Diagnostic records /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
•

Leader in continuing dental education

•

www.indiandentalacademy.com


Introduction……
Duncan says in Shakespear’s Macbeth,
“THERE’S NO ART TO FIND THE

MIND,S CONSTRUCTION IN THE FACE…

Orthodontic Diagnosis


Diagnostic Database in orthodontics
ESSENTIAL
• CASE HISTORY
• CLINICAL EXAMINATION
• STUDY MODELS
• CERTAIN RADIOGRAPHS
- IOPA
- BITE WING
- PANORAMIC
• FACIAL PHOTOGRAPHS

SUPPLEMENTAL
. SPECIALISED RADIOGRAPHS
- CEPHALOMETRIC RADIOGRAPHS
- HAND WRIST RADIOGRAPHS
- OCCLUSAL RADIOGRAPHS
- CONE SHIFT TECHNIQUE
- DIGIGRAPH
- CRANIOFACIAL IMAGING
. ELECTROMYOGRAPHY
. BASAL METABOLIC RATE
. DIAGNOSTIC SET UP
. PHYSIOPRINTS
. OCCLUSOGRAMS


Case history
Case history can be divided in to
Medical history

Dental history

Family history

patient history

Prenatal

Postnatal


Clinical examination
1. General examination.
2. Extraoral examination.
3. Intraoral examination.


General examination
 State of development: Age related/
overdeveloped/ underdeveloped, mentally
normal/early/late developer,
lively/quiet/nervous/phlegmatic

 Body height……..cm
 Body weight………kg
 Stature: strong/tall/average/short/adipose
 Nutritional status: good/ bad
 Dental age:…….years
 Skeletal age:…….years

Extra oral examination
• Facial asymmetry: shift of maxillary
midline relative to the facial midline.
• Head form/ cephalic index:
dolichocephalic/ mesocephalic/
brachycephalic/ hyperbrachycephalic.


Facial index: It is assessed using distance between
nasion and gnathion, the bizygomatic width.

• Euryprosopic type : patient exhibits
wider face with wider apical based
jaws in transverse dimension.
• Leptoprosopic type : patient exhibits
narrow face with narrowing of coronal
arch and the apical base in transvers
dimensions.

Facial profile:• straight profile
• Convex profile
• Concave profile


Frontal view:• Facial symmetry
-vertical midsagittal plane.
-upper horizontal plane.
that is bipupillary plane
-Lower horizontal plane,
through the stomion.
-Bilateral marking of orbital
point.

• Facial asymmetry


Lips - posture and nasolabial angle
•

According to korkhaus;
Different variations of lip profiles & the
lip step are:. positive lip step ,a symptom of class III
profile.
. slightly negative lip step seen in normal
profile.
. marked negative lip step, a symptom of
class II profile.

 Nasolabial angle;
. Decreased due to maxillary
prognathism.
. normal ( 1020 )
. Increased due to maxillary
retrognathism.

Lips - dysfunctions
A

• A- competent lips ;-Lips in
contact when the musculature
is relaxed.

• B- Incompetent lips ;Anatomically short lips with a
wide gap between the upper
and lower lip in relaxed state.
• C- Potentially incompetent
C
lips;-labialy placed upper
incisors interpose between the
lips and prevent the normal lip
D
• seal.
D- Everted lips ;- This is a lip
seal with weak tonicity of lip
musculature, often with
bimaxillary dental www.indiandentalacademy.com
protrusion.
B

Intra oral examination
Dental findings;• No of teeth present should be recorded.
• Patients oral hygine status should be evaluated.
• Measurement of overjet and overbite.


Soft tissue examination:• Maxillary, mandibular labial frenal
attachment and lingual frenal
attachment should be examined.


• Gingiva:-inflamed / hyperplastic / recession
• Periodontal diseases:- periodontal status
should be recorded in periodontal chart
form.
• Oral mucosa:- examined for pathologic
changes.
• Palate:- high / average / flat
• Apical base examination In transvers and
sagittal direction .

Tongue posture, length and width &
swallow pattern :A broad and low lying tongue, as seen in
class lll cases, will extend over the dental
arches and will have lateral indentations and in
case of a long tongue it reach the tip of the
nose .


Types of swallow

Normal matured
somatic swallow

Infantile swallow
in neonates


Habitual tongue
thrust swallow

TMJ dysfunction..
Diagnosis of the general systemic disease and local
pathology which is the causative factor in TMJ disorder is
very critical in management of TMJ disorders. The TMJ
disorder may be due to,
• Developemental or Functional disturbance of the
musculoskeletal system of TMJ.
• ENT disease
• Adenopathy
• Disorders of neural origin
• Collagenous disease
• Bone dyscrasias
• Traumatic disorders
• Arthritis
• Psychogenic factors….etc

Functional examination
• Examination of the postural rest position and
maximum intercuspation.
• Examination of the temporomandibular joint.
• Muscle palpation.
• Examination of mandibular movements.
• Examination of orofacial dysfunctions.


