Diagnosis & treatment planning

Diagnosis &
Treatment Planning
www.indiandentalacademy.com

“The first step toward cure is to
know what the disease is......”

The Goal of an Orthodontist..........
1. To obtain optimal occlusion with in a
framework of skeletal bases.
2. With the nerves, muscles surrounding in
harmony.
3. Normal function and stability.
4. And maintaining the health of the
surrounding tissues (PDL, gingiva, TMJ,
etc…).
3www.indiandentalacademy.com

Basic objectives of orthodontic
treatment
Jackson’s TriadJackson’s Triad
 Functional Efficiency
 Structural Balance
 Esthetic Harmony

Jackson’s Triad:
 Functional stability
 Structural balance
 Esthetic harmony

TO be spoken out by sir, No need of this
slide, thus delete it before presentation.
 Although this is definitive, it is obvious that it means different
things to different persons, so much so that large segments
of orthodontic profession, if presented with single case, would
start out in different directions toward different objectives by
different orthodontic means.
 The last should matter little except that orthodontists, being
committed to certain appliances with their inherent limitations,
are not free to be objective about their objectives.
 Concepts and standards have been devised which are
subservient to appliance limitations.
 These concepts and resultant orthodontic objectives are as
different as black and white.
A CRITICAL ANALYSIS OF ORTHODONTIC CONCEPTS AND OBJECTIVES
William L. Wilson –AJO-DO 1957

Some diagnosis are
 Easy,
 Many are difficult and
 Few are impossible
yet all are important , for diagnosis is the
trump factor in providing orthodontic care.care.
osis

One century back EDWARD. H. ANGLE rightly said:
“In studying a case of malocclusion, give no thought to the
 methods of treatment or
 appliances
until the case shall have classified and all peculiarities and
variation from the normal in
 type,
 occlusion and
 facial lines have been thoroughly comprehended.
Then the requirements and proper plan of treatment
become apparent”.

The orthodontist must …
1. Know normal features of occlusion and
dentofacial complex.
2. Recognize the various characteristics of
the malocclusion & dentofacial deformity.
3. Understand the nature of the problem and
the etiology, if possible.
4. Design a treatment plan based on the
specific needs of the individual.

Therefore, this presentation is
divided into following sections:
1. Know Normal features of occlusion and
dentofacial complex.
2. Recognize the Various characteristics of
the malocclusion & dentofacial deformity.
3. Understand the Nature of the problem and
the etiology, if possible.
4. Design a Treatment plan based on the
specific needs of the individual.

1.
Normal Features
of Occlusion & Dentofacial Complex

The Beginning …

2.
Diagnosis
or
Recognizing the various
characteristics of the malocclusion &
dentofacial deformity.

Diagnosis
 The goal of the diagnostic process is to
produce a complete description of the
patient’s problems and make a problem list.
 To obtain the problem list, a collection of
relevant information is required. This
collection is called a database.

Mechano-Mechano-
therapytherapy
Diagnosis & Treatment Planning -
Steps
Patient History
Clinical
Examination
Analysis of
Diagnostic Records
Classification Problem List
= Diagnosis
Treat pathology
(caries, gingivitis etc.)
Treat pathology
(caries, gingivitis etc.)
Problems
in
priority
order
A
B
C
D
Possible
solution to
individual
problems
OptimalOptimal
TreatmentTreatment
PlanPlan
Data
Base
A
B
C
D

The Database
It is obtained from 3 sources.
1. Patient history, & interview data.
2. Clinical (extraoral, functional & intraoral)
examination.
3. Analysis of diagnostic records (models,
radiographs, cephalograms, photographs
etc.).

The Database
DATA
BASE

Patient History
 Name:
 Age:
 Sex:
 Address:
 Referred by:
 Presenting complaint:

Family history
 Parents
 General & dental condition (malocclusion).
 Consanguinous / Non-consanguinous marriage
 Siblings
 General & dental condition (malocclusion).
 History of any orthodontic treatment.

