Orthodontic Diagnosis for General Practitioners

1. 1 Orthodontic Orthodontic Diagnosis For For G General practitioner eneral practitioners s Prepared by Prepared by Dr. M Dr. Mohammed ohammed Alruby Diagnosis Alruby Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Orthodontic diagnosis deals with recognition of the various characteristics of the malocclusion. It involves collection of data in a systematic manner to help in identifying the nature and cause of the problem. Comprehensive orthodontic diagnosis is established by use of certain clinical implements called diagnostic aids. Consideration of general health, appearance and attitude: The first step in any orthodontic examination is to form a general idea of patient's health status, physical appearance and attitude toward orthodontics. Case history: Case history involves eliciting and recording of relevant information from the patient and parents to aid in the overall diagnosis of the case. The information is gathered from the patient and parents. Personal details: Name: the patient's name should be recorded for the purpose of communication and identification. Most patients like being called by their name. Addressing the patient by his or her name has a beneficial psychological effect as well. In case of children it is wise to record their pet names. Age: the patient's chronological age should be recorded. Age consideration helps in diagnosis as well as treatment planning. There are certain modalities that are best carried out during the growing age. Growth modification procedures using functional and orthopedic appliances are carried out during the growth period. Surgical respective procedure is best carried out after the cessation of growth. ** Dental age determination: can be determined by two different methods: -Stage of eruption of teeth. -Stage of tooth mineralization on radiograph. Determination of the dental age from observation has been the only method available for long time. In certain cases however, the accuracy of the method is limited. When determining the dental age radiographically according to the stage of germination, the degree of development of individual teeth is compared to a fixed scale. ** Skeletal age evaluation: assessment of the skeletal age is often made with the help of a hand radiograph which can be considered the biologic clock. For the analysis of skeletal maturity the stage of mineralization of the carpal bones must be determined thereafter the development of the metacarpal bones and phalanges should be evaluated. For the evaluation of the hand radiograph various indicators regarding the development and maturity are established which occur regularly in a definite sequence during skeletal development. Sex: the patient sex should be recorded in the case history. This is important in planning treatment, as the timing of growth events such as growth spurts is different in males and females. Females usually precede males in onset of growth spurts, puberty and termination of growth. Address and occupation: this help in evaluation of socio-economic status of the patients and parents. Some countries have normal slight bimaxillary protrusion. We can determine the awareness of the patients and his or her parents to the orthodontic treatment and this affect the patient's cooperation. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 Chief complaint: The patient's chief complaint should be recorded in his or her own words. For any patient need orthodontic treatment, complaint from: 1-Impaired dentofacial esthetic and this important to the patient because the teeth appear unaesthetic, that can lead to psychological problems. 2-Impaired function. Medical history: Before orthodontic treatment is undertaken, a full medical history is recorded. Fortunately, very few medical conditions contraindicate the use of orthodontic appliances most of these conditions may require certain precautionary measures to be taken prior to or during the orthodontic therapy. Diabetic patient must be under control and also needs special care before and during treatment. Patients having rheumatic fever or cardiac anomalies require antibiotic coverage. It is advisable to delay orthodontic treatment in patients suffering from epilepsy until it is controlled. The medical history should include information on the drugs usage. The use of certain drugs like aspirin may impede the orthodontic tooth movement. Patient that take a long time suffer from metabolic disease as calcium and phosphorus disorder need special care because this can affect the quality of the bone formation. Ask the patient about cancer, asthma, anemia, liver disease, sleep problem, heart problem, speech and hearing problem, also need to ask about allergy to certain drugs or others like latex or nickel. The use of long time with steroids leads to less resistance to infection. Patient with thyroid hormone deficiency has a generalized root resorption. Dental history: The dental history of the patient should include information on the age of eruption of deciduous and permanent teeth. Ask about the dental health and care and times of tooth brushing, history of tooth decay, extraction and restoration, and trauma to dentition or TMJ. History about the caries index to the patient and the cooperation during any operative procedure. Family history: Observe the anomalies that present in the family of the patient, as certain types of malocclusion like Class II or Class III skeletal malocclusion has familial background. Some congenital defects as cleft palate or cleft lip have familial background. Behavior of the patient: Behavior of the patient depends on: 1-Patient motivation for treatment. 2-What he or she expect as a result of treatment. 3-How patient cooperation or un-cooperation is likely to be. ** Patient motivation: the patient motivation may be external that supplied by pressure from another individual as parents or his or her friends that they need the teeth to look better. Or it may be internal motivation that comes from within the individuals and based on his or her assessment of situation and need for treatment. It is difficult to find purely internal motivation especially in children but can be developed in adolescence. The motivation affects the cooperation as the cooperation is better for the patient feels that the treatment is benefit for him than that feels that this treatment similar to anything done to him. So it is necessary to ask the patient, do you need the orthodontic treatment and why, to establish what motivation is rarely. ** Patient expectation: is very much related to the type of motivation. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 ** Patient cooperation: this more likely to problem in children than adults and determined by: 1-The extent to which the child sees the treatment is benefit. 2-The degree of parents' control. General examination: The general examination comprises of the general assessment of the patient. An observant clinician usually begins his general examination as soon as the patient enters the clinic. This general examination as Height and weight, gait, posture, this can give an idea about: -Growth and maturation of the patient that may have dento-facial correlation. -Abnormalities in gait are usually associated with neuromuscular disorder that may have dental correlation. -Abnormal postures can predispose to malocclusion due to alteration in maxilla- mandibular relationship. Extra-oral examination: The patient should be seated in the dental chair in an upright position and his head is placed well over the vertebral column, and the Frankfort horizontal plane should be roughly parallel to the floor and this position in the chair not usual for intra-oral examinations. Frontal examination of the face: Firstly, divide the face into three thirds, upper, middle, lower third, (in vertical direction) Upper third extended from the hair line to glabella and composed of cranium and forehead. Middle extended from glabella to the junction of the nose and upper lip (subnasal). Lower extended from subnasal to menton, and the lower third is divided into upper lip portion and lower lip portion. Generally, the three thirds should be equal to each other in its proportions. ** For horizontal direction: determine the facial midline of the face that passes through soft tissue nasion, tip of the nose, and philtrum of the upper lip and this is an imaginary line on the face and examine the structures on the face in relation to this line, the both sides should be equal in horizontal direction. Patient that has normal vertical and horizontal proportions is considered as a normal patient. Alar width: equal the size from the inner canthus of the eye to the inner canthus of the eye on the other side. Mouth width: equal the inter-pupillary line of the eye. Profile examination: The vertical relationship of the face can be examined from the profile view as from the frontal view, so it divided into three thirds and examine its relation to each other. The profile is assessed by joining the two reference lines: 1-A line joining the forehead and the soft tissue point A (deepest point in the curvature of the upper lip) 2-A line joining point A and soft tissue pogonion (most anterior point on the chin). Based on the relationship between the two lines, three types of profile exist. Convex: ------- --------------------- - Class II-------- Retrognathic face. Concave: --------- ------------------- Class III ------- Prognathic face. Straight or slight convex face: -----Class I -------- Orthognathic face. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 ** Clinical assessment of facial profile: 1-Visual examination of the patient during rest. 2-Palpation of maxillary and mandibular basal bone by index and middle finger when the teeth in occlusion, but the thickness of the lips may interfere with this assessment so the lips may retract to give a good diagnosis. Pleasing of the patient: The esthetic of the patient is difficult to detect because the esthetic is variable in its means and differ from one person to another, the pleasing of the patient depends on the opinion of the patient and doctor and others, and also depend on coincident of the facial proportions to each other in vertical and horizontal direction and presence of a symmetry or not. Examination of chin: The chin position is evaluated with the patient's head oriented along the Frankfort horizontal plane (FH), an imaginary line is drawn from soft tissue nasion perpendicular to FH plane. If the chin falls significantly behind this line, it indicates anteroposterior mandibular deficiency, if the chin is significantly in front of this line, it indicate anteroposterior mandibular excess. Mentolabial sulcus: the mento labial sulcus is a concavity seen below the lower lip. Deep mento- labial sulcus is seen in Class II division 1 malocclusion while is shallow in bimaxillary protrusion. Mental activity: normally the mentalis muscle does not show any contraction at rest. Hyperactive mentalis muscle as Class II division 1 cases puckering of the chin. Examination of the nose: Many congenital diseases are associated with abnormal nasal morphology: as congenital syphilis that characterized by depressed nasal bridge, skeletal deep bite that characterized by large nose and wide apertures, skeletal open bite that characterized by long slender nose and narrow apertures. The size, shape and position of the nose determine the esthetic appearance of the face, so the assessment of the nose is important before treatment because rhinoplasty may be necessary later. Nose size: normally the nose is one third of the total facial height (from hair line to lower border of chin). Nostrils: they are oval in shape and should be bilaterally symmetrical. Stenosis of the nostril may be indicating impaired nasal breathing. Width of the nostril is approximately 70% of the length of the nose. Nasolabial angle: it is the angle formed between the lower border of the nose and a line connecting the intersection of nose and upper lip with the tip of the lip (labrale superius) this angle is normally 100 degree -+10 degree. It reduces in patients having proclined upper anterior teeth or prognathic maxilla. It increases in patients with retrognathic maxilla or retroclined maxillary anterior teeth. Facial symmetry: From the clinical point of view, there is no face that is symmetrical at all in all facial dimensions either for vertical and horizontal because there is a small degree of bilateral facial asymmetry exists in all normal individuals. This can be revealed most readily by comparing full face photographs with composites consists of two right and two left sides and this called normal Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