Examination of the postural rest position and
maximum intercuspation


Examination of the temporomandibular joint


Auscultation & palpation of the T M J

Auscultation
of T M J

Lateral
palpation
of T M J

posterior
palpation
of T M J

Examination of masticatory muscles of T M J
 Palpation of lateral
pterygoid muscle.
 Palpation of temporalis
muscle.
 Palpation of masseter
muscle.
 Recording the maximum
interincisal distance.

Electro-myographic examination (EMG)
• EMG is occasionally used to confirm a
clinical diagnosis of muscle dysfunction.
• For ex.: In sever class ll division l
malocclusion, the mentalis muscle is
hyperactive, upper lip is hypo functional
and in addition , buccinator contracts
excessively and the posterior fibers of
temporalis exerts considerable influence
to above muscle activity. this muscular
imbalance can be assessed by using
EMG.

Examination of mandibular movements during
functional maneuvers

• Left:-opening and closing paths in sagittal plane.
• Middle:-opening & closing arcs in horizontal plane
• Right:-opening and closing paths in frontal plane.

• Articulators & mounted
diagnostic models are
used to determine if the
bite is in a proper
relationship to the TM
joint.


Diagnostic records includes…
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Study models
Facial photographs
Intraoral photographs
panoramic & intraoral radiographs.
Cephalometric radiographs.
Digital imaging:- Digital photography
- Digital radiography
- Digital cephalometry / digigraph
- Digital video cephalometry
- Digital study models / OrthoCAD
a) Conventional craniofacial imaging:- Traditional CT scan [ CT ]
- Magnetic resonance imaging [ MRI ]
b) contemporary and evolving imaging techniques:- Cone beam Volumetric tomography [ CBCT ]
- Surface mapping with Structured light
- Laser scaning
- Stereophotogrammetry

Study cast analysis:- Gnathostatic model by
SIMON, 1926

• These plaster models are oriented to the
midpalatal raphe, tuberosity plane and the
occlusal plane for study cast analysis .these
model analysis helps in a three dimensional
assessment of the maxillary and mandibular
dental arches and there occlusal relationships.
• The upper surface of the maxillary study model
corresponds to frankfurt horizontal plane.

•
•
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•
•
•
•
•
•

Study models are used for
To calculate total space analysis.
To assess and record the dental anatomy.
To assess and record the intercuspation.
To assess and record arch form.
To assess and record curves of occlusion.
To evaluate occlusion, with aid of articulator.
To measure progress during treatment.
To detect abnormalities ( distorted arch form)
To provide a record before, immediately
after, and several years following treatment
for the purpose of studying treatment
procedures.

Permanent & mixed dentition model analysis
Permanent Dentition:
1. Pont’s index.
2. Korkhaus analysis.
3. Linder harth index.
4. Arch perimeter
analysis.
5. Bolton tooth size ratio.
6. Ashley Howe’s
analysis.
7. Peck and Peck index.

1.
2.
3.
4.
5.

Mixed dentition :
Moyers mixed dentition
analysis.
Huckaba’s analysis.
Hixon & old father
method.
Nance carey’s analysis.
Total space analysis.


Pont’s analysis (1909 )
• It is used to determine the
ideal dental arch width from
combined mesiodistal width
of the maxillary ( 2 1/ 1 2 )=X
• The ideal arch width in
premolar region is calculated
by (X/80)×100
• The ideal arch width in molar
region is calculated by,
(X/64)×100

Palatal height analysis
• Palatal height is measured in
the midsagittal plane in the
region of the upper 1st molars
on the level of the occlusal
plane using korkhaus three
dimensional orthodontic
divider.
• Palatal
= Palatal height × 100
height
posterior arch width
index
• The average index value is 42%
• Inference:- If >42%
high palate.
- If <42%
shallow palate.,

Ashley howe’s analysis
• According to howe’s , crowding is not
only due to tooth size, but it can also
result when there is inadequate
apical base.
• It can be calculated by determining ,
-- TTM (tooth material)
- PMD (premolar diameter)
- PMBAW (premolar basal arch
width)
- BAL (basal arch length)
• Compare PMD & PMBAW
• Calculate
PMBAW% =PMBAW × 100
TTM
• Results compared with howe’s
measurements table.

Inference
1.The patient values should fall with in the suggested range.
2. If PMD>PMBAW, expansion is contraindicated.
If PMBAW>PMD, expansion is indicated.
3. If PMBAW × 100
TM
- Less than 37%
basal arch deficiency case requiring
extraction of teeth.
- If >44%
Ideal case & dose not need extraction.
- If between 37% to 44%
Borderline case, which may/
may not require extraction.


Arch perimeter analysis
• It use to find the difference
between the basal bone and
tooth material
• It is used to evaluate
- tooth material (space
required)
- arch perimeter (space
available)
-arch length discrepancy
Arch perimeter analysis done on
lower arch is called carey’s
analysis.

Boltans analysis


Table of average values for the overall and
anterior ratio’s of maxillary and mandibular
tooth width according to boltan


Photography
ABO Requirements
1.
2.
3.
4.
5.
6.
7.
8.
9.

