral History
Patients personal history include details
of :
1.Pre-Natal History
Include details of :
Nutritional disorders,
Drugs taken,
Disease and
Accidents of the mother during
pregnancy.
Drug induced deformities like thalidomide
can lead to orofacial deformities.
 Cont…
German measles during first trimester
of pregnancy can cause cleft lip/ cleft
palate.
Injury at the time of birth particularly
to the jaws affects the growth.
Injury to TMJ either due to intra
uterine pressure or pressure due to the
forceps delivery can result in ankylosis.
 Cont…
2. Post-Natal history
Includes information on
 The type of feeding
 The presence of habits
 Fracture of the jaws or teeth
 The milestone of normal development which
include
 Time of Crawling,
 Time of eruption, shading of the deciduous teeth,
 Time of Walking and
 Time of Talking.
 Cont…
Patients Social history includes
Knowledge of patient’s,
Socio economic status and
Concern of the parents and patients will
helps in assessing the extent of
cooperation that can be expected from
them during the treatment.
The distance at which the family lives; and
an estimate of traveling time to and from
potential appointments should be noted.
 Cont…
Access to transport, the ease with which a
responsible adult can accompany the
child patient, together with information
relating to forthcoming events that may
influence attendance, are important.
Patients motivation for treatment,
What he or she expects as a result of
treatment, and
Levels of patients cooperation.
 Cont…
 Motivation for seeking treatment can be
classified as external or internal.
1. External motivation
 Is that pressure supplied by another
individual, as with a reluctant child who is
being brought for orthodontic treatment by
a determined parents or an older patient
who is seeking alignment of incisor teeth
because her boy friend( or his girlfriend)
wants the teeth too look better.
 Cont…
2. Internal motivation
 Pressure comes from within the individual
and is based on his or her own assessment of
the situation and desired for treatment.
 Quite young children can encounter
difficulties in their interaction with others
because of their dental and facial appearance,
which sometimes produces a strong internal
desire for treatment.
 Older patients usually are aware of functional
or psychosocial difficulties related to their
malocclusion, and so are likely to have some
component of internal motivation.
 7. Review of systems
Asking series of questions going from
“head to toe”
The Review of Systems questions may
uncover problems that the patient has
overlooked (not taken into account) ,
particularly in areas unrelated to the
present illness.
 8. General Clinical
Examination
General physical examination involves:
Inspection
Palpation
Percussion
Auscultation
 Cont…
 There are two goals of the orthodontic
clinical examination:
1. To evaluate and document
 Oral health,
 Facial esthetic, and
 Jaw function.
2. To decide which diagnostic records &
treatment options are required.
 Cont…

Orthodontic clinical examination

comprises assessment of the patient
Extra orally
Intra orally
General body system.
 2. Clinical examination of the
patient

I. Extra – Oral
Examination
 I. Extra – Oral
Examination
 An observant clinician usually begins his general
examination as soon as the patient enters the door.
 The clinical examination should begin by adjusting
the position of the patient in such a way that the
Frankfurt horizontal plane is parallel to the floor.
 The relationship of the mandible to the maxilla
should be assessed in all three planes of space:
 Anteroposteriorly,
 Vertically and
 Transversally.
Cont…

A. Shape of the head
BRACHYCEPHALIC :
 Is broad and short head shape.
 Describes an individual with a larger than
average cranial width and usually presents with
a broad, square head shape and low mandibular
plane angle.
 BRACHYFACIAL :
 Is an individual characterized by a:
 Broad square face with a strong chin,
 Flat lip posture,
 Low mandibular plane angle
 Cont…

BRACHYCEPHALIC &
BRACHYFACIAL
 Cont…
 DOLICHOCEPHALIC:
 Is long and narrow head shape.
 Describes an individual that has a narrower
cranial width and usually presents with a long,
narrow shape and high mandibular plane angle.
 DOLICHOFACIAL
 Is an individual that has a:
 Long, narrow face with a
 High mandibular plane angle,
 Poor chin development and
 An anterior-posterior face height imbalance.
 Cont…

DOLICHOCEPHALIC &
DOLICHOFACIAL
 Cont…
 MESOCEPHALIC:
 Is average head shape.
 Describes an individual that falls between
the brachycephalic and dolichocephalic
types and has an average cranial width.
 MESOFACIAL :
 Is an individual who has well balanced
facial features.
 Cont…

MESOCEPHALIC &
MESOFACIAL
 B. Facial profile
 The patient’s facial profile is examined by
standing on the side of the patient.
 The facial profile helps in diagnosing gross
deviations in the maxillo mandibular
relationship.
 The facial profile view is used to evaluate the
nose, chin, lips and facial convexity.
 For clinical evaluation of the facial profile, three
soft tissue points are taken into consideration:
 Nasion,
 Point A, and
 Pogonion.
 Cont…
 The profile is obtained by joining the
following reference lines:
A.A line joining the forehead and the soft
tissue point A
( deepest point in curvature of upper lip)
B.A line joining point A and the soft tissue
pogonion (most anterior point of the chin).
Based on the relationship between these
two lines three types of profile exist:
 Straight
 Convex
 Concave
 Cont…
1. Straight profile
 When all the three points lie in the
same vertical plane, the profile is
said to be straight.
 The two lines form nearly straight
line.
 It usually seen in case of class I
malocclusion.
Cont…
 Cont…
2. Convex profile
 If the A point is ahead or the pogonion
point is placed behind, then the profile is
said to be convex.
 This kind of profile seen in prognathic
maxilla or retrognathic mandible.
 It is seen in cases of class II division 1
malocclusion.
Cont…
 Cont…
3. Concave profile
 If the A point is placed behind or the
pogonion is placed ahead , the
profile is said to be concave.
 This type of profile is associated with
a prognathic mandible or a
retrognathic maxilla.
 It is seen in cases of class III
Malocclusion.
Cont…
Cont…
Cont…

C. Skeletal pattern
The patient should be comfortably seated upright.
Tilting of the head upwards increases the
prominence of the chin, and conversely tilting the
head downwards has the opposite effect.
 Therefore it is important to ensure that the
patient is positioned so that his or her Frankfort
plane is horizontal.
The skeletal pattern should be assessed in all three
planes of space.
 Anteroposterior
 Vertical
 Transverse
 I. Anteroposterior
( Sagittal Plane)
The patient should be viewed from the side
and the relative position of the maxilla and
mandible assessed.
The following classification of skeletal pattern
is universally recognized:
Class I
 Orthognathic, the mandible is 2–3 mm
posterior to maxilla.
Class II
 Retrognathic, the mandible is retruded
relative to the maxilla.
Class III
 Prognathic, the mandible is protruded relative
to the maxilla.
Assessment of skeletal
relationship
 Cont…
This classification only gives the
position of the mandible and the
maxilla relative to each other and
does not indicate where the
discrepancy lies.
Ideally the maxillary skeletal base is
seen 2-3 mm forward compared to the
mandibular skeletal base when teeth
are in occlusion.
 II. Vertical
 The patient is viewed from the side.
 The vertical assessment comprises two
separate evaluations:-
1. Facial Height (FH)
2. Frankfort mandibular planes angle (FMPA)
 Cont…
A. Facial height (FH):
The distance from the eyebrow to the
base of the nose should equal the
distance from the base of the nose to
the lower most point on the chin.
 If the latter distance is increased, the
lower facial height is described as being
increased, and vice versa.
 Cont…