6. 6 a symmetry , which usually result from small size differences between the two sides and this should be distinguished from the high disproportion in horizontal and vertical direction. Examination of lips: In normally relaxed unstrained position of the lips, the lips are sealed together, upper lip measure one third of the lower face height, and lower lip measure two third of lower face height. Normally the upper lip covers the entire labial surface of the upper incisors except about 2-3mm from the incisal edge. The lower lip covers the entire labial surface of lower central incisors and about 2-3mm of the incisal edge of the upper incisors. Color of lips: the two lips should be had a similar color and texture but in some cases that the lower lips rests beneath the upper incisors during swallowing, it usually redder, heavier, moist and smooth. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

7. 7 Lip steps: positive lip step: as in Class III. Negative lip step: as in normal case and normal profile. Marked negative lip step: as in case of Class II. Types of lips: 1-Competent lip: the lips are slight contact when the musculatures are relaxed. 2-Incompetent lips: the lips are morphologically short that does not form a lip seal in relaxed state. The lip seal can occur by active contraction of the lip musculature. 3-Potentially incompetent lips: they are normal lips fail to form seal due to proclined upper incisors. 4-Everted lip: it is a hypo-trophied lip with redundant tissue but weak muscular tonicity. Lip dysfunction: can be observed during speaking and swallowing and present as lip sucking and lip insufficiency. Any change in lips during function is a symptom of oro-facial dysfunction. Physiologic analysis of the lips and face: 1-During rest: during rest upper and lower lips meet each other lightly without active contraction to provide anterior oral seal, sometimes the lips may be habitual a part in few nasal breathers without dental interference. 2-During function: a-Mastication: during normal mastication the lips are held lightly together. Strong contraction will be seen in sever Class II malocclusion with large over jet. b-Swallowing: during normal mature swallowing, the lips touch lightly without active contraction, the facial muscles does not contract; the temporal muscle is contracting to elevate the mandible. Examination of breathing: In normal breathing the lips touch lightly and breathing is achieved through the nose. But in mouth breathing the lips are a parted, the mandible and the tongue assume in low position to provide an adequate oral air way. The normal breathing is important because it allow stimulation of the growth of the nasal air way by pressure of air through the nasal air way. There are types of tests that used to examine the mode of breathing: 1-Mirror test: place a mirror in the front of the nasal orifices, the mirror is cloud in the case of nasal breather. 2-Cotton butterfly test: place a thin cotton fiber against the nasal orifices it will move in case of nasal breathing. This test used to determine unilateral nasal blockage. 3-Water test: the patient is asked to fill his mouth with water and retain it a period of time. While the nasal breathers accomplished this with ease, mouth breathers fined the task difficult. 4-Observation: In nasal breathers the external nares dilate during respiration. In mouth breathers, there is either no change in the external nares or they may constrict during inspiration. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