 Motivation of patient for treatment :
 Internal
 External
 Reasons for taking treatment :
 Esthetics
 Functional
 Hygiene
 Speech
 Pubertal status :

Prenatal History
 Health of mother during pregnancy.
 Diseases : Bacterial / Viral
 Medication :
 Radiation :
 Trauma :
 Type of delivery :
 Normal
 Caeserian
 Forceps

 TMJ ankylosis due to
prenatal trauma
(High forceps delivery)
Change the picture
to Ali’s Patient with
Sleep Apnea Syndrome

Postnatal History
 Feeding :
 Breast feeding
 Bottle feeding
 Milestones of development :
 Standing
 Walking
 Running
 Speech

Postnatal History
 Diseases :
 Past
 Present
 Medication :
 Past
 Present
 Nutritional status :

Postnatal History
 Habits :
 Thumb sucking
 Mouth breathing
 Tongue thrusting
 Lip biting

Diagnosis & Treatment Planning -
Steps
Patient History
Clinical
Examination
Analysis of
Diagnostic Records
Classification Problem List
= Diagnosis
Data
Base

Clinical Examination
Consists of
 General examination
 Extraoral examination
 Functional examination
 Intraoral examination
 Soft tissues
 Hard tissues

General Examination
 Build:
 Slight
 Moderate
 Well
 Height :
 Weight :
 Gait :
 Posture :
 Body type :
 Ectomorphic
 Mesomorphic
 Endomorphic

Body Types
Ectomorph Mesomorph Endomorph

Clinical Examination
Extraoral Examination
 Shape of head :
DolichocephalicMesocephalicBrachycephali
c
 Facial form :
Brachyfacial Mesofacial Dolichofacial
Diagnosis
6 www.indiandentalacademy.com

Diagnosis
Facial form
Brachyfacial-
Short & wide
Mesofacial-
Average
Dolichofacial-
Long & narrowwww.indiandentalacademy.com

 Facial Symmetry : VerticalHorizontal
Diagnosis

Horizontal Facial Symmetry
Diagnosis

Diagnosis
Symmetric
face
Asymmetric
face2 www.indiandentalacademy.com

OriginalRight composite Left composite
Diagnosis

 Facial Profile : Straight
Convex
Concave
Diagnosis
N’
Sn
Pg’

Straight
Profile
Convex
Profile
Concave
Profile
Facial Profile
Diagnosis

Facial Profile
Straight profile
Diagnosis
Convex profile Concave profile

 Facial divergence :
StraightPosteriorAnterio
r
Diagnosis
N’
FH Plane
Pg’

Facial divergence
Diagnosis
Straight
Divergence
Posterior
Divergence
Anterior
Divergence6 www.indiandentalacademy.com

 Nose : Size
Nasolabial angle :
Normal (90-1000
)ObtuseAcute
Diagnosis

 Lips :
Size :NormalShortThinThickEverted
Posture : CompetentIncompetent-
Anatomic
Dental
Physiologic
Diagnosis
Competent
lips

Diagnosis
Lip Incompetency
Due to short upper lip
(Anatomical)
Due to proclination
(Dental)
Due to mouth breathing
(Physiological)www.indiandentalacademy.com

 Lips
Lip trap
Interlabial gap : ……….mm
Tonicity : NormotonicHypertonic
Hypotonic
Diagnosis
Lip trap 6www.indiandentalacademy.com

Lip tonicity
Normotonic lips Hypotonic upper &
hypertonic lower lips
Diagnosis

 Mentolabial sulcus :
NormalShallowDeep
Diagnosis
4
Normal Shallow Deep

 Chin : Adequate Recessive Excessive
Adequate
chin
Recessive
chin
Excessive
chin
Diagnosis

 Face height : Upper anterior to lower
anterior face height ratio.
(Normal 45%:55%).
Diagnosis
3
45%
55%

 Frankfort Mandibular plane angle :
Normal(250
) High(>350
) Low(<150
)
Diagnosis
FH Plane
Mand. Plane

Functional Examination
 Respiration : Nasal Oral Oronasal
Diagnosis
2
Mouth Breathing

 Mastication :
 Deglutition : Normal Abnormal (Tongue
thrust)
Diagnosis
Infantile swallow Tongue thrust swallow

Tongue thrusting
Diagnosis
Simple tongue thrust Complex tongue thrust

 Speech : Dysfluency Dysarticulation
 Path of closure :
Anteroposterior : NormalDeviated
Lateral : NormalDeviated
Diagnosis

Path of closure - Anteroposterior
Diagnosis

Lateral deviated path of closure
Diagnosis

 Perioral muscle activity :
Hyperactive mentalis Hypotonic upper
lip Cheek dysfunction
Diagnosis
4Hyperactive mentalis Cheek dysfunctionwww.indiandentalacademy.com

 TMJ : Pain tenderness
Clicking
Maximum protrusion of mandible
 Maximum opening (incisal edges) :
……..mm
 Freeway space : ………mm
Diagnosis