Assessment of lower facial height: In an averagely

proportioned face the distance x from a point between the
eyebrows to the base of the nose is equivalent to the
distance y from the base of the nose to the chin.
 Facial Height
Upper facial height (UFH)
Lower facial Height (LFH)
Total facial height (TFH)
Ideal proportion of UFH is 45 % of the
total facial height.
Ideal proportion of LFH is 55 % of the total
facial height.
Upper facial height
(UFH)
It is clinically measured from the bridge
of the nose to the lower border of the
nose.
Cephalometrically UFH is measured
from Nasion to Anterior Nasal Spine (N
to ANS )
 Lower facial Height (LFH)
 It is clinically measured from the lower
border of the nose to the lower border of
chin.
 Cephalometrically, LFH is measured from
anterior nasal spine to menton (ANS to Me)
 Lower Facial Height is low in
A. Growing children
B. Skeletal deep bite cases
C. Class II division 2 cases
 Lower Facial Height is increased in
A. Skeletal open bite cases
B. In long face syndrome
 Cont…
From an orthodontic point of view, we are
concerned mainly about the lower facial
height because we can bring about
changes only in the lower facial height.
The upper facial height cannot be
influenced or changed by orthodontic
treatment.
 Importance of LFH in
treatment planning
Anterior bite plane (ABP) is indicated for the
correction of deep bite in cases where the
lower facial height is decreased.
Anterior bite plane is contraindicated in cases
where the lower facial height is increased as it
further increases the height of the face and
makes the chin less prominent.
 Evaluation of Facial
Proportion
 A well proportioned face can be divided
into three equal vertical thirds using
four horizontal planes:
 At the level of hair line
 At the supra orbital ridge
 At the base of the nose
 At the inferior border of the chin
Cont…
 Cont…
B. Frankfort mandibular planes angle (FMPA) :
 If the angle between these two planes is
around the average of 28, then the lines would
intersect approximately at the back of the
head.
 If the FMPA
 Is increased the lines would meet before the
back of the head, and
 Is reduced they would cross beyond.
 Cont…
The vertical skeletal relationship is also evaluated
by measuring the Frankfurt mandibular plane angle
(FMA) depending upon the point where the two
planes- Frankfurt horizontal plane and mandibular
plane meet to form the FMA angle: the cases can be
divided as average, low or high angle cases.
On average FMA angle is about 25 degree to 30
degree.
If it is more it is considered as high angle case and
If it is less, it is considered as low angle case.
 Cont…
Average FMPA angle cases
The two planes meet at the occipital region.
Low FMPA angle cases
The two planes meet beyond the occipital
region.
Also called a horizontal growing face.
High FMPA angle cases
The two planes meet in the mastoid region or
in front of the ear or anterior to the occipital
region .
It is called a vertical growing face.
Assessment of the
FMPA
Cont…
 III. Transverse
It is important to remember that all faces are
asymmetric to a small degree. However, any
marked discrepancies should be noted.
For this assessment the patient should be viewed
anteriorly and, if an asymmetry is noted, also
examined by looking down on the face from
above.
 Facial asymmetry may be observed by standing
directly behind the patient and looking down
across the face, checking the coincidence of the
midlines of the nose, upper and lower lips and
midpoint of the chin.

D. Facial esthetic analysis
The patients facial symmetry is examined
to determine disproportions of the face in
transverse and vertical planes.
 Facial asymmetry is a reduction of
proportion between the left and right
sides of the face.
 In most people the right and left sides are
not identical.
 Thus some degree of asymmetry is
considered normal.
 Asymmetry that are gross and are detected
easily should be recorded.
Cont…
For ideal proportion
from the frontal view
the width of the base
of the nose should be
approximately the
same as the
intercanthal distance
(solid line), while the
width of the mouth
should approximate
the distance between
 Cont…
 Facial asymmetry often associated with syndromes
which can complicate treatment.
 Gross facial asymmetry may be due to conditions
such as:
 Congenital defects
 Hemifacial hypertrophy- There are many factors but
the most valid factor is due to increased neurovascular
supply to the affected side.
 Hemifacial atrophy (Romberg Syndrome)-Although
the cause is presently unknown, peripheral nerve
dysfunction, trauma, infection, heredity, and a regional
unilateral progressive systemic sclerosis have been
proposed the possible causes.
 First arch syndrome.
 Unilateral condylar hyperplasia.
 E. Soft tissues
A. Lips: The following should be considered:
 The form, tonicity, and fullness of the lips. For example,
are they full or thin, hyperactive, or with little tone?
Lip competence:
 Competent lips meet together at rest without any
muscular activity.
 Usually, the lips are said to be competent if they touch
each other lightly or there is interlabial gap of about 0
to 1mm.
Lip incompetent:
 Lips are incompetent, short, hypotonic and fail to form
a lip seal in cases of class II division I malocclusion.
 Cont…
Lower lip position relative to the upper incisors.
A high lower lip line is often one of the etiological
factors in Class II division 2 malocclusions.
Lower lip trap seen in class II division I
malocclusion.
The length of the upper lip and amount of upper
incisor shown.
 Usually the upper lip covers the labial surface of
upper anterior except the incisal third or 2 to 3
mms.
 The normal upper incisor show, at rest, is 2–3 mm
in females and less in males.
 Cont…
High lower lip line relative to the upper
central incisors which has resulted in
their retroclination.
 Differential diagnosis
of Lips
A. Competent lips
 The lips are in slight contact when the
musculature is relaxed.
B. Incompetent lips
 Morphologically inadequate or short lips
which do not form a lip seal in relaxed state.
 The lip seal can only be achieved by active
contraction of the perioral and mentalis
muscles.
 Commonly seen in class II division I
malocclusion.
Example: small size of the upper lip or short
upper lip.
 Cont…
C. Potentially competent lips
 Sometimes lips are of adequate or normal in
size but fail to form a lip seal function
properly due to the proclined upper incisors.
 Functionally inadequate lip.
 Example: In class II division 1 malocclusion
cases, lower lip forms the oral seal with the
lingual surface of maxillary incisors due to
the proclination of the maxillary anterior
teeth. Lip Trap.
 Cont…
D. Functionally abnormal lips
 Normally during swallowing, the lips
do not contract.
 In cases where the lips contract
during swallowing, they are said to be
functionally abnormal lips.
 Seen in tongue thrust patients.
E. Cleft lips
F. Double lip
Double lip
 F. Examination of
A. Chin
Chin
 can be :
 Normal
 Recessive as in class II cases
 Prominent as in class III cases
B. Mento Labial Sulcus
 The concavity region between the lower lip and the
mentalis muscle is called mento labial sulcus. It can
be
 Normal as seen in class I cases.
 Deep as seen in Angles class II division 1
malocclusion cases.
 Shallow as in cases of bi- maxillary protrusion
 Cont…
C. Mentalis Muscles
 Normally during swallowing there is no
contraction of perioral muscles and mentalis
muscles.
 In cases of Angles class II division 1
malocclusion and tongue thrust swallowing
contraction of mentalis is seen.
 This hyperactivity of mentalis can be seen as
puckering (wrinkle) or orange peel
appearance.
 G. Assessment of
Temporomandibular
Joints
Standing behind the patient the site of the
condyles is palpated while the patient opens and
closes their mouth.
Joints are examined for tenderness and clicking or
crepitus on opening and closing.
The maximum mouth opening is determined by
measuring the distance between the maxillary and
mandibular incisal edges with the mouth wide
open.
The normal inter – incisal distance is 40 - 45mm.
In cases of TMJ pain dysfunction cases the inter-
incisal distance increases during the initial stages
due to hypermobility of the TMJ; eventually the
mouth opening is limited, thereby the inter-incisal
distance decreases.
 Cont…