8. 8 Marked negative lip step negative lip step positive lip step Incompetent lip competent lip Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

9. 9 Normal tooth displays gum smile Intra-oral examination: Examination of tongue: Shape, color and configuration are assessed at the first clinical examination. The tongue can be small, long, or broad in relation to the oral cavity. Tongue size: In normal position of the tongue the lateral border touch the lingual cusps of molars and premolars, the tip of the tongue rest on the lingual surface of the lower centeral incisors, and the dorsum of the tongue touches the palate lightly the clinical picture of a long tongue which can reach the tip of the nose. When the lips are a parted by the mouth mirror or cheeks are withdrawn by cheek retractors, normal tongue activity may be inhibited and what is observed is accommodation to the stretching of the lips and cheeks. Abnormalities of the tongue can upset the muscle balance and equilibrium leading to malocclusion. Presence of large tongue size is indicated by the presence of imprints of the teeth on the lateral margins of the tongue giving it a scalloped appearance. The lingual frenum should be examined for tongue tie, in patients having tongue tie there is an alteration in the resting position of the tongue as well as impairment of tongue movement. Observe the tongue during swallowing, observe the role of the tongue during mastication, and observe the role of the tongue during speech. Examination of the palate: The palate should be examined for the following finding: 1-Presence of any swelling on the palate can be indicative of an impacted tooth, presence of cyst or other bony pathosis. 2-Mucosal ulceration and indentation are features of traumatic deep bite. 3-Presence of clefts in the palate is associated with discontinuity of the palate. 4-The third rugae is usually in line with the canines. This is useful in the assessment of the maxillary anterior proclination. The oral health is closely related to pharyngeal condition, inflamed, hypertrophied tissue or infected tonsils may give rise to alteration in the tongue posture, mandibular posture, swallowing or breathing reflexes. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

10. 10 Examination of gingiva: The gingival should be examined for any inflammation, recession, and other mucogingival lesions. Presence of poor oral hygiene is usually associated with generalized marginal gingivitis. It is common to find anterior marginal gingivitis in mouth breathers due to dryness of the mouth caused by the open lip posture. Presence of traumatic occlusion can cause localized gingival recession. In case of hyper active mentalis muscle, there is an inflammation on the lower anterior segment. (Hyper active mentalis muscle characterized by deep mento-labial sulcus and this habitual pattern of muscle impedes the forward development of anterior alveolar process in the mandible, this abnormality can occur together with lip sucking) Examination of dentition: The dentition is examined and the following data are recorded: 1-Number of teeth present inside the oral cavity. 2-Number of unerupted and missing teeth. 3-Evaluation of the size of the teeth. 4-Examine the sequence of eruption of the teeth. 5-Examination of individual malposed teeth: malposition of teeth must be evaluated according to their developmental status, not by their ultimate position in the line of the arch, for example: maxillary cuspids usually erupt high in the alveolar process point mesially and labially in such position normal only if there is adequate space in the arch for the tooth. 6-Occlusal relationship of the teeth: with the mandible in the retruded contact position or the ideal occlusal position, the examiner should explain the occlusal relationship of the teeth in details, begging at one side in the molar region and advancing around the arch to the opposite side. 1-Note the precise intercuspation of each of posterior teeth and whether the intercuspation is symmetric. 2-Determine precisely the anteroposterior relationship of the molars and cuspids. 3-Measure the incisors relationship both vertically and horizontally. (Over jet and over bite). 4-Note any lake of incisal stopper as in an open bite and fined any explanation for their absence. 5-Palpate the teeth to observe any mobility of it. Attached lingual frenum long size tongue Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

