orthodontic diagnosis, including medical and dental history, radiographic analysis, functional analysis, micro mini aesthetics, skeletal maturity indicators. extraoral and intraoral examination. classification of malocclusion.

1. ORTHODONTIC
DIAGNOSIS
By :
Dr. Anjali Rajeshkumar Jaiswal
1st Year Post Graduate Student
1

2. • Diagnosis:
– The study and interpretation of the data
concerning a clinical problem in order to
determine the presence or absence of
abnormality.
2

3. • Orthodontic
diagnosis
should be
routinely based
on various
methods of
examination.
• Comprehensive
orthodontic
diagnosis is
established by
use of certain
clinical
implements
called
diagnostic aids.
3

4. Diagnostic aids
ESSENTIAL
• Case history
• Clinical examination
• Study models
• Certain radiographs-lateral
cephalometry, OPG
• Facial photographs
SUPPLEMENTAL
• Specialized radiographs-
occlusal
• Hand wrist radiograph
• Electromyography
examination
• CT scan
4

5. Diagnostic process
5

6. • The process of orthodontic diagnosis lends
itself well to the PROBLEM ORIENTED
APPAROACH.
• The diagnosis and treatment planning are
made in a series of logical steps.
• The first two steps constitute diagnosis.
They are:
1. Development of an adequate diagnostic
database
2. Formulation of a problem list – the diagnosis –
from the database.
6

7. • For orthodontic purposes, the database may
be thought of as derived from three major
sources:
(1) patient questioning,
(2) clinical examination of the patient, and
(3) evaluation of diagnostic records, including dental
casts, radiographs, and photographs.
7

8. Questionnaire/Interview
• Chief concern
• Medical and Dental history
• Physical growth evaluation
• Social and behavioral evaluation
8

9. Chief concern
• There are three major reasons for patient
concern about the alignment and occlusion of
the teeth:
– Impaired dentofacial esthetics that can lead to
psychosocial problems,
– Impaired function, and a
– Desire to enhance dentofacial esthetics and
thereby the quality of life
9

10. Medical history
• A careful medical and dental history is needed
for orthodontic patients both to provide a
proper background for understanding the
patient’s overall situation and to evaluate
specific orthodontically related concerns.
• Two areas deserve a special attention
– Trauma resulting in TMJ injuries
– Medication of any type for systemic diseases
10

11. Various medical conditions and
precautions
MEDICAL CONDITIONS IMPLICATIONS ACTION
Allergies Allergic reactions Determine material
causing allergy and
substitute for a nonallergic
material
Coagulation disorders Bleeding risk Avoid treatment plans
involving extractions
Diabetes Periodontal breakdown Monitor adequate control
of the disease, consult
periodontist
Epilepsy Medication causing gingival
hypertrophy
Monitor excellent plaque
control
11

12. MEDICAL CONDITION IMPLICATION ACTION
Heart valve conditions Endocarditis Premedication when fitting
bands
High BP Drugs like Ca channel
blockers cause gingival
hyperplasia
Monitor oral hygiene
HIV Opportunistic infections,
periodontal diseases, cross
infection
Consult physician
Leukemia Mucositis, ulcerations Remove appliances until
remission
Physical/ mental handicap Gingivitis, muscle
hypo/hyper
activity, excess salivation
Good oral hygiene aids like
electric toothbrush,non
compliance treatment
mechanics
12

13. MEDICAL CONDITIONS IMPLICATIONS ACTION
Rheumatoid arthritis TMJ degeneration Monitor TMJ, manage with
surgeon if severe
degeneration
Xerostomia Caries Monitor for loose
appliance, consider
fluoride rinses
Pregnancy Gingival inflammation Monitor oral hygiene
13

14. Prenatal history
14

15. Dental history
• Information about age of eruption and
exfoliation
• Earlier treatment received by the patient –
shows the attitude towards treatment
• Previous extraction – Amount of damage to
the cortical plates, resorption & remodeling
status of the bone at the extraction site
15

16. Physical growth evaluation
• Rapid growth during the adolescent growth
spurt facilitates tooth movement, but growth
modification may not be possible in a child
who is beyond the peak of the growth spurt.
Name of spurt Female Male
Infantile/ childhood
growth spurt
3yrs 3yrs
Mixed dentition/ juvenile
growth spurt
6-7yrs 7-9yrs
Pre-pubertal/ adolescent
growth spurt
11-12yrs 14-15yrs
16

17. Growth chart
Used to follow a child over time to
evaluate whether there is an
unexpected change in growth
pattern.
• Ask questions about how rapidly
the child has grown recently
• Secondary sexual characteristics
• Height - weight records and the
child’s progress on standard
growth charts can be obtained
from the child’s pediatrician
17

18. 18

19. Hand wrist radiograph
• The ossification and development of the
carpal bones of the wrist, the metacarpals of
the hands, and the phalanges of the fingers
form a chronology of skeletal development
• The state of ossification of ulnar sesamoid or
hamate bones can be used to obtain an
estimate of the timing of the adolescent
growth spurt.
19