Quality prints either in black and white or color.
Head should be oriented accurately in all 3 planes
of space and in F-H plane.
1Lateral view- facing to the right , serious
expression ,lips closed lightly.
1Anterior view- serious expression
Background free of distractions.
1lat view ,1ant view- (optional) with lips apart.
1 ant view- (optional) smiling.
Quality lighting with no shadows.
Ears exposed for purpose of orientation.

10.Eyes opened, looking straight ; glasses removed .

Facial photographs.
• For ideal photographic representation of the
face, the camera should be positioned in the
“portrait” position to maximize use of the
photographic field. Orienting camera in
“landscape” position captures much of the
background and diminishes the size of the face
in the picture.


Extra oral photographic views
• Acc. to Proffit :– Frontal view with lips relaxed
– Frontal view with lips together
– Profile view with lips relaxed
– Profile view with lips together
– Smile (Angular or frontal)


Extra oral photographic views
• According to T M. Graber and R
L. Vanarsdall
1.Frontal view
- at rest with lips repose.
- at maximal intercuspation, with lips
closed.
- a Dynamic (smile)
- a close-up image of posed smile.
2.Oblique ( three-quarter, 45-degree ) view
- Oblique at rest
- Oblique on smile
- Oblique close-up smile
3.Profile view
- Profile at rest with lips relaxed
- Profile smile
4.Optimal Submental view

Commonly used extra oral photographs

Frontal
view

Frontal
dynamic
(smile)
view

Oblique
three
quarter
view

Profile
view


ABO requirments for intraoral photographs.
 Quality, standardized intraoral prints in colour.
 Patient’s dentition oriented accurately In all three
planes of space.
 One frontal view in maximum intercuspation.
 Two lateral views – right and left.
 Optional: Two occlusal views- maxillary and
mandibular.
 Free of distractions – cheek retractors, labels
and fingers.
 Quality lighting revealing anatomical contours
and free of shadows
 Tongue retracted.
 Free of saliva and/or bubbles
 Dentition clean.

Intra oral photographic views

Right lateral view

Frontal view

left lateral view

• The occlusal
Maxillary occlusal view photograph should
be taken using a
front surface mirror
to permit 90° view of
the occlusal surface.
Mandibular occlusal view

Uses of intra oral photographs,
• It enable orthodontist to review the hard
and soft tissue findings from the clinical
examination during analysis of all the
diagnostic data.
• To record hard and soft tissue conditions
as they exist before treatment.
• Photographs helps to record white-spot
lesions of enamel, hyperplastic areas and
gingival clefts to document that such
preexisting conditions are not caused by
orthodontic treatment.

Radiography


Topographic anatomy of the skeleton of the hand..


Maturation indicators of hand bones for determining
skeletal age ..
There are 3 stages of
ossification of the
phalanges ..
• 1st stage - Epiphysis shows
the same width as the
diaphysis .
• 2nd stage - In capping
stage, the epiphysis
surrounds the diaphysis
like a cap.
• 3rd stage – In U-stage bony
fusion of epiphysis and
diaphysis occur.

Analysis of hand radiographs according to
Bjork, Grave and Brown:
•

1st stage of maturation PP2 =stage
Epiphysis of the index finger (PP2)
has the same width as the diaphysis.

•

2nd stage: MP3= stage Epiphysis of
the middle finger (MP3) is of the
same width as the diaphysis

•

3rd stage : pisi-,H1 and R = stage
this stage has 3 distinct ossification
areas,
Pisi- stage = Visible ossification of
the Pisiform.
H1- stage = ossification of the
hamular process of the hamatum.
R stage = same width of epiphysis
and diaphysis of the radius.


4th stage: S- and H2-stage
S-stage = First mineralisation of the
sesamoid bone of the
metacarpophalanngeal joints of the
thumb.
H2-stage = Progressive ossification of
the hamular process of the hamatum.

 5th stage: MP3, PPI and R stage
In this stage the diaphysis is
covered by the cap shaped
epiphysis at the middle phalanx,
proximal phalanx, and radius.

6th stage: DP3 – stage Visible union of
epiphysis at the distal phalanx of the
middle finger.
7th stage: PP3 – stage Visible union of
epiphysis and the proximal phalanx of the
little finger.
8th stage: MP3 – stage Union of epiphysis at
the middle phalanx of the middle finger is
clearly visible.
9th stage: R- stage Complete union of
epiphysis and diaphysis of the radius. The
ossification and skeletal growth is finished.

Julian singer’s method of Hand wrist radiograph
assessment (1980)
According to singer’s There are 6 stages to determine
the maturational status of the patient,
• Stage one (early):- Absence of pisiform, absence of hook
of hamate & epiphysis of proximal phalanx of second
finger being narrower than its diaphysis.
• Stage two (prepubertal):- Initial ossification of hook of
hamate, initial ossification of the pisiform and proximal
phalanx of second finger being equal to its epiphysis.
•

Stage three (pubertal onset):- There is beginning of
calcification of ulnar sesamoid, increased width of
epiphysis of proximal phalanx of 2nd finger & increased
calcification of hook of hamate & pisiform.

• Stage four (pubertal):-characterized by calcified ulnar
sesamoid and capping of the diaphysis of the middle
phalanx of 3rd finger by its epiphysis.
• Stage five (pubertal deceleration):-characterized by fully
calcified ulnar, sesamoid, fusion of epiphysis of distal
phalanx of third finger with its shaft, & epiphysis of radius
and ulna not fully fused with respective shafts.
• Stage six (growth completion):- No remaining growth
sites seen.


Cervical vertebral maturation as a
predictor of the growth


The five stages of cervical vertebral
maturation used to predict the phases of
growth.
by Baccetti and colleagues
CVMS I: The lower borders of the
first three cervical vertebrae are
flat, with the possible exception
of a concavity at the lower
border of C2 in almost half of
the subjects. The bodies of
both C3 and C4 are trapezoidal
in shape.


• CVMS II: A concavity is present at
the lower borders of both C2 and C3.
The bodies of C3 and C4 may be
either trapezoidal or rectangular
horizontal in shape.

• CVMS III: A concavity is now present
at the lower borders of C2, C3, and
C4. The bodies of both C3 and C4
are rectangular horizontal in shape.


• CVMS IV: The bodies of C3
and /or C4 are square in
shape. If not square, one of
the two cervical vertebrae is
still rectangular horizontal.

• CVMS V: The bodies of C3
and. / or C4 are rectangular
vertical in shape. If not
rectangular vertical,- one of
the two cervical vertebrae is
still square.

Full mouth radiographs..
• Full mouth radiographs
before commencement of
orthodontic treatment is
of a valuable aid in
accurate assessment of
the periodontal condition
and the apices of the
roots.
• These diagnostic records
will help in assessment of
areas of root resorption at
the completion of
mechanotherapy.

Occlusal radiographs
• occlusal radiographs r the
diagnostic aids wihich
help to locate
supernumerary teeth at
midline, and to ascertain
accurately the position of
unerupted maxillary
cuspids


Orthopantomogram (opg)
• The panoramic radiograph gives a survey of the
T M J, entire dental condition and abnormalities
of the mixed dentition in one single exposure.
• Radiologic findings like hypoplasia, impacted
teeth, narrow tooth germ posistion, root canal
filling, root resorptions, amount of bone loss,
bony trabecular pattern, bony pockets, any root
fragments, third molars, supernumerary teeth
and pathological lesions at root apex and other
findings can be evaluated using panoramic
radiographs.

Shift cone technique / clarks technique

• For locating position
of impacted canines .


cephalometrics


Cephalometric records
• Cephalometric analysis is a 2D
representation and analysis of
a 3D patient ,using a numerous
reference points and lines
made on patients lateral
cephalogram.
• These reference points and
lines are located in the
skeletal, dentoalveolar and soft
tissue regions of the headfilm.


The information that can be ascertained
from the cephalometric analysis are...
 Classification of the facial patterns.
 Relationship of jaw bases before treatment.
 Monitoring of skeletodental relationships during
treatment
 Relationship of the axial inclination of incisors.
 Assessment of the soft tissue morphology.
 To predict Growth pattern and direction of growth.
 Localization of the malocclusion.
 Treatment possibilities and limitations.
 Determination of mandibular rest position.
 Assessment of trauma after facial injuries.

Cephalometric reference points


Cephalometric reference planes


Purpose of different cephalometric analysis
 For diagnosis – Ex:- Down’s analysis.
 For treatment planning - Ex:- Steiner’s analysis.
 For growth predictions – Ex:- Serial cephalograms, visual treatment
objective of Holdaway, Ricketts analysis…etc
 For surgical orthodontics - Ex:- Burstone’s analysis (COGS)
 For Soft tissue evaluation - Ex:- Arnett analysis, Holdaway, Meredith
analysis, Burstone analysis…etc
 For studying symmetry – Ex:- Rickett’s analysis.
 For airway evaluation – Ex:- McNamara analysis.

Frontal cephalogram
• To evaluate facial
asymmetry.
- Grummon’s analysis.
- Rocky mountain analysis.
• To diagnose malocclusion
in transverse plane.


Structural Classification of Dentofacial
Assymetries
Broadly classified into Dental, Skeletal,
Muscular and functional.
• A. Dental Asymmetries: can be due to
Local factors such as loss of deciduous teeth,
congenitally missing teeth, habits and lack of
exactness in genetic expression.
 B. Skeletal Asymmetries: Their deviation may
involve one bone such as maxilla or mandible
or it may involve a no. of skeletal and muscular
structures on one side of the face.

• C) Muscular Asymmetries :

Hemifacial atrophy or cerebral palsy,
abnormal muscle functional

• D) Functional Asymmetry:

can result from the mandible being deflected
laterally or antero - posteriorly, if occlusal
interferences prevent proper intercuspation
in centric relation.

occlusograms
• Occlusogram is a 1:1 reproduction of the
occlusal surfaces of plaster models on a sheet
of tracing paper or they are the direct positive
photographs in negative form of plaster study
cast.
Clinical significance:• It is a reliable way of determining minute changes in the
arch form & position of teeth before, during and after
orthodontic treatment.
• This method provides a simplified method for
measurements to determine the arch length discrepancy.

Diagnostic set-up by H.D. kesling
• It is valuable in,
•
•
•

•

Borderline cases to know,
-whether to extract or not.
-whether to extract 1st
premolar or 2nd premolar.
Possibility of aligning
incisors, whenever incisor
extraction is planned as at of
treatment plane.
All possible types of occlusal
arrangement for patients with
abnormal occlusal problems
like, missing teeth, badly
broken teeth etc…


Diagnostic records in case of fixed
mechanotherapy….


Stage 1 - Pre treatment records ……Date:-…………….
• Extra oral photographs.

• Intra oral photographs.

• Diagnostic study
models.

Am J Ortho Dentofacial Orthop, October 2004

Pretreatment lateral cephalogram and its cephalometric tracing for
diagnosis,and pretreatment panoramic rodiograph.


Stage 2- Progress treatment records .

Date:-………

• Progressive Mid treatment
photograpic records.
• Mid treatment intra oral
photographs.
• Progressive treatment
diagnostic study models.


Progress lateral cephalogram, and the progress
cephalometric tracing superimposed on the pre
treatment tracing.

•

Progress panoramic radiograph...


Stage 3 - Post treatment records.

Date:-…………..

• Post treatment
photographic records.
• Post treatment intra oral
photographic records.
• Post treatment study
models records.


Post treatment lateral cephalogram and its cephalometric
tracing superimposed with pretreatment lateral
cephalometric tracing records to evaluate the results
achieved at the end of the tratment. e

•

Post treatment panoramic radiogram.


Technobytes and Digital imaging

• The transition from film to digital has been happening
at a faster pace in the fields of Orthodontics,where the
photographic & radiographic images (periapical,
occlusal, OPG, cephalometric, and skull radiographs)
are being acquired digitally, stored as a diagnostic
record with in a server locally, and eventually
accessed for diagnostic purposes, along with the rest
of the patient data via the patient management
software.

Goals and principles of craniofacial imaging:General imaging goals: Image the entire region of interest.
 View the entire region of interest in at least 2 planes at right
angles to each other ( 3D )
 Obtain images with maximum detail, minimal distortion &
minimal superimposition.
Clinically determined imaging goals: To identify normal & abnormal anatomy.
 Determine root length & root alignment.
 Determination of the status of TMJ.
 Determine the relationship b/w tooth space requirement and
jaw dimensions.
 Determine maxillomandibular spatial relationships.
 Determine past, present & expected craniofacial growth
magnitude and direction.
 Determine effects of treatment on the craniofacial anatomy.
 Identify and localize supernumeraries and impacted teeth.

Digital imaging records includes..
• Digital photography
• Digital radiography
• Digital cephalometry- Digigraph
• Digital study models


Digital photography

• Pixel (Picture
element)
• Voxel (Volume
element)
• Spoxel (Space
element)

•

•

CCD - Charged Couple Device (Charge
Coupled Device?)
CMOS – Complementary Metal Oxide
Semiconductor
ADC – Analog to Digital Converter

•

Light

•

Sensor

Electric charge

storage of digital images in Memory

ADC

Digital Photography
Advantages

Disadvantages

- Instant viewing of pictures
-cameras prices are still
- mistakes can be rectified
high.
immediately
-As digital images can be
- No film or processing is
retouched , they can’t be
required
useful for medico-legal
- Manipulation of data on
requirements as
computer, easy duplication
traditional negatives.
- Organization of data
- No rolls – saves money ,
no aging of photos.
- Decreas storage problems
& easy retrieval in need.
- Immediate Transmission
of data

Digital Radiography
RadioVisuoGraphy (RVG)
 Imaging done with a CCD
 very high resolution
 optimal shape and size of the
sensor
 sensor thickness 4 mm


Digital Radiography
Data collection:
Electric
al
charge

Image

• CCDs
• Amorphous Selenium
• Amorphous Silicon
• Phosphor plates

Sensor

digitizer

X-ray

Structure of sensor
Scintillator

CCD

Fiber optic layer

X-ray imaging with CCD

• Scintillator converts x-rays to photons.
(light)
• Fibro optic layer Conducts photons to
CCD and stops radiations.
• CCD converts photons tgo
electrons(charges).
• Electric circute amplifies the signal and
converts the analog signal in to digital.

pixels

•

Imaging cycle

1.Load intraoral or panoramic
imaging plate
5. Erase imaging plates
for reuse

2. Take X ray
Image on computer

3. Mount imaging plates in carousel

4. Place in scanner & Scan images


[Storage phosphour imaging plates]

Advantages of digital radiography
- Images can be manipulated using softwear filters
(brightness, contrast and saturation can be altered
which make identification of anatomic tissues easy)
- Alternative to conventional film
- Same machine and settings used for DenOptix &
regular cephalograms and OPGs.
- No chemicals or dark room is required .
- Environment friendly- no heavy metal wastage
- Can be reused thousands of times
-Immediate Transmission of images
- Image is instantly www.indiandentalacademy.com
obtained Saving clinic staff time.