11. 11 Broad size tongue tongue show indentation Simple tongue thrust swallowing retained infantile swallowing Lateral tongue thrust Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

12. 12 Normal swallowing abnormal swallowing behavior Highly attached labial frenum Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

13. 13 Functional examination: Orthodontic diagnosis should not be restricted to static evaluation of the teeth and their supporting structures but should include the examination of the various functional units of the stomatognathic system. The functional examination should include the following: 1-Assessment of postural rest position and inter-occlusal space. 2-Path of closure. 3-Examination of temporomandibular joint. 4-Examination of swallowing. 5-Examination of speech. Assessments of postural rest position and inter-occlusal clearance: The postural rest position is the position of the mandible at which the muscles that close the jaws and those that open them are, in a state of minimal contraction to maintain the posture of the mandible. At the postural rest position, a space exists between the upper and lower jaws, this space called the inter-occlusal clearance or the free-way space. Normally the free-way space is 3mm in the canine region. The following are some of the methods used to record the postural rest position: 1-Phonetic method: the patient is asked to repeat some consonants like "M" or "C", the mandible return to the postural rest position 1-2 seconds after the exercise. The patient is told not to change the jaw, lip or tongue positions after the phonation, as the dentist a part the lips to study the inter-occlusal space. 2-Command method: the patient is asked to perform certain functions as swallowing. The mandible tends to return to rest position following this act. 3-Non command method: the patient is distracted so as not to perceive which type of examination is being carried out. While being distracted the patient relax as well and the mandible revert the postural rest position. 4-Tapping method: the chin is placed between the thumb and the fore finger, the clinician uses this grip to carry out passive opening and closing movements of the mandible in rapid succession in order to relax the masticatory muscles prior to determining the rest position. Verify whether the musculature has been relaxed by palpating the sub- mental muscles. 5-Direct intra-oral method: Vernier calipers can be used directly in the patient's mouth at the canine region to measure the free-way space. 6-Direct extra-oral procedure: two marks are placed one at the tip of the nose and another one at the chin in the midsagittal plane. The distance between the two points is measured after instructing the patient to remain at rest position. Later the patient is asked to occlude the teeth and the distance between the two points is again measured. The difference between the two readings is the free-way space. 7-Indirect extra-oral procedure: the inter-occlusal space is determined in the radiograph. Two lateral cephalogram, one at rest position and the other at the centric occlusion, the differences between the two measures is the free-way space. Evaluation of the path of closure: The path of closure is the movement of the mandible from rest position to habitual occlusion; abnormalities in the path of closure are seen in some forms of malocclusion. 1-Forward path of closure: a forward path of closure occurs in patients with edge to edge incisors relationship. In such patients, the mandible is guided to a more forward position to allow the mandibular incisors to go labial to the upper incisors. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