II. INTRA- ORAL

EXAMINATION
 ORTHODONTIC
ASSESSMENT OVERVIEW
Equipment required in orthodontic
assessment are:
 A mirror,
 Probe,
 A small Stainless Steel (SS) engineer's ruler.
 II. Intra- oral

examination
Intra oral examination of the patient
should begin by examining the following
details:
A. Evaluation of Oral Health status.
 The hard and soft tissue of the oral
cavity must be assessed.
 The general guideline is that any problem
of disease or pathology must be under
control before orthodontic treatment.
 Cont…
 These includes
 Medical problems,
 Dental caries,
 Oral mucosal lesions
 Pulpal pathology and
 Periodontal disease.
 It is often said that the dentist should over
looking missing teeth and yet almost every dentist
concentrating on details rather than the big
picture.
 It is easy to fail to notice a missing or
supernumerary lower incisor.
 Cont…
It has been said that orthodontists forget to
ask the patient to open wide, thus missing any
dental pathology, whilst generalists forget to
ask the patient to close together, thus missing
any malocclusion!
 B. Gingiva

The gingiva should be examined for:

Interdental (interproximal ) Papilla
Free Gingiva (Marginal gingival)
Attached gingiava
Gingival sulcus - evaluated using graduated
probes.
Inflammation - Presence of poor oral hygiene is
usually associated with generalized marginal
gingivitis.
Bleeding
Recession
 Cont…
Muccogingival lesions - ANUG
Hyperplastic gingiva seen in patients who
take phenytoin.
 Epulis or pyogenic granuloma or
pregnancy tumor
 Traumatic occlusion - In class, II division 2
the mandibular labial gingival tissue is often
traumatized by the excessively tipped upper
central incisors.
 c. Oral Mucosa

 Look for
 Color
 Ulcers
 Patches
 Nodules
 Fibromas
 D. Frenum

 The maxillary labial frenum at times be thick,

fibrous and attached relatively low.
 Such an attachment prevents the two
maxillary central incisors from
approximating each other thereby
predisposing the midline diastema.
 Upper labial frenum low attachment
associated with median diastema.
 Abnormal frenal attachment are diagnosed by
a blanch test where the upper lip is stretched
upwards and outwards for a long time.
 Cont…
The presence of blanching in the region of
the inter-dental papilla is diagnostic for
abnormal frenum.
Lower lingual frenum attachment is
examined by asking the patient to protrude
the tongue.
If the patient is unable to protrude the
tongue it is due to abnormal lingual frenum
and is called as tongue tie or ankyloglosia.
 E. Tongue
 Abnormalities of the tongue can upset the
muscle balance and equilibrium leading to
malocclusion.
 Presence of an excessively large tongue is
indicated by the presence of imprints of the
teeth on the lateral margins of the tongue giving
it scalloped appearance.
 The lingual frenum should be examined for
tongue tie.
 Tongue thrusts are usually adaptive, i.e. the
tongue is placed forward between the teeth to
achieve an anterior oral seal during swallowing.
 Cont…
In class II division 1 the tongue occupies a
lower posture thereby failing to counteract
the buccinators activity.
The unrestrained buccinators activity
results in narrowing of the upper arch at
the premolar and canine regions thereby
producing a V-shaped upper arch.
In class III the tongue occupies a lower
position, resulting in a narrow upper arch.
 F. Palate

Look for the depth and width of the plate

(Deep & Narrow palate ) and any other
developmental abnormalities like:
Torous palatinous
Palatal cysts
Cleft palates
Adenomas (Pleomorphic Adenomas ).
Gummas
Tertiary syphilis; gummas of the
palate.

Necrosis in the
centre of the palate
has caused
perforation of the
bone and two
typical round
punched-out holes.
 G. Teeth
- Check for size, form, structure and number
1. Arch Traits :
 Maxillary
 mandibular teeth
2. Set Traits (dentition traits) :
 Primary (deciduous)
 Secondary (permanent) dentitions.
3. Class trait :
 Incisors
 Canines
 Premolars
 Molars.
 Cont…
4. Individual Tooth malposition
 inclination
 Distal inclination
 Mesial inclination
 Lingual inclination
 Buccal inclination
 displacement
 Mesial displacement
 Distal displacement
 Lingual displacement
 Buccal displacement
 Cont…
version
Mesioversion
Distoversion
Transversion /Transposition
Axiversion
Torsiversion / Rotation
Supraversion
Infraversion
 Cont…
 Crowding: Condition where there is positional
irregularity of tooth crowns.
 Uncrowded,
 Mildly crowded - (0-4 mm),
 Moderately crowded (>4 but <7 mm) or
 Severely crowded (>7 mm).
 Spacing: Condition where space is present between
the teeth.
 Rotation:
 Open bite: Condition where there is lack of vertical
overlapping of teeth in centric occlusion.
5. Number of teeth- Assess for
Cont…
 Teeth present
 Teeth under erupted
 Teeth missed
 Teeth impacted
 Supernumerary
 Mesodens
 Anodontia -Congenitally missing teeth
6. Variation in tooth size
 Microdontia
 Macrodontia
 Peg shape laterals
 Cont…
7. Variation of Tooth morphology
 Germination or Twining:
 Is double or fused teeth ;
 Is the result of splitting of a single tooth
germ.
 These teeth generally have a single root and
a common pulp canal, but are notched
incisally.
 Appears in primary dentition more
frequently than in the permanent dentition.
 Cont…
Fusion:
 Is the union of two adjacent tooth germs
always involving the dentine.
Have separate roots and pulp chambers.