20. Anatomy of hand wrist
20

21. Bjork, Grace and Brown method
• Divided skeletal development into 9 stages.
• Each stage represents the level of skeletal
maturity.
• Chronologic ages were given by Schopf in
1978.
21

22. • Stage 1—(male-10.6y
female-8.1)– the
epiphyis and
diaphysis of the
proximal phalanx of
index finger are
equal. Occurs approx
3 years before the
peak of pubertal
growth spurt
22

23. • Stage 2-(male-12y
female-8.1) –the
epiphysis and
diaphysis of the
middle phalanx of
the middle finger are
equal.
23

24. • Stage 3 (Male-12.6y Female-9.6y)—1.hamular
process of the hamate exhibits ossification
2.Ossification of pisiform 3.The epiphysis and
diaphysis of radius are equal
24

25. • Stage 4 (Male-13 y
Female-1o.6y)-initial
mineralization of the
ulnar sesamoid of the
thumb.
• Increased ossification
of the hamular process
of the hamate bone.
• Marks the beginning
of pubertal growth
spurt.
25

26. • Stage 5----(male-
14y; female-11y)-
marks the peak of
the pubertal spurt.
• Capping of the
diaphysis by the
epiphysis is seen in
middle phalanx of
the third finger,
Proximal phalanx
of the thumb and
In radius.
26

27. Stage 6 (male-
15y;female-13y)
• Signifies the end
of pubertal
growth spurt
• Union between
diaphysis and
epiphysis of distal
phalanx of middle
finger.
27

28. • Stage 7—
(male-15.9
female- 13.9)
• Union
between
epiphysis and
diaphysis
proximal
phalanx of
little finger
28

29. • Stage 8 –
(male-15.9
female-13.9)
• Fusion between
epiphysis and
diaphysis of
middle phalanx
of the third
finger
29

30. • Stage 9
(Male-18.5y
Female-16y)
• Fusion
between
epiphysis
and
diaphysis of
the radius
30

31. Fishman Skeletal Maturity Assessment
• It uses four stage and six anatomical site
located on thumb, third finger ,fifth finger and
radius.
• 11 discrete adolescent maturity indicators
covering the entire period of adolescent
growth, are found on these sites.
31

32. • 4 stages of bone maturation are used in this
method. They are-
1. Epiphysis equal in width to diaphysis
2. Appearance of adductor sesamoid of the thumb
3. Capping of epiphysis
4. Fusion of epiphysis
32

33. • SMI 1- 3rd finger proximal phalanx
shows equal width of the
epiphysis and diaphysis
• SMI 2-width of the epiphysis
equal to that of the diaphysis in
the middle phalanx of 3rd finger
• SMI 3-width of the epiphysis
equal to that of the diaphysis in
the middle phalanx of 5th finger
• SMI 4-appearance of adductor
sesamoid of the thumb
• SMI 5-capping of the epiphysis
seen in the distal phalanx of 3rd
finger
33

34. • SMI 6- capping of the epiphysis seen
in the middle phalanx of 3rd finger
• SMI 7- capping of the epiphysis seen
in the middle phalanx of 5th finger
• SMI 8-fusion of epiphysis and
diaphysis in the distal phalanx of 3rd
finger
• SMI 9- fusion of epiphysis and
diaphysis in the proximal phalanx of
3rd finger
• SMI 10- fusion of epiphysis and
diaphysis in the middle phalanx of 3rd
finger
• SMI 11- fusion of epiphysis and
diaphysis in the radius.
34

35. 35

36. Vertebrae Maturity Indicators- Hassel
and Farman
36

37. • CVMI-1- Initiation stage- c2,c3 and c4 inferior
vertebral bodies are flat, superior vertebral bodies are
tapered from posterior to anterior(wedge shaped), 80-
100 % of growth remains
• CVMI-2- Acceleration stage -concavities are
developing in the lower borders of c2 and c3,lower
border of c4 vertebral body is flat,c3 and c4 are more
rectangular in shape,65- 85 % of growth remains.
37

38. • CVMI-3- Transition stage -distinct concavities are seen
in the lower borders of c2 and c3,concavity is
developing in the lower border of c4,c3 and c4 are
rectangular in shape, 25-65 % of pubertal growth
remains.
• CVMI-4- Deceleration stage -distinct concavities are
seen in the lower borders of c2 ,c3 and c4,c3 and c4
are nearly square in shape,10-25% of pubertal growth
remains
38

39. • CVMI-5- Maturation stage- accentuated
concavities of c2,c3 and c4 inferior vertebral body
borders are observed,c3 and c4 are square in
shape, 5-10 % of the pubertal growth remains
• CVMI-6- Completion stage- deep concavities are
present in c2,c3 and c4 inferior vertebral body
borders ,c3 and c4 are greater in height than in
width, pubertal growth is complete.
39