14. 14 2-Backward path of closure: in cases of Class II division 2 exhibit premature incisor contact due to retroclined maxillary incisors. Thus the mandible is guided posteriorly to establish occlusion. 3-Lateral path of closure: lateral deviation of the mandible to the right or to the left is associated with occlusal prematurity and narrow maxillary arch. Examination of the temporomandibular joint: 1-Auscultation: sounds made by the temporomandibular joints can be evaluated with a stethoscope; even slight abnormal sounds can be registrated. Also the timing of the click during opening or closing. 2-Lateral palpation of the temporomandibular joint: exert slight pressure on the condyle with index finger to palpate both sides simultaneously, resister any tenderness to palpation of the joints and any irregularities in condylar movement during opening and closing. The coordination of the action between the right and left condylar head should be assessed at the same time. 3-Posterior palpation of the TMJ: position of the little finger in the external auditory meatus and palpate the posterior surface of the condyle during opening and closing movement of the mandible, palpation should be carried out in such a way that the condyle displaces the little finger when closing in full occlusion. 4-Recording inter-incisal distance: in maximum jaw opening the distance between the incisal edge of the upper and lower central incisors are measured with Boley gauge. The extent of maximum jaw opening between the incisal edges is usually 40-45 mm. in cases with dysfunction, hyper mobility is often registered in the initial stage and limitation in the later stage. Examination of swallowing: In newborn, the tongue is relatively large and protrudes between the gum pads and takes part in establishing the lip seal. This kind of swallow is called infantile swallow and is seen till 1 1/2 to 2 years of age. Infantile swallow is replaced by mature swallow as the buccal teeth start erupting. The persistence of infantile swallowing can be a cause for malocclusion, thus the swallowing pattern of individual should be examined. The persistence of infantile swallow is indicated by the presence of the following features: a-Protrusion of the tip of the tongue. b-Contraction of perioral muscles during swallowing. c-No contact at the molar region during swallowing. Examination of speech: Certain malocclusion may cause defects in speech due to interference with the movement of the tongue and lips. This should be observed while conversing with the patient. The patient can be asked to read out from a book or asked to count from 1 – 20 while observing the speech. Patients having tongue thrust habit tend to lisp while cleft patients may have a nasal tone. Orthodontic study models: It is the positive replica of the teeth and their supporting structure, it should be reproducing accurately all the anatomical details of the teeth, alveolar process, mucobuccal folds, palate, frenal attachments as well as the exact relationship of the mandibular and the maxillary dental arch. Good models begin with good impression, orthodontic impression should displace the lips and cheeks, so that; the full depth of mucobuccal sulci is recorded. This over extension of Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

15. 15 impression is obtained by building up the tray periphery with wax or by using special orthodontic trays. The position of maximum intercuspation should be recorded by getting the patient to bite through softened wax that is important for: 1-Recording the proper intercuspation especially in cases of poor occlusal fit due to extraction or tongue thrust. So that it is wise to check the occlusion in the mouth and compare it to the occluded cast to insure that the model is correctly articulated. 2-Trimming the upper and lower cast together without change in the occlusal relationship or fracture of the teeth. Information obtained from study models: 1-To examine the occlusion from the lingual aspect as well as from the labio-buccal aspects. 2-To explain the treatment plane to the patient and his or her parents. 3-To detect the direction to which the teeth should be moved. 4-To determine the individual teeth malposition, rotation, axial inclination, midline shifting, occlusal fitness and degree of over bite and over jet. 5-Arch length analysis either in mixed or permanent dentition. 6-The construction of diagnostic set up. 7-As pretreatment record to which results of treatment can be compared and as pos treatment record to which the stability of occlusion can be checked. 8-Determination of transverse and anteroposterior a symmetry of the arch. 9-Classification of malocclusions. 10-It makes it possible to simulate treatment procedure on the cast such as mock surgery. (N.B) Gnatho-static models: they are study models where the base of the maxillary cast is trimmed to correspond to the Frankfort horizontal plane. Diagnostic set up: the individual teeth and their associated alveolar process are sectioned off and replaced on the model base in the desired positions. The diagnostic set up helps in simulating the various tooth movements that are planned for patients. Uses of diagnostic set up: 1-It is useful in difficult space management problems to ascertain before orthodontic treatment is begun, and the amount, direction of each tooth must be move. 2-It is best mathematical representation of the problem during the mixed dentition. 3-It is a popular practical technique for visualizing space problem in three dimensions in the permanent dentition. 4-It well demonstrates the amount of space created by the extraction and the tooth movement necessary to that space. 5-It also aid in choosing which teeth to be extracted. The cast is cut using a fretsaw blade to separate the individual teeth. A horizontal cut is made 3mm apical to the gingival margin. Vertical cuts are made to separate the individual teeth, the individual teeth are set in desired position using red wax. Mixed dentition analysis: the purpose of mixed dentition analysis is to evaluate the amount of space available in the arch for eruption of permanent teeth and occlusal adjustment. Nance analysis: the length of the dental arch from the mesial surface of one mandibular 1st molar to the mesial surface of the corresponding tooth on the opposite side was always shortened during the transition from the mixed dentition to the permanent dentition and this because of the lee way space. ** The width of the erupted four mandibular permanent incisors is first measured. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