Concrescence ?
Union of the roots of two or more teeth
because of the merging of their cementum
Germination or Twining
Fusion
Fusion
Concrescence
 Cont…
Hutchinson’s incisors:
Results of prenatal syphilis; screw driver
shaped incisors broad cervically and
narrowing incisally.
Mulberry molars:
Multiple tiny tubercles with poorly
developed indistinguishable cusps.
Talon cusps
Talon cusps
 Cont…
8. Tooth Wear-Assessment of tooth wear
 Abrasion –Wear of dental tissue by mechanical
processes
 Erosion –Wear of dental tissue by chemical processes
 Attrition - Wear of dental tissue by physiological
processes
9. Vitality, carious, restoration ,fracture,
discoloration, mobility, hypoplasia , malformation
of the tooth, veneers, crowns and bridges .
- Mild to sever fluorosis is resistance to etching and
fixed orthodontic is difficult.
 Cont…
FLUOROSIS
Mild Form: - mild form of mottling,
exhibiting white opaque flecks near the
incise edges with the surface remaining
smooth and intact.
Moderate Form: - Moderate form of fluoride
mottling with ridges of hypoplasia; white
and brownish enamel.
Severe Form: - Severe form of fluoride-
induced hypoplasia and discoloration with
associated cracking and chipping of enamel.
Focal enamel
Hypoplasia
Focal enamel Hypoplasia
Local or focal enamel hypoplasia
involving only one or two teeth is
relatively common.
Cause is unknown (Idiopathic) .
A common form of focal enamel
hypoplasia of known cause is Turner
Tooth which results from localized
inflammation or trauma during tooth
development.
 Cont…
10. Carious cavity- Assessment of decayed tooth
 Class I- Class I Cavity includes those cavity originated in
pit or fissure surfaces.
 Class II- Class II cavity originating on proximal surfaces
of posterior teeth that is molar and Premolar teeth.
 Class III- Is a smooth surface lesion that is found in the
proximal surface of anterior teeth but not including the
incisal edge of the tooth.
 Class IV -Involves the proximal surface of the anterior
teeth including the incisal edge.
 Class V- Involves the cervical one third of the buccal and
lingual surface of any tooth.
 Class VI
 Cont…
11. Fractured Tooth- Assessment of
fractured tooth:
Ellis classification
Class I: Fracture within the enamel.
Class II: Fracture of enamel - dentine.
Class III: Fracture involving pulp.
Class IV: Fracture involving the roots.
 Cont…
12. Tooth Injury- Assessment of tooth injury:
 Concussion: Injury to supporting tissues of tooth, without
displacement.
 Subluxation: Partial displacement, but commonly used to
describe loosening of a tooth without displacement.
 Luxation: Displacement of tooth (laterally, labially, or
palatally).
 Intrusion: Displacement of tooth into its socket. Often
accompanied by fracture of alveolar bone.
 Extrusion: Partial displacement of tooth from its socket.
 Avulsion: Traumatic removal of the tooth from the its
socket.
 Cont…
13. Tooth Mobility - Assessment of tooth mobility
The continuous loss of the supporting tissues in
progressive periodontal disease may result in
increased tooth mobility.
- Faciolingual mobility
- Mesiodistal mobility
- Alveolo-occlusal (Vertical ) mobility
Tooth mobility may be classified in the following way:
 Degree 1: Mobility of the crown of the tooth 0.2 - 1
mm in horizontal direction
 Degree 2: Mobility of the crown of the tooth
exceeding 1 mm in horizontal direction.
 Degree 3: Mobility of the crown of the tooth in
vertical direction as well.
 Cont…
14. Edentulous Tooth (Arches)- Assessment
of tooth loss:
Kennedy 1928 Classification of the
partially edentulous arches
Class 1 = Bilateral free end;
Class 2 = Unilateral free end;
 Class 3 =Unilateral bounded;
Class 4 = Anterior, across the mid- line.
 Cont…
15. Molar Relationship
A. Class I Molar Relationship
B. Class II Molar Relationship
C. Class III Molar Relationship
 Cont…
16. Transverse Malrelation Assessment
 Cross bite.
Scissorbite.
Shift in the upper or lower midline
 Cont…
17. Horizontal (Overjet ) Assessment:
 It is the horizontal overlapping between
the upper and lower anterior teeth.
 Normally it is 2 -3 mms.
 Overjet can be
 Normal
 Increased
 Decreased
 Edge to edge
 Reverse overjet or cross bite
Cont…
 Cont…
18. Overbite ( vertical )Assessment :
 It is the vertical overlapping of upper and lower
anterior teeth.
 Normally it is 2 -3 mms
 Overbite can be
 Normal
 Deep bite – when the over bite is greater than 2
-3 mms.
 Closed bite - Where the upper anterior overlap
the lower anterior completely. Characteristic
future of class II division 2 malocclusion.
 Open bite - Lack of vertical overlapping of teeth.
Over-bite
Excessive Over-bite
Cont…
 Cont…
19. Assessment Curve of spee:
Curve of spee is measured by placing a flat
surface of touching the incisors and
posteriorly up to the second molar.
It can be
 Flat curve of spee- All teeth touch the flat
surface.
 Deep curve of spee- The occlusal surfaces
of the posterior teeth form a curve which is
more than a millimeter in depth.
Curve of Spee
 Cont…
20. Evaluation of path of closure
Is the movement of the mandible from rest
position to habitual occlusion.
Forward path of closure:
 occurs in the patients with mild skeletal
prenormalcy or edge to edge (class III
Malocclusion) incisors contact.
 In such patients the mandible is guided to a
more forward position to allow the mandibular
incisors to go labial to the upper incisors.
 Cont…
Backward path of closure:
 Class II division 2 cases exhibit premature
incisor contact due to retroclined maxillary
incisors. Thus the mandible is guided
posteriorly to establish occlusion.
Lateral path of closure:
 Lateral deviation of the mandible to the
left or right side is associated with occlusal
prematurities and a narrow maxillary arch.
 Conditions which lead to
altered path of closure
1. Lingually or palatally erupting incisors.
2. Occlusal prematurities. – Forward path of closure
3. Habitual forward positioning which occurs in case of
Angle’s Class II division I malocclusion.
4. Forward displacement or forward path of closure is
seen in cases of Angle’s Class III cases.
5. Backward displacement or posterior displacement is
seen in cases of Angle’s Class II division 2 cases.
6. Lateral path of closure in cases of unilateral cross bite.
7. Lateral path of closure is associated with narrow
maxilla.
 3. Evaluation of diagnostic
records

I. Model Analysis
 Model or Cast Analysis
Model Analysis is one of the essential
diagnostic aids in orthodontic treatment .
Orthodontic models are accurate plaster
reproduction of the teeth and their
surrounding soft tissues.
Orthodontic models can be
 Study model
 Working model

Orthodontic model can be defined as a positive

replica of the dental arches and their
contiguous structures
 Cont…
Study model are an essential diagnostic aid that
makes it possible to study the arrangement of
teeth and occlusion from all directions.
Study models help us:
 To visualize the patients occlusion from all
aspects.
 In making the necessary measurements of:
 The tooth

 The dental arches and

 The Arch width.

 Cont…
 Parts of the study model
1. Anatomic portion
Comprises teeth and their
contiguous structures
2. Artistic portion
 USES OF STUDY MODELS

 It enable the study of the occlusion from all

aspects.
 It enable accurate measurements to be made on
tooth size, arch width & arch length.
 It helps in assessment of treatment progress by
the dentist as well as the patient.
 It helps in assessing the nature and severity of
malocclusion.
 Helpful in motivation of the patient and to
explain the treatment plan as well as progress
to the patient and parents.
 Cont…
 It makes possible to stimulate treatment procedure
on the cast such as mock surgery.
 Useful to transfer records in case the patient is to
be treated by another clinician.
 Used as a record for further reference both during
and after treatment.
 Used as a reference to other orthodontist when the
case has to be transferred.
 Used as a teaching aid to the students, patients and
parents.
 Used as a legal document and evidence.
 Used as a research purpose.
 Cont…
 The following are some of the analysis
used in permanent and mixed dentition.
 Permanent Dentition
1. Ponts Index.
2. Korkhaus analysis.
3. Linder Harth Index.= same as Ponts
4. Arch perimeter analysis.
5. Bolton tooth size ratio.
6. Ashley Howe’s analysis.
 Cont…
 Mixed Dentition
1. Huckaba’s analysis.
2. Hixon and old father’s analysis.
3. Nancy Carey’s analysis.
4. Moyer’s Mixed Dentition analysis.
5. Total space analysis.

