Diagnosis is very important in dental and as well as medical field also with proper diagnosis treatment planning also easy and prognosis rate high. In orthodontics proper diagnosis is major factor for successful outcome.

1. DIAGNOSIS IN
ORTHODONTICS

2. Contents
• Introduction
• Conventional Orthodontic diagnosis and treatment planning
• Problem Oriented Approach of diagnosis and treatment planning
1) Evolution
2) Principles
3) Formulation of data base
4) Factors to be considered in treatment planning
5) Drawbacks
• Recent advances in diagnosis and treatment planning methodologies
• Conclusion
• Refrenceces

3. INTRODUCTION
• Conventional orthodontic diagnosis is based on E.H Angles line of occlusion.
• Angle considered hard tissue rather than soft tissue and facial esthetics in
correcting a malocclusion.
• Angle solved problem by focussing on the ideal dental occlusion.( Angles
paradigm)
• Now a days diagnosis is based on soft tissue paradigm introduced by
J.L Ackerman.

5. • Soft tissue paradigm states that both the goals and limitation of orthodontic and
orthognathic treatment are determined by the soft tissues of the face, not by the
teeth and bones.
• Focus on clinical examination rather than examination of dental cast and
radiographs

7. DEFINITION
“The recognition and systematic designation of anomalies, the practical
synthesis of the findings, permitting therapy to be planned and indication to
be determined, thereby enabling the doctor to act”.- Thomas Rakosi

8. • Diagnosis, treatment planning, and treatment execution are the steps involved in
successful care of malocclusions.
• Diagnosis is the definition of the problem.
• Treatment planning is based on diagnosis and is the process of planning changes
needed to eliminate the problems.
• Treatment is execution of the plan.

10. • Diagnosis must be comprehensive and not focused only on a single aspect of what
in many instances can be a complex situation.
• Orthodontic diagnosis requires a broad overview of the patient’s situation and
must take into consideration both objective and subjective findings.
• Prior to initiating treatment, orthodontists perform a comprehensive examination
consisting of medical and dental history and an intraoral examination.

11. • Diagnostic records are then collected which normally includes photographs, study
models, panoramic and cephalometric radiographs.
• The records provide clinicians with the necessary facial, dental and skeletal
information needed to thoroughly diagnose and plan the orthodontic treatment

12. COMPREHENSIVE DIAGNOSIS
• comprehensive diagnosis should be a summary of the most important facts and
should not take insignificant secondary symptoms into account as they are of no
relevance to the treatment.
• Essential orthodontic examinations include seven different analytical techniques
are all of the same relevance for orthodontic diagnosis.
• Computer analysis has also been employed for orthodontic diagnostics over the
past few years

15. PROBLEM ORIENTED APPROACH

16. • The problem-oriented approach to diagnosis and treatment planning has been
advocated in medicine and dentistry as a way to overcome tendency to
concentrate on only one part of patient problem.
• Problem oriented approach introduced into the medicine by Lawrence L. Weed in
1964.
• William Proffit introduced it into the dentistry.
• The essence of problem oriented approach is to develop a comprehensive data
base of pertinent information so that no problems will be overlooked.

17. • The goal of diagnostic process is to produce a complete description of the
patient’s problems and make a problem list
• To obtain a problem list , a collection of relevant information is required. This
collection is called DATABASE
• Comprehensive database of pertinent information that precludes the possibility of
problems being overlooked
(Contemporary Orthodontics: fifth Edition: William. R. Proffit, Henry .W
Fields,David M Sarver)

19. Principles
⮚ Development of an adequate diagnostic database
⮚ Formulation of problem list which is the diagnosis from the database
⮚ Prioritization of the items on the orthodontic problem list, so that most important
problem receives highest priority for treatment.
⮚ Consideration of possible solutions to each problem list, to the individual
problems.
⮚ Evaluation of interaction among possible solutions to the individual problems.
⮚ Synthesis of optimal treatment plan calculated to maximize benefit to the patient
and minimizes risks, costs, and complexity.
⮚ Presentation of the plan to the patient in such a way that the informed consent is
obtained.

20. Development of problem list
• Pathological problems like gingivitis,caries etc must be controlled.
• Developmental problems related to malocclusion is the orthodontic problem list.
• Initial developmental problem list is made using Ackerman profit classification, which
characterises five dentofacial traits.
1) Dentofacial appearance
2) Alignment/symmetry
3) Anteroposterior plane of space
4) Transverse
5) Vertical

21. Setting priorities for the orthodontic problem list
⮚ Patients perception of his or her condition is important in setting priorities
⮚ Focus most important problem for a patient
⮚ Give importance to the chief complaint
⮚ focus of the plan is what he or she wants

22. Factors in evaluating treatment possibilities
• After making priority list, next step is list out all possible treatments to each and
every problem.
• Each problem must be considered individually
• No possibilities will be overlooked

23. Factors to be considered are,
• Interaction among possible solutions
• Compromise
• Analysis of benefit versus cost and risk
• Other considerations

24. Interaction among possible solutions
• Some possible solutions to high priority problem would also solve
other problems.
Compromise
• In patients with many problems, it may not be possible to solve them
all.
• Careful setting of priorities from the problem list is particularly
important.
• If any necessary compromises are made, patients most important
problems are solved while less important problems are left intreated.
• Goal with great importance should be favoured

25. Analysis of benefit versus cost and risk
• Cost- risk / benefit analysis
• Consider money, cooperation. discomfort, time
• Avoid burden of treatment

26. Other considerations
• Should the treatment time be minimized because of possible exacerbation of
periodontal disease?
• Should treatment option left open because of uncertainity of growth pattern?
• Visible orthodontic appliances be avoided?