16. 16 ** The width of the unerupted canines, 1st premolar and 2nd premolar on the radiograph should be measured. If one of the premolars on one side is rotated, we can use the similar tooth on the other side. *** The two measurements give an indication to the space needed to accommodate all the permanent teeth anterior to the 1st permanent molars. *** Next step is to determine the amount of space available for the permanent and this by using of 0.026-inch brass wire contoured on the arch surface and passing from the mesial surface of 1st permanent molar of one side to the mesial surface of 1st permanent molar on the other side. The wire should pass through the buccal cusps of posterior teeth and the incisal edge of anterior teeth for the lower arch, and for the upper arch should passing on the palatal surface of the incisors. Then calculate the length of the brass wire that represents the space available. Permanent dentition analysis: 1-Space analysis in permanent dentition: For patients with mal-alignment of teeth resulting from lack of space, it is important to determine from the study casts the amount of crowding in the maxillary and mandibular arches. The purpose is to determine the differences between space available and space required for tooth alignment. This means that two measurements are required in each arch for intra-maxillary analysis of space requirement: 1-Calculation of space required. 2-Calculation of space available. The Nance analysis: 1-Recording the mesiodistal w3idth of each tooth material to the 1st permanent molar. The sum total of the width corresponds to the necessary space required (ideal dental arch length). 2-Recording the actual arch length using a soft wire this is contoured to the individual arch shape and placed on the occlusal surface over the contact points of the posterior teeth and palatal surface of upper anterior teeth an d incisal edge of lower anterior teeth, the distance between the mesial contact points of the 1st permanent molars on both sides – recorded from the straightened – the amount of space available in the dental arch (actual arch length). 3-The assessment of space relationship is the result of the difference between the ideal and actual arch length (negative value= space deficiency, positive value = space excess) Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

17. 17 Upper arch length lower arch length Measurement of tooth material Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

18. 18 2-Bolton' tooth ratio analysis: Objective: 1-Studied the inter arch effects of discrepancies in tooth size to devise a procedure for determining the ratio of total mandibular versus maxillary tooth size and anterior mandibular versus maxillary tooth size. 2-Study of these ratio helps in estimating the over bite and over jet relationship that well obtain after treatment finished. 3-Study of the effects of contemplated extraction on posterior occlusion and incisor relationship and the identification of occlusal disharmony produced by interrelation of tooth size in-compatibility. Procedure: over all ratios (Sum of width of 12 mandibular teeth / Sum of widths of 12 maxillary teeth X 100 = 91.3% (mean ratio). The mean ratio result in ideal over bite and over jet relationships. If the ratio increases, the discrepancy is due to excessive mandibular tooth material. In the chart, one locates the figure corresponding to the patient's maxillary tooth size, opposite is the desired mandibular measurements. The difference between actual and the desired mandibular measurements is the amount of excessive mandibular teeth material when ratio is greater than 91.3 %. If the ratio is less than 91.3% the difference between the actual maxillary size and the desired maxillary size is the amount of excessive maxillary tooth material. Anterior ratio: (Sum of the width of 6 mandibular anterior teeth / sum of the width of 6 maxillary anterior teeth X 100 = 77.2%. The desired anterior ratio is 77.2% which provide ideal over bite and over jet relationships. If the angulations of the incisor are correct and if the labio-lingual thickness of the edges are not excessive. If the anterior ratio increased, there is excess mandibular tooth material and vice versa, i.e. there is excessive maxillary tooth material. If less than 77.2% there is excess maxillary tooth material. A quick method check for anterior tooth size discrepancies can be done by comparing the size of the upper and lower lateral incisors and quick check for posterior teeth size discrepancies is to compare the size of the upper and lower second premolars which should be equal size. N: B: Care must be taken in the use of this analysis since Bolton's formula don't take into account quantitatively the incisor angulations. Disharmony between the width of upper and lower teeth can be improved by 1- Alter the normal extraction plane to compensate for size discrepancies. 2-Interdental stripping. 3-In extreme cases by increasing the mesiodistal tooth size by adding composite resin or crown. 4-Changing the inclination of the incisors. 5-Accept a small space in one of the arches, usually distal to the lateral incisors. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