I. Ponts Index.
Pont in 1909 suggested a method for
determining the ideal dental arch width from
the combined mesiodistal width of the
maxillary central and lateral incisors.
Ponts analysis helps in:
Determining whether the dental arch is narrow
or normal.
Determining the need for lateral arch
expansion.
Determining how much expansion is possible
at the premolar and molar regions.
 Cont…
Procedure:
Measure the mesio - distal width of the 4
maxillary incisors and sum up the value.
This value is called sum of incisors (S.I.).
Measure the arch width in premolar region
from the distal pit of upper first premolars
to the distal pit of opposite first premolar.
Measure the arch width in molar region
from the mesial pit of upper first molar to
the mesial pit of opposite first molar.
 Cont…
Pont suggested that the ratio of combined
incisor to transverse arch width was ideally
0.8 in the bicuspid area and 0.64 in the
first molar area.
Calculate the ideal arch width in premolar
region using the formula:
= Sum of Incisor (S.I.) × 100 /80
 Calculate the ideal arch width in molar
region using the formula:
= Sum of Incisor (S.I.) × 100 /64
Cont…
 Cont…
Inference:
If the calculated value is greater than the
measured value , then the arch is narrow
for the sum of incisors width and the arch
needs expansion.
If the measured value is greater than the
calculated value then the arch is wider for
the sum of incisors width and there is no
need for arch expansion.
 Cont…
Drawbacks of Ponts analysis
This analysis is based on the study of
French population hence universal validity
is questionable.
This analysis does not take into
consideration the alignment of teeth.
This analysis does not consider
malformation of teeth example peg
laterals.
 II. Arch perimeter
analysis
This analysis helps us to find out the difference between
the basal bone and the tooth material.
 It is performed on the upper arch cast.
The same analysis on the lower cast is called Carey’s
analysis .
Procedure
Measure the mesio –distal width of all the teeth from
the second premolar on one side to the second
premolar on the other side. i.e. 54321 - 12345 and
sum it up.
= This gives us the tooth material or the space
required.

Cont…
Measure the arch perimeter using brass wire from
the mesio –buccal line angle of maxillary first
permanent molar and pass the wire along the
contact of premolar and through the incisive
papilla and through premolar of the opposite side
up to mesio buccal line angle of maxillary first
permanent molar.
= This gives us the Arch perimeter (Space
available)
Arch Perimeter (Space available) < Tooth material
(space required) Implies Arch length discrepancy
 Cont…
Inference
By comparing the tooth material and arch
length required, we can obtain the extent of
the arch discrepancy.
If the tooth material is more than the space
available then there can be crowding /
spacing shortage.
If the tooth material is less than the space
available then there can be spacing/ space
excess.
 III. Carey’s analysis
(lower arch)
Carey’s analysis helps in determining the extent
of the discrepancy between arch length and
tooth material.
It is performed on the lower cast.
Procedure
Measure the mesio -distal width of all the teeth
from the second premolar on one side to the
second premolar of the other side and sum it up.
This gives us the tooth material or space
required.
 Cont…
Take a brass wire, place it on one side of
the mesio-buccal line angle of lower first
permanent molar and pass it along the
buccal tips of premolars and the cingulii
of aligned anterior teeth and pass it along
the buccal cusp tips of premolars up to
the mesio buccal line angle of the
opposite side of lower first permanent
molar. This gives us the space available.
Arch perimeter (Space available) < Tooth
material (space required) Implies Arch
length discrepancy
 Cont…
Inference
By comparing the tooth material and arch
length required, we can obtain the extent of
the arch discrepancy.
If the tooth material is more than the space
available then there can be crowding /
spacing shortage.
If the tooth material is less than the space
available then there can be spacing/ space
excess.
 Cont…
Depending upon the space shortage, line of
suggested treatment planning is as follows:
If the discrepancy is between 0 – 2.5 mm -
noon extraction case
If the discrepancy is between 2.5 to 5mms –
extraction of the second premolar is
recommended.
If the discrepancy is more than 5mms
extraction of the first premolar is
recommended.
 Beerendonk
Dental Vernier caliper

IV. Bolton analysis
Tooth size is an important factor to be taken in to
consideration in orthodontic diagnosis and
treatment planning.
According to Bolton there exists a ratio between
the mesio – distal widths or maxillary and
mandibular teeth.
According to Bolton many malocclusions occur as
a result of abnormalities in tooth size.
The Bolton’s analysis helps in determining
disproportion in size between maxillary and
mandibular teeth.
Average proportion between upper and lower teeth
in overall and anterior region helps to create a
normal overjet and overbite.
 Cont…
Procedure:
Sum of mandibular 12/ Sum of maxillary 12:
The mesio - distal width of all the teeth mesial to
the second permanent molars is measured and
summed up.
i.e. {(654321I123456) / (654321I123456)}
Sum of mandibular 6/ maxillary 6:
The mesio distal width of all the teeth mesial to
the first premolars is measured and summed up.
i.e. {(321I123) / (321I123)}
 Cont…
Determination of Overall Ratio (Total Bolton
Index = TBI)
The Over All Ratio is determined using the
formula:

 According to Bolton dental arches are

proportional to each other when TBI is 91.3% +
1.91.
 Cont…
Inference:
If the overall ratio exceeds 91.3 % the
discrepancy is due to the excessive
mandibular tooth material.
If overall ratio is less than 91.3% it indicates
maxillary tooth material excess.
TBI is supposed to be ideal, if the sum of
mesiodistal width of maxillary teeth exceeds
the mandibular ones by 7.5 to 9.5 mm.
 Cont…
Determination of Anterior Ratio (Anterior
Bolton Index = ABI):
The Anterior Ratio is determined using the
formula

According to Bolton Anterior dental arches are

proportional to each other when ABI is 77.2 % +
1.65.
 Cont…
Inference:
If the anterior ratio is more than 77.2%,
it indicates mandibular anterior excess.
If the anterior ratio is less than 77.2%,
it indicates maxillary anterior excess
II. RADIOGRAPHS USED IN
ORTHODONTIC DIAGNOSIS
 Cont…
Radiographs have established themselves as a valuable
tool in orthodontic diagnosis. .
Radiographs are used for the following purposes in
orthodontics:
To assess general development of
dentition: Presence, absence and state of
eruption of the teeth.
To establish the presence or absence of
supernumerary teeth.
To determine the extent of root resorption
of deciduous teeth.
To study the extent of root formation of
the permanent teeth.
 Cont…
 To confirm the presence and extent of
pathological and traumatic condition.
 To study the character of alveolar bone.