27. Patient parent consultation : obtaining informed consent
• Paternalism versus autonomy
• Include patient in making final decision
• Explain about advantages and disadvantages of treatment approaches.

28. The detailed plan : specifying the treatment procedures
• Two criteria must meet
1) effectiveness
2) efficiency
• The treatment plan must specify which, and the effectiveness and efficiency of the
various possibilities must be considered.

29. Questionnaire,
interview
Clinical
examination
Analysis of
diagnostic records
Database Problem list=Diagnosis

30. • For orthodontic purposes, the database may be thought of as derived from three
major sources:
• (l) Questions of the patient (written and oral),
• (2) Clinical examination of the patient,and
• (3) evaluation of diagnostic records, including dental
casts, radiographs and photographs

31. 1. QUESTIONNAIRE OR INTERVIEW
• The goal is to establish the patient's chief complaint (major reason for seeking
consultation and treatment), usually by a direct question to the patient or parent.
• To obtain information,
a) Medical and dental history
b) Physical growth status
c) Social and behavioural factors

32. CASE HISTORY
• Case history is defined as a planned professional conversation which enables the
patient to communicate his/her symptoms, feelings, and fears to the clinician and
recorded in the patient’s own words so as to obtain an insight into the nature of the
patient’s illness and his/her attitudes to them .
• Purpose of case history is to understand the development of the malocclusion, so
that by early elimination of the causative factors, correct therapy can be
undertaken.

33. • Personel details like name, age, sex, address and occupation should be recorded.

34. CHIEF COMPLAINT
• Three major reasons for patient concern about the alignment and occlusion of the
teeth:
1. Impaired dentofacial appearance and a diminished sense of social well being,
2. Impaired function,
3. Impaired oral health
( The contemporary Orthodontics, 5th ed, W.R Proffit)
• Chief complaint emphasis on whether the patient is seeking functional or
esthetic improvement or both

35. MEDICAL HISTORY
⚫ Specific questions should include medical conditions which may limit orthodontic
treatment. E.g. diabetes mellitus, epilepsy
⚫ allergy specially LATEX & NICKEL(Latex gloves and elastics and wire and
bracket containing nickel)

37. DENTAL HISTORY
• Patients or parents attitude.
• Indicator of patient’s susceptibility towards Periodontal disease or caries.
• H/O traumatic injury to teeth: orthodontic treatment exacerbate periapical
symptoms that are already present.
• Dental health awareness.

38. DRUG HISTORY
• reveals systemic disease or metabolic problems that the patient did not report in
any other way.
• Do not contraindicate orthodontic treatment if the medical problem is under
control, but special precautions may be necessary.
• For example, in a patient with controlled diabetes
• orthodontic treatment would be possible
• but would require especially careful monitoring, since the periodontal breakdown
that could accompany loss of control might be accentuated by orthodontic forces .

39. Physical growth evaluation
• Individuals physical growth status should be explored by asking questions to the
patient or parents.
• Adolescent growth spurt
• Skeletal class 2
• Vertebral maturation to assess skeletal age.

41. Family History
• A family history can begin with an inquiry as to whether any sibling of patient
have required orthodontic treatment and a discussion about nature of problems.
• The position of child in family should be noted.
• A relatively large number of dysgnathias are inherited and transmitted through a
dominant gene eg.
• Skeletal open bites
• Bimaxillary protrusion
• Class III malocclusion

42. Common problems of familial origin/genetics affecting face and
jaw: Cleft lip/palate, syndromes
Common problems of familial origin affecting the dentition:
• Peg-shaped or missing lateral incisors
• Partial hypodontia of premolars
• Supernumerary teeth
• Macro or microdontia

43. Social and Behavioral Evaluation
• Explore several related areas:
✔the patient's motivation for treatment,
✔expectations as a result of treatment, and
✔ how cooperative or uncooperative the patient is likely to be
• Motivation for seeking treatment can be classified as
1. external or
2. internal

44. • External motivation is that supplied by pressure from another individual, as with
a reluctant child who is being brought for orthodontic treatment by a determined
parent.
• Internal motivation, on the other hand, comes from within the individual and is
based on his or her own assessment of the situation and desire for treatment.

45. 2. CLINICAL EVALUATION

46. • Two goals of the orthodontic clinical examination:
• ( 1) to evaluate and document oral health, jaw function, facial proportions and
smile characteristics; and
• (2) to decide which diagnostic records are required

47. • Health of oral hard and soft tissues must be assessed for potential orthodontic
patients
• Any medical problems, periodontal disease, caries, pulpal pathology must be
controlled.
• Among jaw and occlusal function mastication, speech, sleep apnea in mandibular
deficiency and the TMJ problems like click, noise, tenderness, opening should be
noted.

48. General examination

49. • General examination begins as soon as patient enters the clinic
• Includes examination of constitution and physique of the patient , height and
weight in relationship to the chronological age and development of the facial
skeleton .
• An evaluation of the somatogram provides an indication of the general growth
tendency.
• Height and weight provide a clue to the physical growth and maturation of
patient

50. GAIT
• It is the way a person walks
• Abnormalities of gait are associated with the neuromuscular disorders.
POSTURE
• Poor postural conditions either lead to malocclusion or accentuate it.
• A stoop shouldered child with the head hung, chin rests on the chest: Mandibular
retrusion.