40. Social and behavioral evaluation
1. The patient’s motivation for the treatment
2. What he or she expects from the treatment
3. How cooperative or uncooperative the
patient is likely to be.
42

41. Clinical examination
• Clinical findings are the prerequisite for the
correct assessment and interpretation of the
quantitative analysis, i.e. the overall general
and the specific clinical findings, which serve
as the foundation of treatment decisions.
43

42. Overall general evaluation
• BODY TYPE
– Ectomorphic: tall & thin
– Mesomorphic: average build
– Endomorphic: short and fat
• BUILD
– Asthenic :thin built and usually possess narrow dental arches
– Plethoric/pyknic: obese built & generally have broad dental
arches
– Athletic : neither thin nor obese ; normally built and normal
dental arches
44

43. 45

44. • GAIT
– Act of walking or locomotion, it is the way person walks.
– Abnormalities of gait are usually associated with
neuromuscular disorder which may have a dental
correlation.
• HEIGHT & WEIGHT
– They give a clue to the physical maturation & growth of
the patient, which may have dentofacial correlation.
• POSTURE
– This refers to the way a person stands.
– Abnormal posture can predispose to malocclusion due to
alteration in maxillo-mandibular relationship.
46

45. 47

46. Cephalic and facial examination
• The shape of the head and facial structures
are assessed, measurements can be evaluated
according to the cephalic index of the head
and the morphologic facial index.
48

47. Cephalic Index
Maximum skull width
CI = _________________________
Maximum skull length
MESOCEPHALIC :Average
shape of the head-Normal
dental arch.
DOLICOCEPHALIC :Long &
narrow head-Narrow
dental arch.
BRACHYCEPHALIC: Broad
& short head-Broad
dental arch.
49

48. Morphologic facial index
Morphologic facial height
MFI = _______________________________
Bi zygomatic width.
Leptoprosopic :
long & narrow face
Mesoprosopic:
Average
face/Normal face
Euryprosopic : Broad
& short face
50

49. Examination of soft tissues
• Extra oral:
– Forehead
– Nose
– Lips
– Chin
• Intra oral:
– Tongue
– Lip and cheek frenal attachments
– Gingiva
– Oral and palatal mucosa
51

50. Forehead-size
52

51. Forehead-slope
FLAT PROTRUDING STEEP
53

52. Nose-size
Normal case
H:V=2:1
Microrhinic type Large
54

53. Nasal-contour
Straight Convex Crooked
55

54. Nostrils
Width of nostril= approximately 70% of the length of nose
Usually oval and
Bilaterally symmetrical
Slight nasal anomaly
With wide nostrils
Cartilagenous septal
deviation
56

55. Vertical lip relationship
Upper lip length - 1/3rd of lower facial height
Lower lip length - 2/3rd of lower facial height
57

56. Lip morphology
Harmonious lip profile Short upper lip Eversion of
mucosal part
58

57. Horizontal lip profile
Protrusion of
Lower lip
Normal case Marked retrusion of
Lower lip
59

58. Lip step- Korkhaus
Positive lip step Normal Negative lip step
60

59. Nasolabial angle
Acute Normal Obtuse
61

60. Chin formation and contour
Normal Protruded chin Retruded chin
62

61. Tongue-shape
63

62. Tongue-size
64

63. Tongue-length
65

64. Lingual frenum
66

65. Labial frenum
67

66. Blanch test
68

67. Gingiva
Healthy Gingiva Thin Fragile Gingiva
Fribrous Gingiva 69

68. Palatal mucosa
70

69. Evaluation of facial and dental
appearance
• Should be done in three steps:
1. Macro esthetics – face in all three plane of space
2. Mini esthetics – the smile framework
3. Micro esthetics – the teeth
71

70. Macro esthetics – frontal examination
72

71. 73

72. 74

73. 75

74. 76

75. Macro esthetics – profile analysis
1. Establishing whether the jaws are proportionately positioned in the
anteroposterior plane of space
77

76. 78

77. 2. Evaluation of lip posture and incisor prominence.
79

78. 80

79. 3. Re-evaluation of vertical facial proportions, and evaluation of mandibular plane
angle
82

80. Mini esthetics – tooth lip relationship
83
• It is important to evaluate not only the
characteristics of the face, but the relationship
of the dentition to the face. This can begin
with an examination of symmetry, in which it
is particularly important to note the
relationship of the dental midline of each arch
to the skeletal midline of that jaw

81. 84

82. 85

83. 86

84. 87

85. Micro esthetics
88

86. 89

87. 90

88. 91

89. 92

90. Drug history
• When force is delivered to a tooth and thereby
transmitted to the adjacent investing tissues, certain
mechanical, chemical, and cellular events take place
within these tissues, which allow for structural
alterations and contribute to the movement of that
tooth.
• Molecules present in drugs can reach the mechanically
stressed paradental tissues through the circulation and
interact with local target cells. The combined effect of
mechanical forces and one or more of these agents
may be inhibitory, additive, or synergistic
93