 They are a valuable aid in cranio dento -

facial analysis.
 To confirm the axial inclination of the

roots of teeth.
 To assess teeth that are

morphologically abnormal.
 CLASSIFICATION OF
RADIOGRAPHS USED IN
ORTHODONTIC DIAGNOSIS
Radiographs routinely used for diagnosis in
orthodontics can be classified into two
groups.
1.Intra – oral radiographs
2.Extra – oral radiographs
Intra – oral radiographs
There are three types of commonly used
intra – oral radiographs. These are:
A.Periapical,
B.Bite wing and
C.Occlusal projection
 Extra – oral radiographs
Includes all views made of the oro -facial
region with the film positioned extra –
orally.
They are useful whenever large areas of
the face and the skull are to be visualized.
 I. Panoramic radiography
 Enable viewing of both maxillary and the
mandibular arches with their supporting
structures.
 Thus a single image covers a major part of the
facial region.
 Uses of Panoramic radiography
1. To assessing the dental development by studying
deciduous root resorpition and root development
of permanent teeth.
2. To View ankylosed and impacted teeth.
3. To Study path of eruption of the teeth.
 Cont…
4. To diagnose the presence and extent of
pathology and fractures of the jaws.
5. To diagnose the presence or absence of
multiple supernumerary teeth.
6. Aids in serial extraction procedures to
study the status of erupting teeth.
7. Useful in the mixed dentition period to
study the status of unerupted teeth.
Cont…
 Advantages of Panoramic
radiography
1. A broad anatomic area can be
visualized.
2. Patients radiation exposure is low.
3. It can be used in patients who are
unable to tolerate intra – oral films or
unable to open the mouth.
 Disadvantages of Panoramic
radiography
1. Distortion, magnifications and overlapping of
the structures occur.
2. The teeth and the supporting periodontal
structures are not as clear as in periapical films.
3. Inclination of anterior teeth cannot be
visualized.
4. Requires equipment that is expensive.
5. Whenever details of a particular area are needed
they have to be supplemented by other
radiographs.
 II. Cephalometric
radiography
 Holly Broadbent and Hofarath In 1931,
Developed cephalometric radiography
 Cephalometric radiography is a standardized form of
skull radiography used extensively in orthodontics to
assess the relationships of the teeth to the jaws and
the jaws to the rest of the facial skeleton.
 Standardization was essential for the development
of cephalometry — the measurement and
comparison of specific points, distances and lines
within the facial skeleton, which is now an integral
part of orthodontic assessment.
 Uses of Cephalometric
x-ray
 The following are some of the applications
of cephalometrics in orthodontics:
1. Helps in orthodontic diagnosis by enabling
the study of skeletal, dental and soft tissue
structures of the cranio- facial region.
2. It helps in classification of the skeletal and
dental abnormalities.
3. Helps in establishing the facial type.
4. Helps in treatment planning.
 Cont…
5. Helps in evaluation of the treatment
results by quantifying the changes
brought about by treatment.
6. Helps in predicting the growth related
changes and changes associated with
surgical treatment.
7. Is a valuable aid in research work
involving the cranio dento – facial region.
 Main
indications
The main clinical indications can be
considered under two major headings
Orthodontics
Orthognathic surgery.
 Cephalometric
Equipment
The basic components of the equipment for
producing a cephalogram are :
An x-ray apparatus; (X-ray Source)-placed in a
fixed distance from a device that holds the x-ray
film and position the head normally it is 5-6 feet.
An image receptor system (X-ray film in
cassette) and
A head holding device called cephalostat
=The cephalosta consists of two ear roads that
prevent the movement of the head in the
horizontal plane.
 Types of Cephalograms
Cephalograms can be of two types:
1. Lateral cephalograms
 This provides a lateral view of the skull
 Gives the orthodontist a sagittal view of
the skeletal, dental and soft tissues.
2. Frontal Cephalograms
 This provides an antero - posterior view
of the skull.
 Lateral
cephalograms
 Cephalometric tracing
/digitizing
 Produces a diagrammatic representation of
certain anatomical points or landmarks evident
on the lateral skull radiograph.
 As a basic system tracing /digitizing could
include:
1. The outline and inclination of the anterior teeth
2. The positional relationship of the mandibular
and maxillary dental bases to the cranial base.
3. The positional relationship of the dental bases
to one another, i.e. the skeletal patterns
4. The relationship between the bones of the skull
and the soft tissues of the face.
 Cephalometric
Landmarks
 Cephalometrics makes use of certain landmarks
or points on the skull which are used for
quantitative analysis and measurements.
 Cephalometric Landmarks can be of two types
1. Anatomic Landmarks: Represents actual
anatomic structures in a cephalogram.
 Hard tissue landmarks

 Soft tissue landmarks

2. Derived Landmarks: Obtained secondarily from

anatomic structures in a cephalograms.
 Cont…
 The land marks that are used in
cephalometric should fulfill certain
requirements.
1. It should be easily seen in a radiograph.
2. It should be uniform in outline.
3. It should permit valid quantitative
measurements of lines and angles
projected from them.
lateral cephalometric
tracing
Cont…
Soft tissue profile
points:
• Glabella (G'),
• Pronasale (Pr),
• Labrale superius
(Ls),
• Labrale inferius
(Li), and
• Pogonion (Pog').
 Main Cephalometric
include:
Landmarks
 Nasion (N). The most anterior point midway between
the frontal and nasal bones on the frontonasal
suture.
 Orbitale (Or). The lowest point on the infraorbital
margin (the inferior bony margin of the orbit).
 Porion (Po). The uppermost point of the bony external
auditory meatus, usually regarded as coincidental with
the uppermost point of the ear rods of the cephalostat.
 Sella (S). The point representing the midpoint of the
pituitary fossa or sella tursica. It is a constructed
point in the mid – sagittal plane.
 Cont…
 point A. It is the deepest point in the midline
between the anterior nasal spine and alveolar
crest between the two central incisors. It is
also called Subspinale.
point B. It is the deepest point in the midline
between the alveolar crest of mandible and the
mental process. It is also called Supramental.
Basion. Is the median point of the anterior
margin of the foramen magnum.
Bolton point. The highest point at the post
condylar notch of the occipital bone.
 Cont…
Anterior nasal spine (ANS). It is the anterior tip of
the sharp bony process of the maxilla in the
midline of the lower margin of the anterior nasal
opening.
Gonion (Go). It is a constructed point at the
junction of ramal plane and the mandibular plane.
Pogonion (Pog). The most anterior point of the
bony chin.
Menton (Me). It is the most inferior midline point
on the mandibular symphysis.
Gnathion (Gn). The most anterior and inferior
point on the bony outline of the chin, situated
equidistant from pogonion and menton.
 Cont…
Articulare (Ar). It is a point at the junction of the
posterior boarder of the ramus and inferior border
of the basilar part of the occipital bone.
Prosthion (Pr). The lowest and most anterior point
of the alveolar bone in the midline, between the
upper central incisors. It is also called supradentale.
Infradentale (Id). The highest and most anterior
point of the alveolar process , situated in the median
plane between the mandibular central incisors.
Posterior nasal spine (PNS). The intersection of a
continuation of the anterior wall of the pterygo -
palatine fossa and the floor of the nose marking the
distal limit of the maxilla.
 Main cephalometric planes
and angles
S-N plane. A transverse plane through the skull
represented by the line joining sella and nasion.
Represents the anterior cranial base
Frankfort Horizontal plane. This plane connects the
lowest point of the orbit (orbitale) and the superior
point of the external auditory meatus ( Porion).
Mandibular plane. A transverse plane through the
skull representing the lower border of the
horizontal ramus of the mandible. There are several
definitions:
 A line joining Menton and Gonion.
 A tangent to the lower border of the mandible
 Cont…
Maxillary plane. A transverse plane through
the skull represented by a joining of the
anterior and posterior nasal spines.
Occlusal plane. It is a denture plane bisecting
the posterior occlusion of the permanent
molars and premolars and extends anteriorly.
SNA. Relates the anteroposterior position of
the maxilla, as represented by the A point, to
the cranial base.
SNB. Relates the anteroposterior position of
the mandible, as represented by the B point,
to the cranial base.
Facial Line - The line joining Nasion and
Pogonion. Used as a measurement of
mandibular prognathism.
Bolton Line – The line joining the Bolton
point and the Nasion.
Y-axis - The line from Sella to Gnathion
De Coster’s Line – The outline of the
internal surface of the anterior cranial
base.
Cephalometric
planes.
A cephalometric
tracing of a lateral
skull radiograph
showing the main
cephalometric planes
an angles.
 Cont…
ANB. Relates the anteroposterior position
of the maxilla to the mandible, i.e.
indicates the anteroposterior skeletal
pattern — Class I, II or III.
Maxillary incisal inclination. The angle
between the long axis of the maxillary
incisors and the maxillary plane.
Mandibular incisal inclination. The angle
between the long axis of the mandibular
incisors and the mandibular plane.
 Cont…
Skeletal Patterns
Cephalometric analyses reveal to the
orthodontist the skeletal component of the
patient’s malocclusion.
Understanding the skeletal pattern is
essential for choosing the proper
treatment mechanics.
 Cephalometric Analysis
 There are three methods of
cephalometric analysis in orthodontic.
I. Downs Analysis
II. Steiner Analysis
III. Tweed Analysis
 I. Downs Analysis
 It is one of the most frequently used
cephalometric analysis.
A. Skeletal Parameters
B. Dental Parameters
 Cont…
A. Skeletal Parameters
1. Facial Angle
2. Angle of Convexity
3. Mandibular Plane Angle
4. Y- Axis (Growth Axis)
FACIAL ANGLE
It is the inside of inferior
angle formed by the
intersection of Nasion –
Pogonion (Facial plane) and
Orbitale - Porion ( F.H.
plane) .
The average value is 87.8
º while
The range is 82 to 95 º.
This angle gives us an
indication of the antero –
posterior positioning of the
mandible in relation to the
upper face.
The magnitude of this
value increases in cases of
skeletal class III with
prominent chin while
It decreases in skeletal
class II cases.
 ANGLE OF
CONVEXITY
This angle is formed by the
intersection of a line from
nasion to point A and a line
from point A to pogonion.
This angle reveals the
convexity or concavity of the
skeletal profile.
The average value is 0 º
while the range is between –
8.5 to 10 º.
A positive angle or an
increased angle suggests a
prominent maxillary denture
base relative to mandible.
A negative angle or
decreased angle of convexity
or a is indicative a
 MANDIBULAR PLANE
ANGLE