51. • Evaluation of dental status is of great importance for the prognostic assessment of
dental development
• Chronological and dental age are synchronous in normal patient
• A child is labeled as early or late developer if there is difference of ± 2 years from
the average value
Dental age can be determined by two different methods
⮚Stage of eruption
⮚Stage of tooth mineralization in radiograph

52. EXTRAORAL EXAMINATION
• The head and face should be examined with the patient seated in an ordinary chair
with the head in natural head position
Natural head position
• Standardized and reproducible orientation of head in space when the subject is
focussing on a distant point at eye level.in NHP, the visual axis should be
horizontal and lips should be relaxed.

53. GENERAL BODY TYPE(PHYSIQUE) - Berger
⚫ ASTHETIC: Thin physique, possess narrow dental arches.
⚫ PLETORIC: Obese, have large square dental arches.
⚫ ATHLETIC: Normally built, being neither thin nor obese. Have normal sized
dental arches.

54. BODY BUILD- SHELDON
⚫ ECTOMORPHIC: Tall & thin physique.
⚫ MESOMORPHIC: Average physique.
⚫ ENDOMORPHIC: Short & obese.

55. CEPHALIC INDEX
• This index is based on the anthropometric determination of the maximum width of
the head and the maximum length
• Classification and index values according to Martin and Saller (1957)

57. MORPHOLOGIC FACIAL INDEX
• Martin and Saller (1957)
• Morphological facial height is defined as the distance between nasion (N) and
gnathion (Gn) and bizygomatic width is defined as the distance between the
zygoma (Zy) points.

58. MORPHOLOGIC FACIAL INDEX

61. FACIAL FORM by Ricketts (AJO 1960)
• Dolicho facial: long and narrow
• Meso facial: average face
• Brachy facial: short and broad
Jaraback : Hyperdivergent, Hypodivergent, Neutral

62. EXAMINATION OF FACIAL AND DENTAL APPEARANCE
A systematic examination of facial and dental appearance should be done in the
following three steps
(i) Facial proportions in all three planes of space (Macro esthetics)
(ii) The dentition in relation to the face (mini esthetics)
(iii) The teeth in relation to each other (micro esthetics)

63. Arnett and Bergman (AJODO 1993) suggested systematic soft tissue clinical
examination using 19 facial traits known as “Facial keys for diagnosis and
treatment planning.”
• It involves examination of patient in 2 views for identification of problems in all
3 planes of space.
I. Frontal
A. Relaxed lip
B. Functional analysis
1. Closed lip
2. Smile
II. Profile
A. Relaxed lip

64. • 19 facial traits are examined
I. Frontal view
A. Outline form
B. Facial level
C. Midline alignments
D. Facial one-thirds
E. Lower one-third evaluation
1. Upper and lower lip lengths
2. Incisor to relaxed lip
3. Interlabial gap
4. Closed lip position
5. Smile lip level

65. II. Profile view
• A. Profile angle
• B. Nasolabial angle
• C. Maxillary sulcus contour
• D. Mandibular sulcus contour
• E. Orbital rim
• F. Cheek bone contour
• G. Nasal base – Lip contour
• H. Nasal projection
• I. Throat length
• J. Subnasale – pogonion line

66. MACRO ESTHETICS
(1) Assessment of developmental age
(2) Frontal examination
(3) Profile analysis

67. (1) Assessment of developmental age
• examining him or her for developmental characteristics and a general impression.
• In a step particularly important for children around the age of puberty when most
orthodontic treatment is carried out the patient’s developmental age should be
assessed.
• The attainment of recognizable secondary sexual characteristics for girls and boys
and the correlation between stages of sexual maturation and facial growth

68. (1) Frontal Examination
• The first step in analyzing facial proportion is to examine face in the frontal view
• Low set ears or eyes that are usually far apart(hypertelorism) may indicate either
presence of a syndrome or a microform of a craniofacial anomaly
• If syndrome is suspected, the patient’s hands should be examined for syndactyly.
Since there are number of dental-digital syndromes

69. FACIAL PROPORTION : RULE OF FIFTH
• Introduced by Farkas and Monro
• For ideal proportions from the frontal view, an ideally proportional face can be
divided into central, medial and lateral equal fifths. The separation of eyes and
width of eyes should be equal and it determines central and middle fifths.
• The nose and chin should be centered with in the central fifth, with the width of
the nose the same as or slightly wider than the central fifth.
• The inter papillary distance should equal the width of the mouth (Ellenbogen et al
(1983)

71. Vertical Facial Proportions (LAW OF THIRDS)
• The artists of the renaissance period, primarily da Vinci and Durer established the
proportions for drawing anatomically correct human faces.
• They concluded that the distance from the hairline to the base of the nose, base of
nose to bottom of the nose and bottom of the nose to chin should be the same
• The artists also saw that the lower third has a proportion of one third above the
mouth to two thirds below

73. Facial Symmetry
• A small amount of facial asymmetry exists in essentially all normal individuals
• This can be appreciated most readily by comparing the real full face photographs
with composites consisting of two right or two left sides

75. (2) PROFILE ANALYSIS
• “poor man’s cephalometric analysis”
• The three goals of facial profile analysis are
(i) Establishing whether the jaws are proportionately positioned in the
anterior posterior plane of space
(ii) Evaluation of lip posture and incisor prominence
(iii) Reevaluation of vertical facial proportions and evaluation of mandibular
plane angle

76. (i)Establishing whether the jaws are proportionately positioned in the anterior
posterior plane of space
• This step requires placing the patient in natural head position
either sitting upright or standing, with the head in this position,
note the relationship between two lines, one dropped from the
bridge of the nose to the base of the upper lip, and a second one
extending from that point downward to the chin .

77. Profile convexity or concavity results from a disproportion in the size of the
jaws, but does not by itself indicate which jaw is at fault. A convex facial
profile (A) indicates a Class II jaw relationship, which can result from either
a maxilla that projects too far forward or a mandible too far back. A concave
profile (C) indicates a Class III relationship, which can result from either a
maxilla that is too far back or a mandible that protrudes forward

78. Facial Divergence
• Term given by Milo Hellman.
• The anterior or posterior inclination of lower face to forehead is called facial
divergence which may be influenced by patient’s ethnic or racial background.
• A line drawn from forehead to chin is used to assess facial divergence.
(i)Anterior divergent: line inclined anteriorly
(ii) Posterior divergent: the line inclined posteriorly
(iii) Straight/orthognathic: straight line, no slant seen

79. A. posteriorly
divergent profile
B. straight profile
C. Anteriorly
divergent profile

80. (II) Evaluation of lip posture and incisor prominence
Lip posture and incisor prominence should be evaluated by viewing the
profile with the patient's lips relaxed.
Charles J Burstone(AJODO 1967) “Lip posture and its significance in
treatment planning”
- relaxed and closed lip position, upper and lower lip length, lip protrusion
relative to sn-pog line

82. • Upper lip protrusion 3.5 mm
• Lower lip protrusion 2.2 mm
Charles J Burstone (AJODO 1967) “Lip posture and its
significance in treatment planning”

83. • This is done by relating the upper lip to a true vertical
line passing through the concavity at the base of the
upper lip (soft tissue point A) and by relating the lower
lip to a similar true vertical line through the concavity
between the lower lip and chin (soft tissue point B)
• lips fall forward from the line-PROMINENT
• Lips fall backward from the line-RETRUSIVE
• Both lips are prominent & incompetent- Anterior teeth
are protrusive.

84. • The teeth protrude excessively if (and only if) two conditions are met:
(1) the lips are prominent and everted, and
(2) the lips are separated at rest by more than 3 to 4 mm which is sometimes termed
lip incompetence .

85. • In the extreme case, incisor protrusion can produce ideal alignment of the teeth instead
of severely crowded incisors, at the expense of lips that protrude and are difficult to
bring into function over the protruding teeth. This is bimaxillary dentoalveolar
protrusion, meaning simply that in both jaws the teeth protrude
• Bimaxillary protrusion ; Samuel J. Lewis ;AJO 1943
• The treatment of bimaxillary protrusion ; P.J Keating; BJO
• Changes in facial profile during orthodontic treatment with extraction of four first premolars (AJO 1989)

86. • The soft tissue profile, growth, and treatment changes. J. Daniel subtelny
(1961 AO)
• emphasize that growth changes within the soft tissue profile will be expressed in
the area of nose , the chin, and the lips.
• Soft tissue changes following treatment will center around the lips, primarily in
the vermilion area.
• Lip posture was found to be correlated closely with the posture of underlying
dental and alveolar structures.

87. The diagnostic line ;Raleigh Williams ,AJO 1967
• There is one cephalometric criterion common to all normal dentitions associated
with harmonious or well-balanced lips, and that is the anteroposterior position of the
incisal edge of the lower incisor relative to the AP line.
• To create harmonious lip balance at the conclusion
of treatment, the tip of the lower incisor must be
brought to a position at or near the AP line
( point A to Pog line).

88. Throat form
• Evaluated in terms of the contour of the submental tissues (straight is better)
• chin throat angle (closer to 90 degrees is better) and throat length (longer is better
up to a point)
• Both submental fat deposition and a long tongue posture contribute to a stepped
throat contour which becomes a double chin.

89. (3) Reevaluation of vertical facial proportions and evaluation of mandibular plane
angle
• Vertical proportions which are evaluated in frontal examination can be reevaluated in
profile view
Evaluation of mandibular plane angle
• In the clinical examination, the inclination of the mandibular plane to the true horizontal
should be noted.
• This is important because a steep mandibular plane angle correlates with long anterior
facial vertical dimensions and anterior open bite malocclusion.
• Flat mandibular plane angle correlates with short anterior facial height and deep bite
malocclusion.