TMJ examination
Diagnosis

Maximum opening
Diagnosis

 Amount of gingival exposure :
During speech : ………mm
During smile : ………mm
Diagnosis
5
Excessive
exposure
during
speech
Gummy
smile

 Visualised Treatment Objective (VTO) :
Diagnosis
Positive VTO

Intraoral Examination
Soft Tissues
 Frenal attachment : Normal Abnormal
Diagnosis
Positive Blanch test 3www.indiandentalacademy.com

 Gingiva : Normal Edematous Fibrous
Attached gingiva :
Pockets :
Diagnosis

 Tongue : Size :
Posture :
Habits :
Diagnosis

Soft Tissues
 Oral Mucosa :
 Palate : Normal High Low
 Oral hygiene :
Diagnosis
High palate5 www.indiandentalacademy.com

Hard Tissues
 Number of teeth present :
 Teeth absent :
 Supernumerary Missing teeth :
Diagnosis

Hard Tissues
 Impacted teeth :
 Shape, size and form of teeth :
Normal Abnormal
 Enamel texture : Normal Hypoplastic
White spots
Enamel cracks
Diagnosis

Enamel hypoplasia and white spots
Diagnosis

Hard Tissues
 Caries Restorations :
 Endodontically treated teeth :
 Occlusal facets wear :
Diagnosis

Maxillary arch
 Shape : Average Vshaped U shaped
Square
 Symmetry :
 Alignment : Crowding Spacing Rotations
Diagnosis

Normal arch
V shaped arch
U shaped arch
Diagnosis

Mandibular arch
 Shape : Average Vshaped U shaped
Square
 Symmetry :
 Alignment : Crowding Spacing Rotations
Diagnosis

Diagnosis
Severe crowding

Arches in Occlusion
 Molar relation : Cl I Cl II Cl III
 Canine relation : Cl I Cl II Cl III
 Incisor relation :
 Overjet : Normal Increased Reverse ……..mm
 Overbite : Normal Deepbite Openbite……mm
Diagnosis
6M Owww.indiandentalacademy.com

Arches in Occlusion
 Transverse relationship : Crossbite
Scissorbite
 Curve of spee : Normal Flat Deep .……
mm
 Midline :
Diagnosis

Normal (Cl I) occlusion
Diagnosis

 Class II molar & canine relation.
Diagnosis

 Class III molar relation.
Diagnosis

Increased overjet
Reverse overjet
Diagnosis
Overjet

Deep bite Open bite
Diagnosis
Over bite

Cross bite
Diagnosis
Scissor
bite

Diagnosis & Treatment Planning - Steps
Patient History
Clinical
Examination
Analysis of
Diagnostic Records
Data
Base
Classification Problem List =
Diagnosis

Analysis of Diagnostic Records
Diagnostic records include.
 Models.
 Radiographs - IOPA, OPG, Handwrist
radiograph.
 Photographs.
 Cephalograms.
Diagnosis

Diagnosis
Radiographic examination
Number of teeth present :
Teeth absent :
Root formation : Permanent teeth
Decidous teeth

 Eruption levels :
 Supernumerary :
 Impacted teeth :
 Third molars :
Diagnosis

 Lamina dura and height of interdental
crest :
 Character of restoration :
 Pathological conditions :
Diagnosis

Handwrist radiograph :
 The stage of ossification of bones in the
radiograph is examined.
 The bones assessed include 1) the ulnar
sessamoid 2) the pisiform 3) hook of
hamete and 4) the metacarpels.
 This assessment is also known as the
Carpel Index
Diagnosis

Ulnar
Sesamoid
Diagnosis
Hook of
hamete
Pisiform

Photographic analysis
 Three extraoral views and five intraoral
views are taken.
 Extraoral views - frontal, lateral and 3/4th
smiling views.
 Intraoral views - frontal, right lateral, left
lateral, upper occlusal and lower occlusal.
Diagnosis

Model analysis
 Bolton’s analysis
 Carey’s analysis
Cephalometric analysis
 Steiner’s analysis
 Tweed’s analysis
Diagnosis

Diagnosis & Treatment Planning - Steps
Patient History
Clinical
Examination
Analysis of
Diagnostic Records
Data
Base
Classification Problem List =
Diagnosis

For want of a good seperation, a molar band was not
seated;
For want of a proper fit, a band became loose;
For want of a fixed band, the archwire became distorted;
For want of comfort on holiday, the father cut the
archwire;
For want of an intact archwire, there was anchorage
loss;
For want of proper anchorage, the case failed.

Diagnosis & treatment planning

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