The mandibular plane

angle is formed by the
intersection of the
Mandibular plane with the
F.H Plane.
The mean value is
21.9ºwhile the range is 17 –
28º.
An increased mandibular
plane angle is suggestive of
a vertical grower with hyper-
divergent facial pattern.
A decreased mandibular
plane angle is suggestive of
a Horizontal grower facial
 This angle is obtained by
joining the Sella –
Gnathion line with the
Porion – Orbitale (F.H.
plane) .
The mean is 59º while
 The range is 53 to 66º .
The angle is larger in
class II facial patterns
than the patients
exhibiting Class III
pattern.
In addition, the Y-axis
indicates the growth
pattern of the individual.
If the angle is greater
than normal, it indicates
greater vertical growth of
mandible.
 B. Dental Parameters

1. Cant of Occlusal plane Angle

2. Inter – Incisal Angle
3. Incisor Occlusal Plane Angle
4. Incisor Mandibular Plane Angle
5. Upper Incisor to A – Pog Line
CANT OF OCCLUSAL
PLANE

This angle is formed

between the occlusal plane
and the F.H. Plane.
Downs constructed the
occlusal plane by bisecting
occlusion of the 1st
permanent molars and the
incisal overbite.
The mean value is 9.3º
while
The range is 1.5 to 14º.
This angle gives us a
measure of the slope of the
occlusal plane relative to
the F.H. plane.
INTER INCISAL ANGLE

This angle is formed

between the long axis of the
upper and lower incisors.
The average reading is
135.4º while the range is
between 130 to 150.5º.
The angle is decreased in
class I bimaxillary
protrusion and Class II,
Division 1 malocclusion =
Protruded incisors whereas
It is increased in a Class
II, Division 2 cases =
Retruded incisors.
 PLANE ANGLE (Lower
Incisor to Occlusal
Plane)
This is the inside inferior
angle formed by the
intersection between the
long axis of lower central
incisor and the occlusal
plane and
 Is read as plus or minus
deviation from a right
angle.
The average value is
14.5º while
The range is between 3.5
to 20º.
An increase in this angle
is suggestive of an
 INCISOR
MANDIBULAR PLANE
ANGLE (Lower Incisor
to Mandibular Plane)

This angle is formed by

the intersection of the
long axis of the lower
incisor and the
mandibular plane.
The mean angulation
is91.4º while
An increase in this
angle is indicative of
lower incisor
proclination.
UPPER INCISOR TO
A- POG LINE
This is a linear
measurement between
the incisal edge of the
maxillary central incisor
and the line joining
Point A to Pogonion.
This distance is on an
average 2.7mm Range is
-1 to 5mm.
The measurement is
Increased in patients
presenting with upper
incisor proclination.
The measurement is
Decreased in patients
presenting with upper
 II. Steiner Analysis
 The Steiner analysis is divided in to
three parts
1. Skeletal Analysis
2. Dental Analysis
3. Soft Tissue Analysis
 Cont…
1. Skeletal Analysis
 SNA Angle
 SNB Angle
 ANB Angle
 Mandibular Plane Angle
 Occlusal Plane Angle
 S.N.A . ANGLE

It is the angle formed by

the intersection of
S.N.Plane and a line
joining nasion and point A.
This angle indicates the
relative antero - posterior
positioning of the maxilla
in relation to the cranial
base.
The mean value is 82º.
A larger than normal
value indicates that the
maxilla is prognathic as in
Class II while
 A smaller value is
suggestive of a
retrognathic maxilla as in
 S.N.B. ANGLE
It is the angle between the
S.N.Plane and a line joining
Nasion to Point B.
 This angle indicates the
antero- posterior
positioning of the mandible
in relation to the cranial
base.
Its average value is 80º.
An increase in this angle
indicates a prognathic
mandible (Class III)
whereas
A less than normal angle
suggests a recessive
mandible (Class II)
A.N.B. ANGLE
This angle is formed by
the intersection of lines
joining Nasion to Point A
and Nasion to Point B.
It denotes the relative
position of the maxilla and
mandible to each other.
The mean value is 2º.
An increase in this angle
is indicative of a Class II
skeletal tendency while
 An angle that is less than
normal or negative angle is
suggestive of a skeletal
Class III relationship.
 Skeletal
relationships
Skeletal pattern (ANB). The skeletal pattern
may be classified broadly according to the ANB
value
1. Skeletal Class I Pattern
 2° < ANB < 4°
2. Skeletal Class II Pattern
 ANB > 4°
3. Skeletal Class III Pattern
 ANB < 2°
PLANE ANGLE
It is the angle formed
between S.N.Plane and
the mandibular plane.
The mandibular plane
used in this analysis is a
line connecting Gonion
and Gnathion.
The average value is
32º.
This angle gives an
indication of the growth
pattern of individual.
A lower angle is
indicative of a horizontal
growing face while
An increased angle
suggests a vertical
ANGLE
The occlusal plane angle
is formed between the
occlusal plane and the
S.N.Plane.
 In this analysis the
occlusal plane represents
a line passing through the
overlapping cusps of first
premolars and first
molars.
It has a mean value of
14.5º.
This angle indicates the
relation of the occlusal
plane to the cranium and
face.
It also indicates the
 Cont…
2. Dental Analysis
 Upper Incisor to N-A (Angle)
 Upper Incisor to N-A (Linear)
 Lower Incisor to N-B (Angle)
 Lower Incisor to N-B (Linear)
 Inter Incisor Angle
N-A (ANGLE)
It is the angle formed
by the intersection of the
long axis of the upper
central incisors and the
line joining Nasion to
Point A.
The normal angle is
22º.
This angle indicates the
relative inclination of
upper incisors.
An increased angle is
seen in patients who
have proclined upper
incisors as in class II
Division 1 malocclusion.
UPPER INCISOR TO
N-A (LINEAR)

It is a linear
measurement between
the labial surface of
upper central incisor and
the line joining nasion to
point A.
This measurement also
helps in determining the
upper incisor position.
Normal value is 4mm.
It increases in cases
with proclined upper
incisors
LOWER INCISOR TO
N-B (ANGLE)
This angle is formed
between the N-B plane and
the long axis of the lower
incisor.
 This angle indicates the
inclination of the lower
central incisor and has a
mean value of 25º.
An increased value
indicates proclination of
lower incisors whereas
 a decreased value
indicates upright or
retroclined lower incisors.
N-B (LINEAR)
It is the linear
distance between the
lingual surface of lower
central incisor and the
line joining Nasion to
point B.
This measurement
helps in assessing the
lower incisor
inclination.
An increase in this
measurement indicates
proclined lower
incisors.
 The normal value
4mm.
INTER INCISOR ANGLE

This is the angle

formed between the
long axis the upper and
lower central incisors.
A reduced inter-
incisor angle is
associated with a Class
II Divission 1
malocclusion or a Class
I bimaxillary .
A larger than normal
angle is seen in Class II
Division 2 malocclusion.
The mean value is
130- 131º.
 Cont…
3. Soft Tissue Analysis
 S. Line
 SOFT TISSUE
ANALYSIS
According to Steiner the
lips in a well-balanced face
should touch a line
extending from soft tissue
contour of the chin to the
middle of an “S” formed by
the lower border of the
nose.
If the lips are located
beyond this line then the
lips are believed to be
protrusive and are
interpreted as a convex
profile.
If the lips are behind this
line they are said to be
 III. Tweed Analysis
 Tweed Analysis makes use of three planes that
form a diagnostic triangle.
 The planes used are:
A. Frankfort Horizontal Plane
B. Mandibular Plane
C. Long Axis of the Lower Incisor
The objectives of the analysis include:
A. Determination of the position of the lower
incisor.
B. Evaluation of prognosis
 Cont…
 The Angles formed by these three planes are:
1. Frankfort Mandibular Plane Angle (FMPA)
 It is the angle formed by the intersection of the
Frankfort horizontal plane with the mandibular
plane.
 The mean value is 25 degree
 An increased FMPA- high angle cases is
suggestive of a vertical growth pattern.
 A decreased FMPA- low angle cases is
suggestive of a horizontal growth pattern.
 Cont…
2. Incisor Mandibular Plane Angle (IMPA)
 It is the angle formed by the intersection
of the lower incisor with the mandibular
plane.
 It indicates the relative inclination of
the lower incisor.
 The mean value is 90 degree.
 Cont…
3. Frankfort Mandibular Incisor Angle
(FMIA)
It is the angle formed by the intersection
of the Lower incisor with the F.H. Plane.
The mean value is 65 Degree.
 Cephalometric postero
-anterior of the jaws
(PA jaws)
This projection is identical to the PA view
of the jaws.
This makes it suitable for the assessment
of facial asymmetries and for preoperative
and postoperative comparisons in
orthognathic surgery involving the
mandible.
Orthodontic problem list
 Cont…
 A summary of findings should be made by the
clinician that highlights the important
information gathered from an examination and
work up of all the diagnostic records.
 The problem list often includes two types of
problems:
1. Those relating to diseases or pathological
process
2. Those relating to disturbances of developments
 Problem listed take into consideration :
1. Andrew six keys to normal occlusion
2. Angles Classification
 Nine Categories of Ackerman and
1. Proffit
Alignment
2. Profile
3. Transverse Deviation
4. Sagittal Deviation-
5. Vertical Deviation
6. Trans sagittal Deviation
7. Sagittovertical Deviation
8. Verticotransverse Deviation
9. Transsagittovertical Deviation
 Cont…
1. Alignment
 Ideal
 Spacing
 Crowding
2. Profile
 Straight
 Convex
 Concave
Cont…
3. Transverse Deviation
 Crossbite
 Buccal
 Palatal
 Unilateral
 Bilateral
 Dental
 Skeletal
 Cont…
4. Sagittal Deviation- Angles Classification
 Class I
 Class II Div. 1
 Class II Div. 2
 Class III
 Dental / Skeletal
5. Vertical Deviation
 Open Bite – Anterior / Posterior
 Deep Bite - Anterior / Posterior
 Dental/ Skeletal
 Cont…
6. Trans sagittal Deviation – Combination of
crossbite and Angles Class
7. Sagittovertical Deviation - Combination of
Angle class deep bite or Open bite
8. Verticotransverse Deviation- Combination
of deep bite or Open bite with crossbite.
9. Transsagittovertical Deviation -
Combination of problems in three plane of
axis
ORTHODONTIC TREATMENT PLAN

TREATMENT PLANING
The treatment plan is created as a response to
the problem list.
The treatment plan describes the procedures
to correct each problem on the list.
Sometimes a problem is listed for which no
orthodontic treatment is planned.
= For example, a retrusive chin may be
corrected with a genioplasty surgery, an option
requiring a referral to an oral surgeon.
The treatment plan includes anchorage
sources such as headgear, transpalatal arches,
interarch elastics, or specific appliances.
 Cont…
 Prioritization of the orthodontic problem list, so that the
most important problem receives highest priority for
treatment.
 Consideration of possible solutions to each problem,
with each problem evaluated for the moment as if it
were the only problem the patient had.
 Evaluation of the interactions among possible solutions
to the individual problems.
 Development of alternative treatment approaches with
consideration of benefits to the patients vs. risks, costs,
and complexity.
 Determination of a treatment concept, with input from
the patient and parent and selection of the specific
therapeutic approach( appliance design,
Mechanotherapy) to be used.
 Cont…
The problem list assessment of the patient - a
summary should be made on the main features
of the malocclusion for e.g.
 Crowding
 Posterior crossbite
 Increased overjet etc
Aims of treatment - This is derived from the
problem list
 Relieve crowding
 Correct crossbite
 Align arches
 Maintain overbite
 When should we conduct
orthodontic Treatment?
This depends upon the particular anomaly.
In the early mixed dentition, treatment is
only indicated to correct incisor crossbites
and posterior crossbites with displacement.
Functional appliance treatment may be
started in the mixed dentition to coincide
with the pubertal growth spurt; however,
the majority of orthodontic treatment is not
started until the secondary dentition has
erupted.
 Cont…
Treatment during the early teens is preferable because:
- the response to orthodontic forces is more rapid,
- appliances are better tolerated, and, most
importantly,
- growth can be utilized to help effect sagittal or
vertical change.
In adults, tooth movement is slower and lack of growth
will limit the type of malocclusion that can be tackled
by orthodontics alone.
 But because of the increased acceptability of
appliances, more adults are seeking treatment.
 Treatment planning form.
Treatment Plan
1.Goals (in response to Problem List)
2.Anchorage sources
3.Complicating Factors
Appliance Plan
1.Draw picture of Removable Appliance
2.Describe Fixed Appliance
Retention Plan
1.Describe Retention Appliance
2.Recommendation to Patient Regarding wear
time for Retainers
 Cont…

END