90. • The mandibular plane is visualized readily by placing a finger or mirror handle
along the lower border

91. • The inclination of mandibular plane to FH plane is measured
• An angle greater than 30 degree points to a vertical grower which signifies that
lower anterior face could be increased.
• Subject with 20 degree or less is designated as horizontal grower
• Children falling between 20 to 30 degrees is called neutral grower

92. • Schwartz profile anlysis (1929)
• It is a photographic method of profile analysis
• Based on relation ship of sub nasale to nasion perpendicular
• 3 types
• 1) Average face – sn on nasion perpendicular
• 2) Retro face – sn lies behind pn
• 3) Ante face – sn lies in front of pn
• Depending on relation of sub nasale to pogonion,lower facial profile divided into
3 types
1) Backward slant( pog behind sn)
2) Forward slant ( pog ahead sn)
3) Straight( pog on sn)

93. Nine profile variants acc. to classification by A.M. Schwartz
• In forward slant : normal , retro face and ante face
• Backward slant : normal , retro face and ante face
• Straight slant : normal , retro face and ante face

95. TOOTH LIP RELATIONSHIPS (MINI AESTHTICS)
• Relationship of dental midline to skeletal midline of jaw
• Assessment of vertical relationship of teeth to lips at rest and on smile.
• Note whether up-down transverse rotation of dentition is revealed when at
rest or at smile.
• Dentists detect transverse roll at 1mm from side to side where as lay person
are forgiving and see it at 2-3mm

96. SMILE ANALYSIS
2 types of smile:
• Posed or social smile which is reproducible and present to world routinely
• Enjoyment smile (Duchenne smile) varies with emotions being displayed.
• Social smile is the focus of orthodontic diagnosis

97. • Following variables need to be considered during smile analysis:
(a) Amount of incisor and gingival display
(b) Transverse dimension of smile relative to upper arch( buccal corridor)
(c) The smile arc
(d) Smile Index
(e)Morley’s Ratio

98. (a) Amount of incisor and gingival display:
• Up to 4 mm display of gingiva in addition to the crown of the tooth or upto 4 mm
lip coverage of the incisor crown is acceptable. Beyond that the smile appearance
is less attractive.
(b) Transverse dimension of smile relative to upper arch( buccal corridor )
• Buccal corridor is the distance between maxillary posterior teeth (especially
premolars) and inside of the cheek
• Minimal buccal corridor is preferred
• Widening the maxillary arch can improve the appearance of the smile
• Too broad an upper arch so that there is no buccal corridor is unaesthetic

99. (c) The smile arc
• The smile arc is defined as the contour of the
incisal edges of the maxillary anterior teeth
relative to the curvature of the lower lip during
a social smile
• If lip and dental contours match, they are said
to be consonant
• A flattened (non consonant ) smile arc

100. (d) Smile Index
• It was given by Ackerman and Proffit
• Smile index describes the area with in the vermilion borders of upper and lower
lip during the social smile
• Smile index is determined by dividing the inter commissural width by the inter
labial gap during smile.
• It is increased where decreased incisor show is present and decreased where
increased incisal show is present

101. • Modified smile index by Vinod Krishnan et al (AJO 2008)
• Modified smile index= inter vermilon distance at midline *100
inter commissural width

102. `
(e)Morley’s Ratio
• It depicts the percentage of incisor show on posed smile with respect to the
clinical crown height
• Average ratio is 75-100%
• A greater ratio would necessitate appropriate measures to decrease the incisor
show
• Common contributors to increased incisor show are vertical maxillary excess,
palatal plane tipping downwards in anterior region, shorter upper lip or greater
crown height
• Smaller ratio depicts less than normal incisor show due to vertically deficient
maxilla, increased length of upper lip or short clinical crown height

103. DENTAL APPEARANCE (MICRO ESTHETICS)
(a) Width relationships(Golden Proportion)
• For best appearance the apparent width of lateral incisor
should be 62% of the width of central incisor
• Apparent width of canine should be 62% of width of lateral
incisor
• Apparent width of first premolar should be 62% width of
canine
• This value of recurring 62% is called golden proportion

104. b) Height -width relationships
• Width of a tooth should be about 80% of its height
• There are many reasons for decreased height of
tooth: incomplete eruption which gets corrected by
itself.
• Loss of crown height from attrition in older
patients which indicate restoration of missing part
of crown, excessive gingival height which is best
treated by crown lengthening etc.

106. Classification of malocclusion
SAGITTAL/ A-P RELATIONSHIP
• 1) Angles classification of malocclusion
• 2) Deway modification of angles classification
• 3) KATZ classification of premolar occlusion
• 4) British incisor classification
• 5) Miguel neto & mucha proposed classification

107. VERTICAL RELATIONSHIP
A) Overbite
B) Deep bite
C) True deep bite
D) Pseudo deepbite
E) Open bite
TRANSVERSE RELATIONSHIP
A) Buccal crossbite
B) Scissor bite
C) Midline

108. Tongue
• Shape, size , posture and function.
• The diagnosis of a macroglossia require more detailed diagnostic
investigation(cine radiography) and can only be made after exact analysis of
tongue position.
• A rough assessment of tongue size can be made by lateral cephalometric
radiograph.
• Change in the tongue position and mobility are often associated with an
abnormal frenum.

109. FRENUM
• One of the most variable anatomical structures present in the oral cavity.
• LABIAL FRENUM-
Mandibular labial frenum is less often associated with midline diastema.
it can lead to gingival recession in anterior region.
LINGUAL FRENUM=
Its abnormal attachment – ankyloglossia or tongue tie
Associated with speech difficulties.
Sometimes produces a mandibular midline diastema.

110. (c) Gingival heights, shape and contour
Gingival height
• Generally the central incisors has the highest gingival level
• Lateral incisor is approximately 1.5 mm lower
• Canine gingival margin is at the level of centrals
Gingival shape
• Gingival shape refers to the curvature of gingival at the margins of tooth
• Maxillary lateral has gingival shape half oval or half circle symmetrically
• Maxillary centrals and maxillary canines have gingival shape that is more elliptical
and oriented distally to long axis of tooth

111. Gingival Zenith
• Most apical point of the gingival tissue
• It should be located distal to the long axis of
maxillary centrals and canines
• Gingival zenith of maxillary laterals should
coincide with their long axis

112. (d) Connectors and embrasures
• The connector is where adjacent teeth appear to touch
and may extend apically or occlusal from the actual
contact point
• The normal connector height is greatest between
centrals and diminishes from centrals to posterior
teeth
• Embrasures are larger in size than connectors and is
filled with interdental papillae

113. (e) Black triangles
• Short interdental papillae leave an open gingival embrasure above the connectors
and these black triangles can detract significantly from the appearance of tooth on
smile
• When crowded and rotated maxillary incisors are corrected orthodontically in
adults, the connector moves incisally and black triangles may appear
(f) Tooth shade and color
• The color and shade of the teeth changes with increasing age, and many patients
perceive this as a problem
• Teeth appear lighter and brighter at a younger age and darker as aging progress.
This is related to deposition of secondary dentine and thinning of facial enamel
• A normal progression of shade change from the midline posteriorly is an
important contributor to an attractive and naturally appearing smile

114. EXAMIANTION OF LIPS
COMPETENT: Slight contact of the lips when the musculature is
relaxed.
• Up to 4mm of lip separation is normal especially in young
children.
INCOMPETENT: Is defined as the inability to seal the lips without
excessive strain.
• • Anatomically short upper lip which do not contact when the
musculature is relaxed.
• Lip seal is achieved after active contraction of orbicularis oris &
mentalis muscle

115. Vig & Cohen “Vertical growth of the lips, A serial cephalometric study” A.J.O
75:405 1979
• Both upper & lower lip grew more than the skeletal lower face.
• The lower lip grew vertically more than the upper lip.
• Most children exhibited lip incompetence at age 6-8 yrs. This is due to incomplete
soft tissue growth & should be considered normal

116. `
POTENTIALLY INCOMPETENT LIPS
• Lip seal is prevented due to protruding max. incisors despite
normally developed lips
EVERTED LIPS
• These are hypertrophied lips with redundant tissue & weak
muscular tonicity
VERTICAL LIP RELATIONSHIP
• In a balanced face the length of the upper lip measures 1/3rd
the lower lip & the chin 2/3rd of the lower face height

117. LIP STEP(KORKHOUS)
• POSITIVE LIP STEP: Protrusion of the lower lip in
relation to the upper lip. Seen in class 3 malocclusion.
• NORMAL LIP PROFILE : Slightly negative lip profile.
The lower lip slightly behind the upper lip.

118. • NEGATIVE LIP STEP:Marked retrusion of the lower lip as a symptom of class 2
malocclusion

119. ANTONIOS H. MAMANDRAS “Linear changes of the maxillary &
mandibular lips” A.J.O 94:405,1988
• Max. lip length in females-14yrs.
• The mandibular vertical lip length growth -16yrs.They attained the max. Lip
thickness by age 14 followed by thinning.
• Males attained max lip length-18yrs,it was not complete. Max lip thickness was
attained by 16yrs.
• Thus the effect of extraction therapy would be more noticeable in females with
straight or convex profile than in males.

120. NASOLABIAL ANGLE
• Value of 110 degree
• Formed b/w a tangent to the lower border of the nose & a line joining the
subnasale with the tip of the upper lip. (Labrale Superius)
• Reduces: max. Prognathism, Proclined anteriors.
• Obtuse: Retrognathic maxilla

121. CHIN
• The bone structure
• Thickness & tone of the mentalis muscle
• Morphology & craniofacial relation of the mandible.
• Recessive, adequate or prominent.
HYPER MENTALIS ACTIVITY: The mentalis muscle becomes hyperactive.
• Seen in class 2 div 1 cases where puckering of the chin (Golf ball appearance) may be
seen.
MENTO LABIAL SULCUS
• It is the concavity present below the lower lip
• Mento labial sulcus is deepen in class II Div 1
• Mento labial sulcus shallow in bimaxillary protrusion
• Normal

122. Normal Deep Shallow

123. CHIN FORMATION & PROFILE CONTOUR
• Protruded chin, marked mentolabial sulcus – retruded lip profile.
• Negative chin, absence of the mentolabial sulcus causing a protruded lip profile.
• Lip closure is difficult in this type of facial morphology.
• Hyperactivity of the mentalis muscle
• Genioplasty required to change the insertion of the mentalis muscle.

124. FOREHEAD
• Relationship of the forehead is considered to the bizygomatic width. It can be
described as Narrow or wide.
• The lateral forehead contour or the slope of the forehead could be Flat,
protruding, steep. The dental bases are more prognathic than in cases with a flat
forehead.