Digital Cephalometry

• Digitization is a process by which analog information is
converted into digital form

Indirect digitization

Digitizing tablet

Electronic pen

Direct digitization

Mouse

Cross hair cursor

Digital Cephalometry
•

Digitization
– Activated by pressing the button
– Location of individual landmarks in a
predetermined sequential manner
– Visual ceph generated by connecting
dots by lines and curves
– Once digitization is complete,any
analysis can be performed in seconds using the
reference points and planes.


Digigraph
The Digigraph Workstation
- It’s a non radiographic
system.
- Two video cameras
permanently aimed &
focused.
- Head holder
-Attached video monitor –
Images,text,numerical data
can be displayed,
stored,modified using a
computer keyboard.

Procedure for Digigraph


Digigraph
• Cephalometric analysis display
- Any of the 14 cephalometric analyses
• Rickets lateral
• Rickets frontal
• Vari-Simplex
• Holdaway
• Alabama
• Jarabak
• Steiner

•
•
•
•
•
•
•

Downs
Burstone
McNamara
Tweed
Grummons frontal
Standard lateral
Standard frontal


Digigraph
•

Visual Treatment
Objective (VTO)

To move part of the picture,
simply touch the light pen
to two points on the screen,
at opposite extremes of the
area to be moved.


Digitalizing study models using OrthoCAD

• OrthoCAD - It is a digital study model capture,
assessment and storage system.
• It provides a 3D record of the original malocclusion,
any stages during treatment and the outcome of the
treatment.

OrthoCAD & 3D digital study models
• OrthoCAD software helps
orthodontist to view,
manipulate, measure &
analyze 3Digital study
models.
• The penta-view of
OrthoCAD ,enable us to
view models from any
direction in desired
magnification on screen,
thus lingual aspect of
maxillary & mandibular
teeth in occlusion can be
clearly seen & assessed
using OrthoCAD .
• Journal of orthodontics- pubmed

OrthoCAD with diagnostic tools
• a) Occlusogram can show
inter-occlusal contacts
using colour -coded
scales.
• b) overbite & overjet can
be assessed by splitting
the model in the midsagittal plane.
• c) splitting can be done at
any point & in any angle .
• d) can measure mesiodistal width of teeth.
• e) Space analysis in arch.
f) can Measurement of arch widths in both the jaws .
Journal of orthodontics- pubmed

Arch perimeter analysis using OrthoCAD

• Similarly other model analysis can also be
carried out using OrthoCAD software .this
software is available with several diagnostic
tools such as measurment analysis (e.g. Bolton
analysis, arch width & length analysis ).

OrthoCAD virtual set-up based on straight wire
philosophy

• OrthoCAD virtual set-up
needs to go through 7
steps to reach final plan.
• Another addition to this is
the OrthoCAD bracket
placement system, which
position brackets
according to their planned
position in 7 virtual
Journal of orthodontics-www.indiandentalacademy.com
pubmed treatment plan stages.

3D study model by laser scanning

• It helps to reveal
accurate occlusal
morphology.
• This technique
permits 360° views of
study models with
high accuracy, as the
images are captured
from several different
angles & hence, it
permit recording of
undercut areas .

Digital study models
Advantages
Disadvantages
• Virtual casts can be kept in
• If the plaster dental
digital format & hence
casts are poor, than
eliminating storage problems.
the obtained digitalized
images will be altered
• Immediate data transmission.
during digitization .
• Measurements on digital casts
is easy, accurate & automatic. • Dental images in mixed
dentition are difficult to
• Digital images can be made
recognize and measure.
bigger and hence localizing
• Digitalizing dental casts
anatomic points easily.
is a laborious process
• Digital study casts can be
that has always to be
used for patient motivation.
made under the same
• Stores original malocclusion in
conditions.
3D formate.
Med oral patol oral cri bucal 2006- pubmed

Computed Tomography
• Equipment
- Scanner table
+gantry
- Computer movable
X
ray system
- Display console


Computed Tomography

 Principle….
X-ray tube (a) rotates in tandem with detectors (b) on
opposite side to image 1 thin axial slice. Gantry is than
advanced through CT machine for next slice.

• An image of a layer within the body is produced while the
images of the structures above and below that layer are
made invisible by blurring
Am J Ortho Dentofacial Orthop, MAY 2005

Working principle

• Two spheres scanned at 3 different angles (0°, 60°, 120°) and
graphs is obtained at each angle position which show absorption of
x-rays as registered by detectors present in the tandem. At
reconstruction phase by using mathematical algorithms, machine
effectively back-project absorption graph data inside scanned
volume. Thus 1D data registered at each rotational position are
combined to produce 2D image of axial slice. Each axial slice is
composed of pixels (small square elements aranged in rows and
columns).
Am J Orthowww.indiandentalacademy.comMAY 2005
Dentofacial Orthop,

Difference between CT and CBCT

• The type of imaging source –detector complex and the
method of data acquisition.

Rendering axial slice in to 3D image

Axial slices of maxilla
showing impacted tooth.

3D Volume composed of voxels. Some
voxels are rendered transparent to show
object inside by using transfer function.

2D cephalogram front and edge on view showing front row of pixels. By
extending a flat pixels image in 3rd dimension using computer algorithm, will
yield a 3D volume.


Computed Tomography
•

Clinical applications
High radiation exposure and high cost
has prevented its use in Orthodontics.

But in certain situations benefits
outweigh the risks and are used in
certain situations like,
 In severe craniofacial deformities where
2D diagnostic records are inadequate
 Treatment predictions with 3D computer
tomographic skull models
 TMJ examination


CT image

• Parallel X-ray
beam is sent
through the
patient.


• 3-D
cephalometric
hard tissue
landmarks.


• 3-D
cephalometric
hard tissue
landmarks.
virtual lateral
and frontal
cephalograms
linked to the 3D hard tissue
representation.

• Set-up of 3-D
cephalometri
c hard tissue
landmarks
linked lateral
and frontal
cephalogram
s.


Potential use of 3D data obtained from CT scan .
1.Impacted tooth position

• The exact position of
impacted tooth and their
relationship to adjacent
roots and there
resorption & their
proximity to any
anatomical structures
can be easily diagnosed.


2. CT scan of maxillofacial region

• CT scan of the maxillofacial region can be
used to visualize both bony structures and
teeth in three dimensions , and used as an
supplemental to 2D cephalometric diagnostic
records.

3.Simulation of torque movements
• 3D evaluation of axial
inclination of teeth can
provide information to
supplement the records
obtained from models.
• It is possible to change
the torque of a single
tooth or a group of teeth
& evaluate the amount of
bone before fenestration
is evident.


4. 3D digital modeling and setup of orthodontic
tooth movement & space closure using CT scan

A

B

• Separation of anatomic
teeth, including roots
from CT scan.

• 3D setup simulating
extraction of 2 first
premolars.


C

• Simulation of
Subsequent space
closure following
orthodontic tooth
movement.


D

• Simulation of subsequent
tooth alignment at the
completion of orthodontic
tooth movement.

• Aligned crowns & roots
and their anatomic
relationship with
surrounding bone with
E
possible fenestrations.
• Helps in assessment of
width of available bone
for buccolingual
movement of teeth.

5.C T scan for T M J examination.
• Computed tomogram
of the right & left T M J
in habitual occlusion .
• Computed tomograms
of the right & left T M J
in maximum openmouth position.


TMJ examination
 Useful in determining

changes in bone density
 Primary imaging method
when internal derangement or
arthrosis is suspected –
clinical diagnosis is not always
sufficient.
 Has advantages when
planning treatment or
operations on jaws and TMJ
diseases and deformities.

6.Airway volume assessment in pt. with
mouth breathing, adenoid hypertrophy, or
sleep apnoea, by application of transfer
function to 3D CT scan
7.Bone rendering with transparent soft
tissues by application of transfer
function ,which render soft tissue
invisible on 3D CT scan.
7. Visualization of internal anatomic
structures by removal of cranium by
box cut to peek inside a 3D volume by
use of transfer function.

Volume rendering

•

Set up of 3-D cephalometric reference
system in conjugation with FH plane,
maxillary plane, occlusal plane,
mandibular plane.(3-D hard tissue &
transperent soft tissue surface
representation)

•

Set up of 3-D cephalometric reference
system in conjugation with FH plane,
maxillary plane, occlusal plane,
mandibular plane.(3-D soft tissue
surface representation)


Cone-Beam CT Device images

•

A key feature of CBCT images is the ability to navigate through
the volumetric data set in any orthogonal slice window [ axial,
sagittal, coronal and panoramic views], instead of just
analyzing 2D crosssectional images from a 3D patient, and help
clinicians think in 3D directions instead of 2D directions.


3D Cone-Beam CT virtual models

•

A. Can be Used In case of Surgical patients and those with
developmental anomalies like hemi facial microsomia where in
case ,if the working condyle is missing, it can be replaced with
costocondral graft by proper planning of surgery using 3D
cone beam CT virtual models .

• B. can be used to evaluate significant facial asymmetry
and missing articular fossa.


3D Cone-Beam CT models

• Can render bone transparent which allows visualization
of developing permanent teeth & It can also be used to
determine the position of the surgical pins or implants in
bone, that might be impairing tooth eruption .

Angular measurements with CBCT
• Sagittal slice of CBCT
showing angular
measurement .

• Linear & angular measurements between anatomical
reference points (inter canine width) using axial view
of CBCT images. www.indiandentalacademy.com

CBCT of condylar head
• CBCT can be used to
establish a 3D setup of
mandibular condyles . It
helps to assess the size ,
shape and position of
mandibular condyle in
glenoid fossa.


Dolphin 3D beta version imaging

• A:- Lateral view of 3D virtual models with transparency of
soft tissue.
• B:- 2D cephalogram generated from 3D models with
orthogonal projection.
• C:- 2D maximum intensity projection cephalogram .


3D Digital modeling and setup
A

C

B

D

E

• 3D superimposition of the anatomic teeth, before
treatment [A & B] and after [C & D] the setup to
visualize the amount of teeth movement before and after
treatment [ E ] by making use of 3D setup


3D digital modeling and setup using CT scan
A

B

A – removal of crowns
from CT scan.
B – separation of roots.

C

C – merging of these
roots with separated
crowns acquired from
models.


Magnetic Resonance Imaging
. Principle:MRI is a type of emission imaging of water in the tissues.
When images are displayed; intense signals show as white
and weak ones as black.
Intermediate as shades of gray.
Cortical bone and teeth with low presence of hydrogen are
poorly imaged and appear black.


MRI
 MRI can clearly differentiate the soft tissue

components
 Preferred imaging technique when information
regarding the articular disc or the presence of
adhesions,or joint effusion is desired
 Indications
 Assessing diseases of the TMJ
 Cleft lip and palate
 Tonsillitis and adenoiditis
 Cysts and infections
 Tumors

Structured light
• principle behind structured light systems is the
projection of a designed pattern on to a surface
that is distorted & interpreted as 3D information
to produce a surface map.
• Because a pattern is projected on to the face,
the colored surface map obtained can be
distracting. For this reason a second image is
often obtained with out the projected pattern.
• In this way the surface map obtained from
projected pattern is used with clean texture map
to produce more realistic 3D images.

Laser scan for 3D facial imaging

• Laser scanner consists of a color camera which is
registered to with the laser scanner.
• Laser scanning provides only the surface map & can not
provide color information of the texture map.
• Prelabeled anthropometric landmarks can be used for
facial analysis using laser scanning.

World journal of orthodontics December 2006

Principal of laser scanner
• A non contact 3D laser
scanner utilize patterned
light technique in the form
of slit or grid projected on
to subject and the
reflected light is than
viewed by CCD camera.
The variable deflections
of reflected light in the
cameras field offer the
depth information. This
method is called optical
triangulation method


Craniofacial analysis using 3D laser scanning
• The soft tissue
landmarks
identified on the
face can be
easily joined to
reproduce 3D
surface of the
face I normal,
class ll and class
lll malocclusion
patients.

Clinical applications of laser scanning

• Construction • Assessment
•
of facial
of facial
templates.
asymmetry
Orthod craniofacial reserch 2006

Difference in pre &
post surgical facial
morphology using
facial templates .

Stereophotogrammetry

• Similar to human visual process
this technique uses 2 images
separated in distance by a small
distance, where in 2 cameras,
configured as a stereopair are
used to capture 3Ddistances of
the surface of the face by
means of triangulation.
• It captures patients skin texture
over the 3D model of face.


15°

50 cms

stereophotogrammetry
• The 3D face is a composite
of 2 halves, each half
representing the image
acquired from each camera.
• Assessment of outcome can
also be performed easily by
visual comparison of pre- &
post-treatment models
placed side by side by using
stereophotogrammetry
scanning.

Application of 3D imaging with stereophotogrammetry

• 3D imaging of face enables us to evaluate face from any
direction in different views with gradual rotations around yaxis from -90 to+90 & +30 to -30 around x-axis, for
subjective clinical assessment of deformities with out the
need of patient recall or the doctor being restricted by time
of clinical assessment.

Photogrammetry applied to craniofacial skeletal
reconstruction using multiple planar radiographs.
• Hear the radiographs
use common
registration points to
produce 3D
coordinate system for
axial and sequence
of transaxial
buccolingual crosssectional views.
• Allow determination of
-bone quality ,height &
width in proposed
implant site.
-visualization of lingual
fossa.
-Localisation of
mandibular canal.

conclusion
• Orthodontic imaging has come a long way since
the “ plaster era” during the times of Edward
angle and Calvin case when plaster was the
recording medium. Later with the advent of
dental impression materials radiographs and
photographic films the orthodontic patient record
evolved in to “Film era”.
Now we are in to evolving “Digital era” in
which new digital technologies are being used to
resolve previous limitations of patient records
and hence the continuing evolution in
orthodontic imaging of virtual patients will be a
key to future orthodontic practice.

Bibliography
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

1. current principles and techniques in orthodontics- by
Thomas.M.Graber & Robert.L.Vanarsdall.
2. colour Atlas of Orthodontic diagnosis- by Thomas Rokosi,
Irmtrud Jonas & Thomas.M.Graber
3. Orthodontic principles and practice- by T.M.Graber
4. Contemporory Orthodontics – by William.R.Proffit
5. Orthodontic Diagnosis- by W.J.B.Houston
6. Handbook of Orthodontics- by Robert.E.Moyers
7 AJODO 2006; August ,volume130 ,no 2 : 257-65
8 AJODO 2006: may, volume 129 ,no 5; 605-617
9 World journal of orthodontics December 2006.
10 Orthod craniofacial reserch 2006
11 AJODO 2005volume 128: 157-60
12 AJODO 2006 volume 127: 627-637
13 AJODO 2005 volume 127 no 5
14 Journal of orthodontics
15 Med oral patol oral cri bucal 2006- pubmed
16 journal of orthodontics 2006- pubmed

•
•

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