91. • NSAIDs:
– Inhibition of the inflammatory reaction produced
by PGs slows the tooth movement.
– The levels of matrix metalloproteinases (MMP9
and MMP2) were found to be increased, along
with elevated collagenase activity, followed by a
reduction in procollagen synthesis which is
essential for bone and periodontal remodeling.
– The whole process is controlled by inhibition of
cyclooxygenase (COX) activity, leading to altered
vascular and extravascular matrix remodeling,
causing a reduction in the pace of the tooth
movement.
94

92. • Eg : aspirin, indimithacin, imidaxole,
flurbiprofen
• In such cases, a specific COX-2 inhibitor, a drug
with no effect on PGE2 synthesis, can be
prescribed.
• Because it selectively blocks COX-2 enzyme
and not COX-1 enzyme, the drug can be safely
employed during orthodontic
mechanotherapy, without causing negative
effects on tooth movement.
95

93. • Bisphosphonates:
– Cause a rise in intracellular calcium levels in
osteoclastic-like cell line, reduction of osteoclastic
activity, prevention of osteoclastic development
from hematopoietic precursors, and production of
an osteoclast inhibitory factor.
– BPNs can inhibit orthodontic tooth movement and
delay the orthodontic treatment.
96

94. • Oral contraceptives:
– Estrogen is considered to be the most important
hormone affecting the bone metabolism in
women.
– It inhibits the production of various cytokines
which are involved in bone resorption by
stimulating osteoclast formation and osteoclast
bone resorption.
– It decreases the velocity of tooth movement.
97

95. • Calcitonin:
– Calcitonin inhibits bone resorption by direct action
on osteoclasts, decreasing their ruffled surface
which forms contact with resorptive pit.
– It is considered to inhibit the tooth movement;
consequently, delay in orthodontic treatment can
be expected.
98

96. • Corticosteroids:
– The main effect of corticosteroid on bone tissue is
direct inhibition of osteoblastic function and thus
decreases total bone formation.
– Corticosteroids increase the rate of tooth
movement, and since new bone formation can be
difficult in a treated patient, they decrease the
stability of tooth movement and stability of
orthodontic treatment in general.
99

97. • Immunomodulatory drugs:
– Immunomodulatory drugs modulate nuclear
factor kappa - Beta , tyrosine kinases in signaling
pathway, IL - 6, MMPs and PGE2, all of which are
essential for the bone remodeling process.
– Cyclosporine A: produce severe gingival
hyperplasia, making orthodontic treatment and
maintenance of oral hygiene difficult.
– Anticancer drugs: are known to produce damage
to precursor cells involved in bone remodeling
process, thereby complicating tooth movement.
100

98. • Anticonvulsants:
– It induces gingival hyperplasia, , making
application of orthodontic mechanics and
maintaining oral hygiene difficult.
– If used during pregnancy, it can produce fetal
hydantoin syndrome characterized by hypoplastic
phalanges, cleft palate, hare lip, and microcephaly.
101

99. • Fluorides:
– Fluoride is one of the trace elements having an
effect on tissue metabolism.
– Sodium fluoride has been shown to inhibit the
osteoclastic activity and reduce the number of
active osteoclasts, thus delay orthodontic tooth
movement and increase the time of orthodontic
treatment.
102

100. Mental attitude of patients
• MM House Classification (1950)
– Philosophical
– Exacting
– Hysterical
– Indifferent
103

101. • Philosophical:
– The best mental attitude for denture acceptance is the
philosophical type.
– This patient is rationale, sensible, calm and composed
in different situations.
– These patients are willing to rely on the dentist’s
advice for diagnosis and treatment.
• Exacting:
– The exacting patient may have all of good attributes of
the philosophical patients; however he may require
extreme care, effort and patience on the part of
dentist.
– This patient is methodical, precise, and accurate and
at times makes severe demands.
– Once satisfied an exacting patient may become the
practioner’s greatest supporter
104

102. • Hysterical:
– The hysterical type is emotionally unstable, excitable
and excessively apprehensive.
– These patients submit to treatment alas a last resort,
have negative attitude, are often in poor health, are
poorly adjusted, often appear exacting but with
unfounded complaints, and have unrealistic
expectations.
• Indifferent:
– The indifferent type of patients presents a
questionable or unfavorable prognosis.
– He is apathetic and uninterested and lacks motivation.
– He pays no attention to instructions, will not co-
operate, and is prone to blame the dentist for poor
dental health.
105

103. Growth changes in soft tissue
• Upper lip length:
– Mean: males- 23.8mm
females- 20.1mm
– From 7 to 18yrs, increased from 19.8mm to
22.5mm in males, and 19.1mm to 20.2mm in
females.
– Average increment 2.7mm in males, 1.15mm in
females.
106

104. • Nose height:
– At 7 years, nearly same in both sexes.
– Rapid increase between 7 to 8 years, slowed down
between 8 to 11yrs, with pubertal acceleration
during 14 to 17 yrs.
• Chin:
– Soft tissue thickness at the level of soft tissue
pogonion showed total increase of 2.7mm in
males and 2mm in females.
107

105. • Nasolabial angle:
– Decreased from 7 yrs to 18 yrs in both sexes.
– Males: from 107.89.4 degrees to 105.89
degrees
– Females: from 114.79.5 degrees to 110.710.9
degrees
• Mentolabial angle:
– Males: 125.38.4 degrees at 7yrs to 125.112.9
degrees at 18yrs
– Females: 136.111.6 degrees at 7 yrs to
127.112.9 degrees at 18 yrs.
108

106. • Lip tonicity:
– Normal lip: minimal tonicity
– Hypertonic lip: firm and redder
– Hypotonic lip: flaccid
• Upper lip:
– With lip tension- contour flattens.
– Flaccid lips form an accentuated curve with the vermilion
lip area showing an accentuation of curve.
– The flaccid lip generally is thick (12 to 20 mm from
anterior vermilion to labial incisor) giving the lip the
appearance of being too far forward relative to the teeth.
• Lower lip:
– When deeply curved, the lower lip is flaccid in character
(Class II, vertical maxillary deficiency).
– When flattened, the lower lip demonstrates tension of
tissues (Class III). 109

107. • Hyperactive mentalis:
– Deep mentolabial sulcus is characteristic of
hyperactive mentalis muscle.
– It impedes forward development of the anterior
alveolar process of the mandible.
– Occurs together with lip sucking or lip thrust.
– Causes puckering of chin
– Seen in Class II div 1 cases
110

108. Functional Analysis
• Functional analysis constitutes a considerable
part of the clinical examination.
• Three most important aspects are:
1. Examination of postural rest position and
maximum intercuspation
2. Examination of temporomandibular joint
3. Examination of orofacial dysfunction
111

109. 1. Examination of postural rest position and
maximum intercuspation
i. Determination of postural rest position
ii. Registration of postural rest position
iii. Evaluation of the relationship: postural rest
position and habitual occlusion, in three planes
of space
112

110. 113

111. Determination of postural rest position
• When the mandible is in the postural resting
position, it is usually 2-3mm below and behind
the centric occlusion- referred to as freeway
space or interocclusal clearance
• Methods:
– Phonetic method
– Command method
– Non-command method
– Combined methods
Speculum – A.M. Schwarz
114

112. 115

113. Registration of postural rest position
• Extraoral direct method:
– Registration by means of skin reference points
• Extraoral indirect method:
– Roentgenocephalometric registration
– Kinesiographic registration – Jankelson (1984)
116

114. 117

115. 118

116. 119

117. 121

118. Evaluation of the relationship: postural rest
position and habitual occlusion
• It is analyzed three dimensionally in the
sagittal, vertical and frontal planes
• Closing movement divided into two phases:
– Free phase
– Articular phase
122

119. • When closing, mandible may undergo
rotational and sliding movement:
– Pure rotational movement
– Rotational movement with anterior sliding
component
– Rotational movement with posterior sliding
component
123

120. Evaluation in sagittal plane
124

121. Class II malocclusions
125

122. Class III malocclusion
126

123. Mandibular prognathism- Pseudo
forced bite
127

124. Evaluation in vertical plane
• The freeway space is assessed.
• Important with deep overbite cases.
• According to Hotz and Muhlemann:
– True deep bite
– Pseudo deep bite
128

125. Evaluation in transverse plane
• Position of midline is observed.
• Relevant is cases with posterior unilateral
crossbite.
• Two types of skeletal mandibular deviation:
1. Laterognathy
2. Lateroclusion
129

126. Laterognathy
130

127. Lateroclusion
131

128. Examination of temporomandibular
joint
132

129. Auscultation and palpation
133

130. Examination of muscles of mastication
134

131. Functional analysis:
Movements of mandible
135

132. • Deviations from the normal mandibular
movements are a result of asynchronic muscle
contractions, malocclusions, etc.
• Deviations are the first signs of initial
temporomandibular joint problems.
• “C” and “S” types of deviations are typical
signs of functional disturbances.
136

133. Radiographic examination
• Radiographs taken in habitual occlusion
and/or in open-mouth position are suitable
for examination.
• When analyzing radiographs, following
findings are registered:
– Position of condyle in relation to fossa,
– Width of joint space,
– Change in shape and structure of condylar head
and/or mandibular fossa.
137

134. 138

135. Examination of orofacial dysfunctions
• Swallowing
• Tongue
• Speech
• Lips
• Respiration
139

136. Swallowing
Normal Swallow
Retained
Infantile
Swallow
140

137. Stages Of
Deglutition
1. Oral Phase
2. Pharyngeal Phase
3. Esophageal Phase
141

138. Tongue thrust
142

139. 143

140. Lips dysfunction
144

141. Lip habits
145

142. Speech dysfunction
• Tongue and lip dysfunctions lead to speech
difficulties, as the normal relationship is
hampered and pronunciation is affected.
146

143. Mouth breathing
147

144. Tongue posture in oronasal respiration
148

145. Examination of breathing mode
• Various methods:
– Mirror test
– Cotton pledget test
– Water holding test
– Observation of nostrils
149

146. 150

147. THANKYOU
151

148. 152

149. 153

150. 154

151. 155

152. Orthodontic classification
• Classification has traditionally been an
important tool in the diagnosis-treatment
planning procedure.
• Classification can be viewed as the (orderly)
reduction of the database to a list of the
patient's problems.
156

153. Classification of malocclusion
• Any deviations from normal occlusion can be
termed as malocclusion, which may vary from
a very slight deviation of a tooth position in
the arch to a significant malpositioning of a
group of teeth or jaws.
157

154. 158
Purpose of Classification :
• Classification helps in diagnosis and planning
treatment for the patients.
• It helps in visualizing and understanding the
problems associated with that malocclusion.
• It helps in communicating the problem.
• Comparison of various malocclusion is made
easy by classification.

155. Classification
Intra arch
Individual
tooth
malpositions
Inter arch
Dental Skeletal
159

156. Individual tooth malpositions
• Mesial inclination or tipping
• Distal inclination or tipping
• Lingual inclination or tipping
160

157. Labial tipping
Infra occlusion
Supra occlusion
161

158. Rotations
• Mesiolingual/distolabial
• Distolingual/mesiolabial
• Transposition
162

159. Malrelation of dental arches
Sagittal plane malocclusion
• Pre normal occlusion- lower arch is more
forwardly placed
• Post normal occlusion- lower arch is more
distally placed.
163

160. Vertical plane malocclusion
Deep bite Open bite
164

161. Transverse plane malocclusion
• cross bite
165

162. ANGLE’S CLASSIFICATION
• NORMAL OCCLUSION
• CLASS I MALOCCLUSION
• CLASS II MALOCCLUSION
• CLASS III MALOCCLUSION
166

163. Normal occlusion
• Normal antero-posterior relationship
between maxilla and mandible.
• Normal molar relationship
• Line of occlusion is a smooth, continuous and
symmetric catenary curve.
167

164. Class I malocclusion
Class I molar relationship
Mesiobuccal cusp of the maxillary first
molar occludes in the buccal groove of
the mandibular 1st permanent molar
168

165. • Crowding, spacing, rotations missing tooth etc.
• Normal skeletal and normal muscle relationship
• Class I bimaxillary protrusion– normal class I
relationship but dentition of both the arches are
forwardly placed in relation to facial profile
169

166. Angle’s class II malocclusion
• Class II molar relationship- disto buccal cusp
of the upper first permanent molar occludes
in the buccal groove of the lower 1st molar
• It is sub classified into
class II division 1
class II division 2
class II subdivision
170

167. Class II div 1
• Class II molar relation
• Proclined upper incisors –increased overjet
• Presence of abnormal muscle activity-
characterstic feature
• Altered tongue positon- accentuates
narrowing of upper arch
• Lip trap- lower lip cushions the palatal aspect
of the upper teeth
171

168. 172

169. Class II div 2
• Class II molar relation
• Lingually inclined upper central incisors
• Labially tipped lateral incisors overlapping
the centrals
• Normal perioral muscle activity
• Abnormal backward path of closure
173

170. 174

171. Class II subdivision
• Class II molar relation on one side and class I
on other
175

172. Angles’ Class III malocclusion
Class III molar relationship-
Mesiobuccal cusp of maxillary first
Molar occludes in the interdental
Space between the distal cusp of
mandibular first molar and second
Molar.
• Classified into-
True class iii
Pseudo class iii
176

173. TRUE CLASS III
• Class III molar relation
• Lower incisors lingually inclined
• Lower tongue posture- narrow upper arch
177

174. PSEUDO CLASS III
• Caused by forward movement of the mandible-
postural or habitual class iii
• Causes of pseudo class iii:-
Occlusal prematurity
Loss of deciduous molars
Large adenoids
178

175. CLASS III SUBDIVISION
• CLASS III MOLAR RELATION ON ONE SIDE AND
CLASS I RELATION ON THE OTHER
179

176. Angle’s line of occlusion:
When the teeth are in normal occlusion the line of
greatest occlusal contact will be found to pass over the
mesial and distal inclined planes of the buccal cusps of
the molars and bicuspids and the cutting edges of the
cuspids and incisors of the lower arch, and along the
sulcus between the buccal and lingual cusps of the upper
molars and bicuspids, hence forward, crossing the lingual
ridge of the cuspids and the marginal ridges of the
incisors at a point about one-third the length of their
crowns from their cutting-edges.
180

177. DRAWBACKS OF ANGLE’S
CLASSIFICATION
• First permanent molar not a fixed point
• Classification is not possible if first molars are
missing
• Malocclusion is considered only in a-p direction
• Individual tooth malocclusion is not considered
• No differentiation between skeletal and dental
malocclusion
• No clue about etiology
181

178. 182
• Modifications by Martin Dewey
Class I malocclusion with-
Type I: Crowded anterior teeth.
Type II: Protrusive maxillary incisors.
Type III: Anterior crossbite.
Type IV: Posterior crossbite.
Type V: Mesial drifting of permanent molar.

179. 183
• Class III with
Type I:Viewed separately, arches are normal,
in occlusion- Edge-to-edge incisor relationship.
Type II:Crowding& lingual relation of
mandibular incisors to maxillary incisors.
Type III:Crowding&cross bite relationship of
maxillary incisor.

180. 184
• Lischer’s modifications – Introduced terms-
1. ‘Neutrocclusion’- Angle’s Class I.
2. ‘Distocclusion’ – Angle’s Class II.
3. ‘Mesiocclusion’ – Angle’s Class III.
He also added the suffix ‘version’
1. Buccoversion.
2. Linguoversion.
3. Supraversion.
4. Infraversion.

181. 185
5. Mesioversion.
6. Distoversion.
7. Axiversion.
8. Torsiversion.
9. Transversion.

182. 186
Simon’s Classification:
• Introduced in 1930s
• Related the teeth to the
rest of the face &
cranium in all three
dimensions.
• Related dental arches to
3 anthropologic planes-
1. The Frankfurt horizontal
plane.
2. The orbital plane.
3. The midsagittal plane.

183. 187
• The vertical relationship (Frankfurt’s plane)-
1. Plane is from porion to orbitale.
2. Closer the dental arch to this plane – attraction.
3. Away from this plane – abstraction.
• The Anteroposterior relationship (Orbital plane)-
1. Perpendicular to the Frankfurt plane.
2. Passes through distal third of upper canine –
‘Simon’s law of the canine’.
3. Further from this plane- Protraction.
4. Closer to this plane – Retraction.

184. 188
• The mediolateral relationship (Midsagittal
plane): It is in the transverse direction.
1. Away from this plane – Distraction.
2. Close to this plane – Contraction.
Advantages of Simon’s classification-
1. Orients the dental arches to the facial
skeleton.
2. Malpositions of teeth & osseous dysplasia
are separated.

185. 189
Ackermann - Proffit Classification
• Developed in 1960s.
• Combination of two schemes – the Angle
classification & the Venn diagram.
• The Venn diagram offers visual
demonstration to the complex interrelated
variables.

186. 190

187. 191
• Classification by groups-
Group 1 – Alignment & symmetry.
Group 2 – Profile.
Group 3 – Lateral or transverse deviations.
Group 4 – Sagittal or anteroposterior deviations.
Group 5 – Vertical deviations.
Group 6, 7, 8 & 9 from interlocking subsets.

188. 192
• Method of application of the classification-
Diagnostic information required.
Step I – Analysis of alignment & symmetry.
 Alignment
 Possibilities are – ideal, crowding, spacing,
mutilated.
Step II – Analysis of profile.
 Anterior or posterior divergence
 Lips – convex, straight, concave.
Step III – Analysis of transverse plane.
 Can be dentoalveolar or skeletal.
 Maxillary or mandibular used to indicate the
jaw involved.

189. 193
Step IV – Analysis of sagittal plane.
 Class
 Angle’s classification applied.
 Can be dentoalveolar or skeletal.
Step V – Analysis of vertical dimension.
 Bite depth
 Can be dentoalveolar or skeletal.
 The possibilities are – Anterior openbite, anterior
deep bite, posterior openbite, posterior collapsed
bite.

190. 194
Advantages-
1. Very comprehensive.
2. Both skeletal & dental aspects considered.
3. Adaptable to computer processing.
Disadvantages-
1. Etiology not taken into consideration.
2. Analysis is essentially static.

191. 195
E.g. of the clinical application of this classification
– Group 9 indicates –
Alignment – both arches crowded.
Profile – Posterior divergent/convex.
Type – Maxillary palatal crossbite, bilaterally,
skeletal & dental.
Class - Class I, excessive overjet, Class II skeletal.
Bite – Openbite, skeletal.

192. Additions to the Five-Characteristics
Classification System
• Two things particularly help more thorough
analysis:
(I)evaluating the orientation of the esthetic line of
the dentition, which is related to but different
from Angle's functional line of occlusion, and
(2) supplementing the traditional three-dimensional
description of facial and dental relationships with
rotational characteristics around each plane of
space
196

193. l. Esthetic line of the dentition.
• In modern analysis,a nother curved line characterizing
the appearanceo f the dentition is important, the one
that is seen when evaluating anterior tooth display
(Figure 6-66).
• This line, the estheticl ine of the dentition, follows the
facial edges of the maxillary anterior and posterior
teeth. The orientation of this line, like the orientation
of the head and jaws,i s bestd escribedw hen the
rotational axeso f pitch, roll and yaw are consideredi n
addition to transversea, nteroposterior and vertical
planes of space.
197

194. 2. Pitch, roll, and yaw in systematic
description
• A complete description, however, requires
consideration of both translation
(forward/backward, up/down, right left) in
three-dimensionasl pacea nd rotation about
three perpendicular axes (pitch, roll and yaw).
• The introduction of rotational axes into
systematic description of dentofacial traits
significantly improves the precisiono f the
description.
198

195. • Pitch, roll and yaw of the estheticl ine of the
dentition is a particularly useful way to
evaluate the relationship of the teeth to the
soft tissues that frame their display.
199

196. 200
Bennet’s Classification
Based on etiology –
1. Class I – Abnormal position of one or more
teeth due to local causes.
2. Class II – Abnormal formation of either arch
due to developmental defects.
3. Class III – Abnormal relationship between U/L
arches
- Between either arches and facial contour.
- Correlated abnormal formation of either
arch.

197. Skeletal classification
• It derives basis from the classic Angle’s
classification and Strang’s interpretation of
the former.
201

198. Skeletal class I: Orthognathic face
Important features may be:
• 1. Straight profile
• 2. Normal ANB angle : 2°
 2
• 3. Normal facial angle
(Downs): 82• to 95•
(mean 87.3D)
• 4. Angle of convexity
(Downs): +10• to -8.5
(mean 0)
202

199. Skeletal class II: Retrognathic face
• That may be due to
prognathic maxilla or
retrognathic mandible
Important features may be:
• 1. Convex profile
• 2. Increased ANB
• 3. Reduced facial angle
• 4. Increased angle of
convexity
• 5. Severe backward rotation
of the mandible may also be
present.
203

200. Skeletal class III: Prognathic face
• That may be due to
prognathic mandible or
retrognathic maxilla
Important features may be:
• 1. Concave profile
• 2. Prominent chin
• 3. Decreased ANB
• 4. Increased facial angle
• 5. Reduced angle of
convexity.
204

201. 205
British Standard Classification
• Incisor classification – Ballard & Wayman (1964).
• Forms the basis of British standard classification.
Class I – Lower incisor edges preclude with or lie immediately below
the cingulum of the upper central incisors.
Class II – Incisor edges lie posterior to the cingulum.
Div 1 – Increase in overjet & proclination of upper central incisors.
Div 2 – Upper central incisors are retroclined.
Class III – Incisor edges lie anterior to cingulum.

202. Katz premolar classification
• Given by Morton Katz (1992)
• Shifted the focus from the molars, canines and
incisors to the region of premolars for the
purpose of classifying malocclusion.
206

203. • Premolar class I:
– It is identified when the most anterior upper
premolar fits exactly into the embrasure created by
the distal contact of the most anterior lower premolar.
– This definition applies when a full complement of
premolars are present, i.e. whether one upper
premolar opposes two lower premolars, or two upper
premolars oppose one lower premolar, or whether
only one premolar is present in each quadrant
207

204. • Premolar class II: Here the most anterior
upper premolar is occluding mesial of the
embrasure created by the distal contact of the
most anterior lower premolar. The
measurement has a (+) sign
208

205. • Premolar class III: Here the most anterior
upper premolar ls occluding distal of the
embrasure created by the distal contact of the
most anterior lower premolar. The
measurement has a (-) sign.
209

206. • Advantages
• The advantages of the premolar classification
system are:
1. This system provides a quantitative treatment
objective that is needed to attain excellent buccal
occlusion.
2. It provides some flexibility in terms of finishing a
case in functional class II or class III buccal
occlusion, while keeping buccal interdigitation as
the prime goal.
3. In deciduous and mixed dentition cases,
emphasis is shifted from the permanent first
molars to the region of current importance, i.e.
deciduous molar region.
210

207. • Disadvantages
• The disadvantages of this system are:
1. Premolars are commonly missing, malformed
or supernumerary, hence measurement is not
always possible.
2. Severely rotated and ectopically erupted
premolars present problems.
3. No consideration for the facial balance and
aesthetics.
211

208. Classification in
primary dentition:
Baum (1959)
212

209. 213

210. References:
• Contemporary orthodontics. William R. Profit,
Henry W. Fields, David M. Sarver. 4th and 5th
edition
• Color Atlas of Dental Medicine: Orthodontics
Diagnosis. Rakosi, Jonas, Graber.
• Orthodontics diagnosis and management of
malocclusion and dentofacial deformity. Om
Prakash Kharbanda. 1st edition.
214

211. References:
• Grave, K.C., Brown, T. Skeletal ossification and
the adolescent growth spurt. AJO: 69. 6. 611-
615, 1976
• Hassel., B. Farman., A.G. Skeletal maturity
evaluation using cervical vertebrae, AJO-DO .
Jan 58-66. 1995.
215