125. NASAL CONTOUR
SRAIGHT CONVEX CROOKED

126. NASAL PROPORTIONS
• Powell et al (1986) ideal nasal width should be approximately 70% of nasal
height (nasion to nasal tip)
• Baum (1982) The nasal length in the mature face should equal the distance from
stomion to menton.
NOSE SIZE
• Normal, microrhinic (small), large

127. PITCH, ROLL, YAW
“Pitch, Roll And Yaw: Describing the spacial orientation of dentofacial traits”
(Ackerman et al, AJODO,2007)
• Three aeronautical rotational descriptors (pitch, roll and yaw) are used to
supplement the planar terms (anterioroposterior, transverse and vertical) in
orientation of the line of occlusion and the aesthetic line of the dentition.
•

129. Pitch deformity
• Downward or upward displacement of dentition viewed along esthetic line is best
described as pitch upward or downward anteriorly or posteriorly

130. Roll Deformity
• Transverse cant of occlusal plane is a roll deformity

131. Yaw Deformity
• Rotation of the aesthetic line of dentition around vertical axis of rotation leads
either
• dental midline shift or unilateral class II or class III relationship. Unilateral
posterior crossbite accompanies more severe yaw

132. FUNTIONAL EXAMINATION

133. Determination of the postural rest position
▪ Patient’s orofacial musculature must be relaxed
▪ Muscle exercises(tapping test) can be used to help relax the musculature prior to
carrying out actual examination.
▪ When using tapping test patient is told to relax and the clinician opens and closes
the mandible passively and with constantly increasing frequency.
▪ When the mandible is in postural resting position,it is usually 2-3 mm below and
behind the centric occlusion(recorded in canine area)
▪ Space between teeth ,when mandible is at rest ,is referred to as freeway space or
interocclusal clearance.

135. • METHODS USED TO DETERMINE THE REST POSITION DURING
CLINICAL EXAMINATION
• Phonetic method
• Command method
• Non-command method
• Combined method

136. Evaluation of temporomandibular joint and condylar movements
• Objective is to assess whether incipient symptoms of TMJ dysfunction are present.
• Early symptoms of TMJ problems include the following:
• Clicking and crepitus
• Sensitivity in the condylar region and masticatory muscles
• Functional disturbances (e.g. hypermobility,limitation of movement,deviation)

137. • Examined for joint sounds ;like click or crepitation
• Initial clicking is sign of retruded condyle in relation to the disc.
• Intermediate is a sign of unevenness of the condylar surface and of articular
disc,which slide over one another during the movements
• Terminal clicking occurs most commonly and is an effect of the condyle being
moved too far anteriorly,in relation to the disc,on maximum jaw opening.

138. CLINICAL FUNCTIONAL EXAMINATION FOR THE
TEMPOROMANDIBULAR JOINT AREA
• Consists of 3 steps:
1.Auscultation
2.Palpation
3.Functional analysis

139. AUSCULTATION
• A stethoscope is used to check for signs of clicking and crepitus.
• The examination is performed by having the patient open and close the jaw into
full occlusion.

140. PALPATION
• Lateral palpation for any joint pain
• Posterior surface of condyle using index fingers placed in the external auditory
meatus.

141. • Palpation for lateral pterygoid muscle
- at maxillary tuberosity area
- mouth is open and mandible displaced
laterally
• Palpation for temporalis muscle
- mouth should be half open

142. • Palpation of masseter muscle

144. RECENT ADVANCES
• CBCT
• DIGITAL MODELS
• COMPUTER AIDED BRACKET PLACEMENT
• SURE SMILE TECHNOLOGY
• CLEAR ALIGNERS
• RAPID PROTYPING

145. CBCT ( Cone Beam Computed Tomography)
• Cone beam computed tomography is a medical imaging technique
consisting X-rays which are divergent, forming a cone.
• two-dimensional (2D) representations of three dimensional (3D) objects
• Two dimensional radiographs are insufficient, especially in complex cases
like impacted teeth, supernumerary teeth and orthognathic surgeries. CBCT
images provide far more detailed information than conventional 2D
radiographs and are user friendly.
• Soft tissues, skull, airway and the dentition can be observed and measured
on CBCT images in a 1:1 ratio.

146. DIGITAL MODELS
• Produced by surface scanning of plaster models (Quick ceph) or
impressions(ORTHOCAD)
• Scanners used-
• Contact 3-d scanner (Nakasima et al)
• Oral scanner (Mah &Sachdeva)
• Non contacting digitizer (Nishi et al)
• The scanner is passed over the teeth in rocking motion to allow visualization of all
tooth surface including undercut areas

147. FABRICATION OF DIGITAL MODELS
1.High quality impressions-alginate-ORTHOPRINT (Zhermack,Rovigo,Italy) or
polyvinylsiloxane & polyether material (Impregnum,ESPE,Germany)
2.Optical scannig- of “Plaster equivalents”to produce 3-d models
3.Downloaded on clinician computer via e-mail
Features of digital softwares
• 3-d browsing
• jaw alignment tool
• color coded occluso grams
• virtual sectioning
• virtual measurements (0.1mm)
• instant model analysis
• easy storage ,transfer &retrieval

148. Limitations of digital models
• Expensive sophisticated equipment
• Supplier or technical support
• Cannot be articulated acc.to pt TMJ
• Loss of data due to degradation over time
• Accuracy questionable
• Comparative evaluation of plaster and digital models

149. Tomassetti et al (AO 2001) did a comparison of computerized Bolton analysis with
3 softwares and the manual method.
Accuracy : Vernier calipers was the most accurate while significant differences were
observed with the 3 softwares.
Speed : QuickCeph was the fastest and V calipers took the most time.
Kusnoto and Evans( AJO 2002) found that using a 3D surface scanner for
digitizing casts the measuring applications involving height and width was
accurate whereas the depth was increased due to the horizontal laser beam which
has to traverse vertically ( time lapse).

150. • Coslalos et al (AJO NOV 2005) using the Orthocad system found measurements
to be reliable in measuring malocclusion except for buccolingual inclinations of
teeth.
• Quimby et al ( AO 2004) compared the accuracy and reliability of
measurements made on computer and plaster models.
• They concluded that:
• 1) Accuracy( validity) : was comparable
• 2) Reproducibility ( reliability) : highly reproducible.
• 3) Efficacy : comparable

151. COMPUTER AIDED BRACKET PLACEMENT
• Virtual bracket placement-additional hardware required with computer aided
bracket placement device
• optimal bracket position
• alignment of teeth.
• virtual wire placement
• torque anticipation: different finishing wires

152. SURE SMILE TECHNOLOGY
• By Rohith sachdeva
• Sure smile is a type of bracket system used by orthodontists for alignment of teeth.
The technique utilizes 3D imaging ,treatment planning software and a robot to
create wires.
• The orthodontists uses digital images of patients mouth using either a white light
scanner or CBCT.
• Once the orthodontist has virtually designed the smile and bite, Sure Smile
software plans the most efficient and direct route for making tooth into the proper
place, and sends this information to a robot that bends and shapes the wire
specifically for that patient.
• The wire with all of the custom bends is then send back to the orthodontist and is
ready to place on the patient.
• The treatment is faster and the patient has only 1 to 2 wire changes when
compared with conventional system

153. CLEAR ALIGNERS
• Clear aligner treatment are orthodontic devices that uses incremental transparent
aligners to adjust teeth as an alternative to dental brackets.
• They are effective for moderate crowding of the front teeth but less effective than
conventional brackets for several other issues.
• they are indicated for mild to moderate crowding(1 -6 mm) and mild to moderate
spacing (1 -6 mm), in cases where there are no discrepancies of the jaw bone.
• Clear aligner treatment involves an orthodontist taking a mold of the patient’s
teeth, which is used to create a digital tooth scan.

154. • The computerized model suggests stages between the current and desired teeth
positions, and aligners area created for each stage. Each aligner is worn for 20
hours a day for 2 weeks.
• These slowly move the teeth into the position agreed between the orthodontist and
patient. The average treatment time is 13.5 months

155. Manufacturers
• Invisalign is manufactured by Align Technology
• Orthoclear
• Clear Correct

156. RAPID PROTOTYPING
• It is a group of techniques used to quickly fabricate a scale model of a physical
part of assembly
• using 3D computer aided design(CAD). Construction of the part or assembly is
usually done
• using 3D printing or Additive layer manufacturing technology.
“Accuracy and reproducibility of dental replica models reconstructed by
different rapid prototyping techniques” Aletta Hazeveld, James J. R.
Huddleston Slater, and Yijin Ren (AJODO 2014)

157. RAPID PROTOTYPING- STEPS

158. • The plaster models were scanned to form high-resolution 3-dimensional surface
models in .still files.
• These files were converted into physical models using 3 rapid prototyping
techniques:
-digital light processing, jetted photopolymer, and 3-dimensional printing .
• Dental models reconstructed by the tested rapid prototyping techniques are
considered clinically acceptable in terms of accuracy and reproducibility and
might be appropriate for selected applications in orthodontics.
• Using this technology two normally separate process of bracket production and
bracket positioning are fused into one unit

159. • IMAGING SOFTWARE TO PREDICT THE SOFT TISSUE CHANGES AFTER
ORTHOGNATHIC SURGERY
“Comparison of an imaging software and manual prediction of soft tissue
changes after orthognathic surgery”- M.S Ahmad Akhoundi (journal of
dentistry)
• Dolphin imaging has become increasingly popular among surgeons and
orthodontists.
• After programming of the hard tissue movement into Dolphin system, the outline
of the soft tissue is changed based on ratios which have been included into the
software.
• Computer generated image prediction was suitable for patient education and
communication. However efforts are still needed to improve accuracy and
reliability of the prediction program and to include changes in soft tissue and
muscle strain

161. CONCLUSION
• Observation is key of understanding.
• Proper diagnosis is must for treatment planning and final result.
• Proper knowledge of normal asethetic principle help to notice something
unusual.

162. References
• The emerging soft tissue paradigm in orthodontic diagnosis and treatment
planning 1999; Ackerman, Proffit, Sarver.
• Facial keys to orthodontic diagnosis and treatment planning Part 1 G. William
Arnett and Robert T. Bergman, AJO 1993.
• Contemporary Orthodontics: fifth Edition: William. R. Proffit, Henry .W
Fields,David M Sarver)
• Charles J Burstone(AJODO 1967) “Lip posture and its significance in treatment
planning”
• The soft tissue profile, growth, and treatment changes. J. Daniel subtelny (1961
AO)
• Medical Disorders and Orthodontics Anjli Patel 1, Donald J
Burden, Jonathan Sandler (2009)

163. • Vig & Cohen “Vertical growth of the lips, A serial cephalometric study” A.J.O
75:405 1979
• ANTONIOS H. MAMANDRAS “Linear changes of the maxillary &
mandibular lips” A.J.O 94:405,1988
• Pitch, Roll And Yaw: Describing the spacial orientation of dentofacial traits”
(Ackerman et al, AJODO,2007
• Tomassetti et al (AO 2001) did a comparison of computerized Bolton analysis
with 3 softwares and the manual method.
• Accuracy and reproducibility of dental replica models reconstructed by different
rapid prototyping techniques” Aletta Hazeveld, James J. R. Huddleston Slater,
and Yijin Ren (AJODO 2014)