19. 19 3-How's analysis How's reported the fact that crowding could result not only from excessive tooth size but also from inadequate apical base, so How's formula for determination whether the apical base could accommodate the teeth. Tooth material (TM) = the sum of mesiodistal diameter of the teeth from the first permanent molars of one side to the other side. Premolar diameter (PMD) = arch width measured at the tip of the buccal cusps of the 1st premolar. PMD /TM: ratio of premolar diameter to tooth material. PMBAW: premolar basal arch width measured by bowed end of Boley gauge at the apical base on the dental casts at the apices of the 1st premolars. BAL: basal arch length is measured at the midline from the estimated anterior limits of the apical base to perpendicular that is tangent to the distal surface of the two first molars. BAL / TM: ratio of basal arch length to tooth material. For normal occlusion how's believed that the PMBAW should equal approximately 44% of mesiodistal widths of the 12 teeth in the maxilla if is sufficient large to accommodates all the teeth. When BAL / TM ratio is less than 37% How's considered that is due basal arch deficiency necessating extraction of premolars. When the PMBAW is greater than the PM coronal arch width expansion of the premolars may be undertaken safely. The objective of How's analysis: it is useful in planning treatment of problem with suspected apical base deficiency whether to be: Extraction. Expansion. Or split the palate. 4-Palatal height:palatal height is defined as a vertical line perpendicular to the mid- palatal raphe which runs from the surface of the palate to the level of the occlusal plane. Palatal height index = palatal height / posterior arch width. The average index is 42%. The index figure is increased when the palatal vault relative to the transverse arch development is high and decreased when the palate is shallow. A high palate is a principal feature of apical narrowing of the maxillary alveolar process which often occurs in cases of chronic mouth breathing, rickets, and in certain types of sucking habits. (The anterior arch width is defined as the distance between the anterior reference points (premolar region). The posterior arch width is the distance between the 1st molars.) 5-Peck and peck: Peck and peck stated that well aligned mandibular incisors possess distinctive dimensional characteristics (smaller mesio-distal (MD) and larger facio-lingual (FL) diameters) The MD /FL index = MD / FL X 100. Lower central incisor = 88.4 SD 4.3 Lower lateral incisor = 90.4 SD 4.8 For Egyptians: Lower central incisors = 88.2 SD 0.58 Lower lateral incisor = 92.3 SD 0.62 If the index is within normal or less ----------------------perfect alignment. If the index is higher than this normal ------------------crowding incisors. Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

20. 20 Irregular mandibular incisors with favorable MD / FL indices reveal that factors other than tooth shape are responsible for crowding. Stripping is described as a clinical procedure for correcting tooth deviations. 6-arch symmetry:(Harvold symmetrograph: The symmetrograph is transparent plastic device with an inscribed grid. Steps: 1-Place the maxillary cast on its base and carefully mark the median palatine raphe with a series of tiny dots. 2-Orient the symmetrograph so that its midline is directly superimposed over the median palatine raphe and parallel to the occlusal surface. 3-Total and partial arch symmetry are quickly visualized and localized as are drifting, tipping and rotation of individual teeth. 4-A similar analysis of the mandibular dentition was made but it was less precise than the maxillary arch because the mandibular lingual frenum is not reliable median structure as the palatine raphe. Symmetrograph Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

21. 21 Anteroposterior and transverse a symmetry Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

22. 22 Shift of midline away from reference line Measurements of curve of spee Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

23. 23 Premolar basal arch width Palatal height (Cast depth) Orthodontic Diagnosis Orthodontic Diagnosis for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby