CHECKING AND DIAGNOSIS
Wang Haiyan
Orthodontics Department
Stomatology Hospital of Wenzhou
Medical University
1.Purpose of Orthodontic Diagnosis
• To evaluate and record the features of a
malocclusion in preparation for planning
treatment
2.Process of Orthodontic Diagnosis
• 1). Questionnaire and Interview
Chief Concern, Medical and Dental History , Physical Growth
Evaluation, Social and Behavioral Evaluation
• 2). Clinical Evaluation
Oral Health , Jaw and Occlusal Function , Dental examination,
Facial and Dental Appearance
• 3). Analysis of Diagnostic Records
• 4). Cephalometics analysis
• 5). Development of a Problem List
Analysis of Diagnostic Records
• 1. Types of model
• 2. Making a model
• 3. Model analysis
• 4. Diagnostic set-up
• 5. Computer-assisted model analysis
Analysis of Diagnostic Records
• 1. Types of model
(1). study model
(2). job model
Analysis of Diagnostic Records
2. Making a model:
Impression taking Cast pouring Occlusion checking
Model trimming
Analysis of Diagnostic Records
3. Model analysis: 1)Space Analysis(Crowding/ Spacing)
space required space available
Crowding=space required-space available
Not enough room: crowding, protrusion, or some combination of the two
Analysis of Diagnostic Records
Types of crowding
I° 0-4mm
II°4~8mm
III °>8mm
I° 0-4mm
II°4~8mm
III °>8mm
space available 12.9cm space required:12.2cm
Analysis of Diagnostic Records
3. Model analysis: Tooth size (Bolton analysis)
• Bolton index is the sum of the upper and lower
anterior teeth crown width ratio between the upper
and lower dental arch and the sum of all the tooth
crown width ratio relationship.
• Ratio of incisors=sum of mandibular incisor width/
sum of maxillary incisor width *100%
• Ratio of total teeth= sum of mandibular tedth width /
sum of maxillary teeth width *100%
• Normal Bolton ratio: incisor 78.8%±1.72%,
total teeth 91.5%土1.51%
Analysis of Diagnostic Records
3. Model analysis: morphological analysis of dental arch
• A. Curve of spee
The cusp tips and incisal edges align so that there is a smooth
linear curve when viewed from the lateral aspect. The mandibular
curve of Spee is concave whereas the maxillary curve is convex
flat: curve of Spee<2mm。
deep: curve of Spee>3mm。
Analysis of Diagnostic Records
3. Model analysis: morphological analysis of dental arch
• B. Symmetry evaluation: Evaluating dental casts from the
occlusal view when the cast bases have been trimmed
symmetrically can make it easier to see a distortion of arch form in
either physical or virtual casts
Analysis of Diagnostic Records
3. Model analysis: morphological analysis of dental arch
C. Length evaluation
arch length
Analysis of Diagnostic Records
3. Model analysis: morphological analysis of dental arch
D. width evaluation
Anterior arch width
Posterior arch width
Analysis of Diagnostic Records
3. Model analysis: morphological analysis of dental arch
D. width evaluation arch width
Analysis of Diagnostic Records
4. Diagnostic set-up
Analysis of Diagnostic Records
• 5. Computer-assisted model analysis
Analysis of Diagnostic Records
• 5. Computer-assisted model analysis
Accurate measurements can be achieved from digital
casts derived from direct intraoral scans.
Analysis of Diagnostic Records
• 5. Computer-assisted model analysis
Tooth-size analysis (Bolton analysis) also is readily available from digital casts. This
requires accurate measurement of the width of each of the teeth, so that the sum of
the incisor widths in each arch, and the sum of the widths of all the teeth, can be
compared with these sums for the other arch
2.Process of Orthodontic Diagnosis
• 1). Questionnaire and Interview
Chief Concern, Medical and Dental History , Physical Growth
Evaluation, Social and Behavioral Evaluation
• 2). Clinical Evaluation
Oral Health , Jaw and Occlusal Function , Dental examination,
Facial and Dental Appearance
• 3). Analysis of Diagnostic Records
• 4). Cephalometics analysis
• 5). Development of a Problem List
Diagrammatic representation of the American standard cephalometric
arrangement. By convention, the distance from the x-ray source to the subject’s
midsagittal plane is 5 feet. The distance from the midsagittal plane to the
cassette can vary but must be the same for any one patient every time so that
magnification is the same and changes from one time to another can be
measured accurately.
Cephalometrics
• 1. Application of cephalometrics
• 2. Cephalometric landmarks
• 3. Cephalometric plane
• 4. Cephalometics analysis
Cephalometric
-------- Application of cephalometrics
Cephalometrics
---Application of cephalometrics
(1) study the growth and development of craniofacial
(2) analysis dental and craniofacial malformations
(3) design the treatment of malocclusion
(4) study the dental and craniofacial change during
treatment and after dental treatment
(5) surgical orthodontic diagnosis and treatment design
(6) analysis of the mandibular function
(1).study the growth and development of
craniofacial
(2). Analysis dental and craniofacial
malformations
Incompetent lips at rest or lip strain on closure
Soft-tissue profiles
Jaw relationships
Dental relationships
The maxilla and incisors are protrusive
Protrusive mandible and incorrect treatment
Good facial balance with
lips approximating the s-line
Convex profile caused by upper and lower
incisor teeth being too protrusive
(3) design the treatment of malocclusion
(4).study the dental
and craniofacial
change before and
after dental treatment
(4).study the dental
and craniofacial
change before and
after dental treatment
(4).study the dental
and craniofacial
change before and
after dental treatment
(4).study the dental
and craniofacial
change before and
after dental treatment
Maxillary
(4).study the dental
and craniofacial
change before and
after dental treatment
Mandibular
Cephalometrics
• 1. Application of cephalometrics
• 2. Cephalometric landmarks
• 3. Cephalometric plane
• 4. Cephalometics analysis
Cephalometrics
----Cephalometric landmarks
Cephalometrics
----Cephalometric landmarks
• 1. Bone
• 2. Soft tissue
Cephalometric landmarks:
1. Bone
• (1) Cranial landmarks
• (2) Maxillary landmarks
• (3) Mandibular landmarks
Cephalometric landmarks:
Cranial landmarks:
• S : sella, the midpoint of the cavity
of sella turcica;
• Na : nasion, the anterior point of
the intersection between the nasal
and frontal bones;
• P.porion: the midpoint of the upper
contour of the external auditory
canal (anatomic porion), or the
midpoint of the upper contour of
the metal ear rod of the
cephalometer (machine porion);
• Bolton point: Bo, Bolton point, the
highest point in the upward
curvature of the retrocondylar fossa
of the occipital bone;
• Ba : basion, the lowest point on the
anterior margin of the foramen
magnum, at the base of the clivus;
Cranial landmarks:
• S : sella, the midpoint of the cavity
of sella turcica;
• Na : nasion, the anterior point of
the intersection between the nasal
and frontal bones;
• P.porion: the midpoint of the upper Na
contour of the external auditory S
canal (anatomic porion), or the Ba
midpoint of the upper contour of
the metal ear rod of the P.porion
cephalometer (machine porion); Bolton point
• Bolton point: Bo, Bolton point, the
highest point in the upward
curvature of the retrocondylar
fossa of the occipital bone;
• Ba : basion, the lowest point on the
anterior margin of the foramen
magnum, at the base of the clivus;
Cephalometric landmarks:
Maxillary landmarks
0r.: orbitale, the lowest point on the
inferior margin of the orbit;
Ptm: pterygomaxillary fissure, the
point at the base of the fissure where
the anterior and posterior walls meet;
ANS: anterior nasal spine, the tip of
the anterior nasal spine
PNS: posterior nasal spine, the tip of
the posterior spine of the palatine
bone, at the junction of the hard and
soft palates;
Maxillary landmarks
Point A : the innermost point on the contour of the premaxilla
between anterior nasal spine and the incisor tooth;
SPr: superior prosthion
0r.
Ptm ANS
PNS Point A
SPr
Cephalometric landmarks:
Mandibular landmarks
Condylion (Co)
The toppest point of the
condyle
Articulare (Ar)
articulare, the point of
intersection between the
shadow of the zygomatic arch
and the posterior border of the
mandibular ramus
Cephalometric landmarks:
Mandibular landmarks
Go
gonion, the midpoint of the
contour connecting the ramus
and body of the mandible.
Me
menton, the most inferior
point on the mandibular
symphysis—that is, the
bottom of the chin
Cephalometric landmarks:
Mandibular landmarks
Pogonion (Pog P, Pg)
the most anterior point on the
contour of the chin
Gnathion (Gn)
the midpoint of Pg and Me
Cephalometric landmarks:
Mandibular landmarks
Point B
the innermost point on the
contour of the mandible
between the incisor tooth and
the bony chin
Infradentale (Id)
The most prominent point of
the inferior alveolar
Cephalometric landmarks:
Mandibular landmarks
lower incisors
points (Li)
the most anterior point of
the incisor cutting edge
Point D
center of the ministy of
mandibular
Cephalometric landmarks:
1---Bo, Bolton point
2---Ba, basion
3--- Ar, articulare
4---Po, porion
6---S, sella
7--- Ptm, pterygomaxillary
fissure
8--- Or, orbitale
9---ANS, anterior nasal
spine
10---point A
11---point B
12---Pog, pogonion
13--- Me, menton
14---Go, gonion
Cephalometrics
----Cephalometric landmarks
• 1. Bone
• 2. Teeth
• 3. Soft tissue
Cephalometric landmarks:
Soft tissue landmarks
• G:the most front point
of the frontal Part
• NS: nasion of soft
tissue
• Sn:the connection
point of columella and
upper lip
Cephalometric landmarks:
Soft tissue landmarks
• the chin point of soft tissue
of (pos): the pogonion of
soft-tissue .
• Soft tissue under the chin
point (Mes) : the lowest
point of the soft tissue chin
• Pharynx point (K):the
connection point of the soft
tissue neck and throat.
Cephalometric landmarks:
Soft tissue landmarks
Lower lip edge point (LL) :
the connection point of the lower
lip mucosa and skin
Upper lip protrusion point
(UL) : the most prominent point
of the upper lip.
Cephalometrics
• 1. Application of cephalometrics
• 2. Cephalometric landmarks
• 3. Cephalometric plane
• 4. Cephalometics analysis
Cephalometrics
----Cephalometric plane
Cephalometric planes
Reference plane is defined
as a relatively stable plane in
N
S
cephalometric analysis. The
P
most commonly used for the
Bo
. Or
anterior skull base
. Sella-Nasion plane
. Frankfort horizontal plane
.
.
. Bolton plane
.
Cephalometric planes
Sella-Nasion plane
SN line -----
connecting the midpoint of
sella turcica with nasion, is
taken to represent the
cranial base.
Cephalometric planes
• Frankfort plane - this is the line joining porion and orbitale. This
plan is difficult to define accurately because of the problems inherent
in determining orbitale and porion.
Cephalometric planes
• Bolton plane
The connection line from
Bolton point to nasion-point.
This plan is used as reference
plane for overlap
cephalometric analysis
Cephalometric planes
Maxillary plane- the
line joining anterior nasal spine
with posterior nasal spine.
Where it is difficult to determine
ANS and PNS accurately, a line
parallel to the nasal floor can be PNS ANS
used instead.
Cephalometric planes
MP.mandibular plane:
(A) the contact line of gnathion
and inferior margin of mandibular
angle
(B) the tangent line of the inferior
border of mandible
(C) (Go-Gn） the line joining
gonion and gnathion which is the
most widely used
Cephalometics plane
Mandibular plane
Intersection angle of MP and FH
Intersection angle of MP and SN
Cephalometric planes
Functional occlusal plane
a line drawn between the cusp tips of the manent molars and premolar
(or deciduous molars in mixed dentition). The functional plane can
change orientation with growth and/or treatment, and so is not particularly
reliable for longitudinal comparisons.
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Cephalometics plane
Soft tissue
Facial plane:
A line between the soft
tissue nasion and the
soft tissue chin.
Cephalometics plane
Soft tissue
The Holdaway line:
a line from soft tissue
chin to the upper lip
Cephalometics plane
Soft tissue
Rickett’s E-plane:
This line joins soft tissue
chin and the tip of the nose.
In a balanced race the
lower lip should lie 2 mm
(± 2 mm) anterior to this
line with the upper lip
positioned a little further
posteriorly to the line
Cephalometics plane
The Facial Proportion
This is the ratio of the lower facial height to the total anterior facial height
measured perpendicularly from the maxillary plane
Cephalometrics
• 1. Application of cephalometrics
• 2. Cephalometric landmarks
• 3. Cephalometric plane
• 4. Cephalometics analysis
Cephalometics analysis
• 1. Steiner Analysis
• 2. Sassouni Analysis
• 3. Harvold Analysis
• 4. McNamara Analysis
• 5. Counterpart Analysis
Cephalometics analysis
1.Steiner Analysis
Anteroposteriol skeletal pattern
1. SNA (°)
2. SNB (°)
3. ANB (°)
Cephalometics analysis
Angle ANB
The skeletal pattern is often determined
cephalometrically by comparing the
relationship of the maxilla and mandible
with the cranial base by means of angles
SNA and SNB.
angle ANB is classified broadly as follows:
ANB < 2° Class III
2°≤ANB ≤4° Class I
ANB > 4° Class II
Cephalometics analysis
1.Steiner Analysis
• 1. The relationship of the upper incisor to the NA
line is used to establish the position of the
maxillary dentition relative to the maxilla. Both the
millimeter distance that the labial surface of the
incisor is in front of the line and the inclination of
the long axis of the incisor to the line are
measured.
• 2. The position of the lower incisor relative to the
mandible is established by similar measurements
to the line NB.
• 3. The prominence of the chin is established by
measuring the millimeter distance from the NB
line to pogonion, the most prominent point on the
bony chin.
Cephalometics analysis
2.Sassouni Analysis
• The Sassouni analysis was the first to emphasize vertical, as well as horizontal,
relationships and the interaction between vertical and horizontal proportions.
Sassouni pointed out that the horizontal anatomic planes—the inclination of the
anterior cranial base, Frankfort plane, palatal plane, occlusal plane, and mandibular
plane—tend to converge toward a single point in well-proportioned faces.
Cephalometics analysis
2.Sassouni Analysis
• Inspection of the horizontal planes for this patient makes it clear that the maxilla is
rotated downward posteriorly and the mandible rotated downward anteriorly.
These rotations of the jaws contribute to an open bite tendency, so the skeletal
pattern revealed here is often referred to as “skeletal open bite.”
Cephalometics analysis
3. Harvold Analysis
• Maxillary length is measured from the temporomandibular joint (TMJ), the
posterior wall of the glenoid fossa, to lower anterior nasal spine (ANS), defined as
the point on the lower shadow of the ANS where the projecting spine is 3 mm
thick. Mandibular length is measured from TMJ to the gnathion, the most anterior
and inferior point on the chin in the lateral views. Lower face height is measured
from hte upper ANS, the similar point on the upper contour of the spine where it is
3 mm thick, to menton.
Cephalometics analysis
4. McNamara Analysis
• Both the anatomic Frankfort plane and the basion–nasion line are used as
reference planes. The AP position of the maxilla and mandible are evaluated with
regard to their position relative to the “nasion perpendicular,” a vertical line
extending downward from nasion perpendicular to the Frankfort plane . The
maxilla should be on or slightly ahead of this line, the mandible slightly behind.
Cephalometics analysis
5. Counterpart Analysis
• Enlow’s counterpart analysis emphasizes the way
changes in proportions in one part of the head
and face can either add to increase a jaw
discrepancy or compensate so that the jaws fit
correctly even though there are skeletal
discrepancies.
• For example, if the maxilla is long (measurement
6), there is no problem if the mandible (7) also is
long, but malocclusion will result if the
mandibular body length is merely normal. The
same would be true for anterior versus posterior
vertical dimensions (1 to 3). If these dimensions
match each other, there is no problem, but if
they do not, whether short or long, malocclusion
will result.
Orthodontic Applications of CBCT
• Ectopically Erupting or Impacted Teeth
Orthodontic Applications of CBCT
• Facial Asymmetry and Complex Orthognathic
Surgery
2.Process of Orthodontic Diagnosis
• 1). Questionnaire and Interview
Chief Concern, Medical and Dental History , Physical Growth
Evaluation, Social and Behavioral Evaluation
• 2). Clinical Evaluation
Oral Health , Jaw and Occlusal Function , Dental examination,
Facial and Dental Appearance
• 3). Analysis of Diagnostic Records
• 4). Cephalometics analysis
• 5). Development of a Problem List
Development of a Problem List
Angle's classification include four groups
Normal Class I Class ll Class lll
Angle's classification include four groups
Angle's classification include four groups
• The Angle classification has come to describe four different things that can be
seen on clinical examination, dental casts, and/or cephalograms: the type of
malocclusion, the molar relationship, the jaw relationship, and the pattern of
growth. Although the jaw relationship and growth pattern correlate with the
molar relationship, the correlations are far from perfect.
Classification by the
Characteristics of Malocclusion
• Step 1: Evaluation of Facial Proportions and Esthetics
• Step 2: Evaluation of Alignment and Symmetry Within
the Dental Arches
• Step 3: Evaluation of the Transverse Plane of Space
• Step 4: Evaluation of the Anteroposterior Plane of
Space
• Step 5: Evaluation of the Vertical Plane of Space
Classification by the
Characteristics of Malocclusion
1.Evaluation of Facial Proportions
and Esthetics
2.Evaluation of Alignment and
Symmetry Within the Dental
Arches
3.Evaluation of the Transverse
Plane of Space
4.Evaluation of the
Anteroposterior Plane of Space
5.Evaluation of the Vertical Plane
of Space
Development of a Problem List
• Patient F.P.
• age 12-3
Patient F.P.: Interview Data
Patient F.P.: Clinical Examination Data
Patient F.P.: Clinical Examination Data
Patient F.P.: Analysis of Diagnostic Record
Patient F.P.: Problem List (Diagnosis)
Classification by the
Characteristics of Malocclusion
• Step 1: Evaluation of Facial Proportions and Esthetics
• Step 2: Evaluation of Alignment and Symmetry Within
the Dental Arches
• Step 3: Evaluation of the Transverse Plane of Space
• Step 4: Evaluation of the Anteroposterior Plane of
Space
• Step 5: Evaluation of the Vertical Plane of Space
Treatment Planning
Treatment Planning
• Patient motivation
• Limitations of orthodontic treatment
• Aims of treatment
• Treatment possiblitities
• Appliance and technology
• Extraction or not and the extraction site
• Anchorage design
• Timing and fee of treatment
• Retention
Planning Comprehensive Orthodontic Treatment
1. Setting Priorities for the Orthodontic
Problem List
2. Factors in Evaluating Treatment
Possibilities
3. Informed Consent: Paternalism Versus
Autonomy
• Gasp: common examination method for teeth , occlusion
and face. Identify some concept: crowding , deep
overbite , deep overjet, open bite, Angle's classification
• Gasp: measure cast common method
• Gasp: common X-ray cephalometry landmark and plane,
Classification by the Characteristics of Malocclusion
• Familiarity: clinical common X-ray cephalometry measure
method.
• Familiarity: kind of age malocclusion treatment indication
