The document presents a comprehensive overview of orthodontic diagnosis, outlining the diagnostic process which includes case history, clinical and functional examinations, and various radiographic analyses. It discusses essential and supplemental diagnostic aids, recent advances in diagnostic technology, and the importance of gathering detailed patient histories and conducting thorough examinations to identify malocclusions. The document further explains evaluation methods for craniofacial development, facial symmetry, and functional assessments of the stomatognathic system.

1. 1

2. ORTHODONTIC DIAGNOSIS
Presented by:-
Manish kumar
2

3. CONTENTS:-
 INTRODUCTION
 DIAGNOSTIC PROCESS
 COMPREHENSIVE DIAGNOSIS
1. Case history
2. Clinical examination
3. Functional examination
4. Radiologic examination
5. Photographic analysis
6. Model analysis
3

4. o Recent advances in diagnosis
a. Xeroradiography
b. Digi Graph
c. MRI
d. Tomography
e. Occlusograms
f. Digital Subtraction Radiography
g . Laser Holograph
h. Photocephalometry
i. Cineradiography
o Conclusion
o References
4

5. INTRODUCTION:-
 Dia – gnosis – Greek word
Dia – Apart and Gnosis – to come to know
 Definition-
“The act / process of identifying or determining the nature
and cause of a disease or injury through evaluation of patient
history , examination and review of laboratory data.”
 Orthodontic diagnosis deals with recognition of the various
characteristics of the malocclusion. It involves collection of
pertinent data in a systemic manner to help in the identifying the
nature and cause of the problem.
 Diagnostic aids – comprehensive orthodontic diagnosis is
established by use of certain clinical implements called diagnostic
aids.
5

6. They are of two types –
a. Essential diagnostic aids -
i. Case history
ii. Clinical examination
iii. Study models
iv. Certain radiographs –
Periapical radiograph
bite wing
Panoramic radiograph
v. Facial radiographs
b. Supplemental diagnostic aids –
i. Specialized radiographs
ii. Electro myographic examination of muscle activity
iii. Hand – wrist radiograph
iv. Endocrine tests
v. Estimation of basal metabolic rate
6

7. DIAGNOSTIC PROCESS
7

8. COMPREHENSIVE DIAGNOSIS
 CASE HISTORY:-
1. Personal details –
NAME –
Communication
Identification
Psychological benefits
AGE –
Diagnosis and treatment planning
Growth modification procedures
Surgical resective procedures
Developmental considerations 8

9. 2. SEX –
Treatment planning
e. g. the timing of growth events such as growth spurts are
different in males and females,
Females precede males in onset of growth spurts, puberty and
termination of growth
3. Address and occupation –
Evaluation of socio – economic status
In selection of an appropriate appliance
Future correspondence
9

10. 4. CHIEF COMPLAINT –
 The patient’s chief complaint should be recorded in his/her own
words.
 This helps the clinician in identifying the priorities and desires of
the patient.
 There are three major reasons for patient concern about the
alignment and occlusion of the teeth:
impaired dento-facial esthetics that can lead to
psychosocial problems,
impaired function, and
a desire to enhance dento-facial esthetics and thereby the
quality of life. 10

11. 5. MEDICAL HISTORY :-
In obtaining the medical history, the orthodontist or assistant
must always ask a few important questions, as
the last time a physician was seen,
any hospitalizations,
any medications currently being taken.
information regarding allergies, especially latex or nickel sensitivity;
history of blood transfusions; and
heart problems such as mitral valve prolapse or rheumatic fever .
6. DENTAL HISTORY :-
The dental history of the patient should include ,
age of eruption of the deciduous and permanent teeth,
history of extraction, decay, restorations and
history of trauma to the dentition. 11

12. 7. PRE – NATAL HISTORY :-
It includes –
The condition of the mother during
pregnancy and the type of delivery.
The use of certain drugs like thalidomide.
Affection with some infections during
pregnancy like German measles.
12

13. principal stages in craniofacial development :-
13

14. 14

15. 8. POST – NATAl HISTORY :-
It include –
The type of feeding,
Presence of habits and
The milestones of normal development.
For e.g. The AAPD endorses the policy statement of the American Academy of
Pediatrics (AAP) on breastfeeding and the use of human milk. The AAP
statement includes the acknowledgment that "breastfeeding ensures the best possible
health as well as the best development and psychosocial outcomes for the infant."
However, both organizations discourage extended or excessive frequency of feeding
times (from the breast or bottle) and encourage appropriate oral hygiene measures
for infants and toddlers.
15

16. 9. FAMILY HISTORY :-
Congenital conditions like cleft lip and palate, skeletal
Class ii and Class iii malocclusion are hereditary in nature.
10. SOCIAL AND BEHAVIORAL EVALUATION :-
Social and behavioral evaluation should explore several
related areas –
The patient’s motivation for treatment,
Expectations from treatment and
Compliance of the patient.
16

17. CLINICAL EXAMINATION :-
 GENERAL EXAMINATION :-
a. Height and Weight –
They provide a clue to the physical growth and
maturation of the patient.
b. Gait –
It is the manner of walking.
Abnormalities of gait are usually associated with
neuro-muscular disorders.
c. Posture –
Posture refers to the way a person stands. Abnormal postures
can predispose to malocclusion due to alteration in maxillo-
mandibular relationship. 17

18. o BODY BUILD(PHYSIQUE) :-
a. Aesthetic – they have a thin physique and usually posses
narrow dental arches.
b. Plethoric – they are obese and have large, square dental
arches.
c. Athletic – they are normally built and have normal sized
dental arches.
SHELDON has classified the general body build
into three types :-
a. Ectomorphic – tall and thin physique
b. Mesomorphic – average physique
c. Endomorphic – short and obese physique
18

19. EXTRA ORAL EXAMINAATION :-
 SHAPE OF HEAD –
• Mesocephalic – average shape of the head. They posses normal
dental arches.
• Dolicocephalic – long and narrow head. They have narrow dental
arches.
• Brachycephalic – broad and short head. They have broad dental
arches.
19

20. oFACIAL FORM :-
• simple classification – round, oval or square.
• scientific classification –
a. Mesoprosopic – average or normal face form
b. Euryprosopic – broad and short face form
c. Leptoprosopic – long and narrow face form
20

21. ASSESMENT OF FACIAL SYMMETRY :-
 The patient’s facial symmetry is examined to determine
disproportions of the face in transverse and vertical planes.
 In most people the right and left sides are not identical , so some
degree of asymmetry is considered normal.
 Gross facial asymmetries can occur as a result of ;
• Congenital defects
• Hemi – facial atrophy/hypertrophy
• Unilateral condylar ankylosis and hyperplasia
21

22. Composite photographs are the best way to indicate normal facial asymmetry.
For this boy, whose mild asymmetry rarely would be noticed and is not a
problem, the true photograph is in the centre. On the right is a composite of the
two right sides, While on the left is a composite of the two left sides. This
technique dramatically illustrates the difference in the two sides. Although the
normal asymmetry usually is less than in this boy, mild asymmetry is the rule
rather than the exception. Usually, the right side of the face is a little larger
than the left ,rather than the reverse as in this individual. 22

23. Facial proportions and symmetry in
the frontal plane. An ideally
proportional face can be divided
into central , medial ,and lateral
equal fifths. The separation of the
eyes and the width of the eyes,
which should be equal ,determine
the central and medial fifths. The
nose and chin should be cantered
within the central fifth, with the
width of the nose the same as or
slightly wider than the central
fifth. The inter – pupillary
distance (dotted lines) should equal
the width of the mouth.
23

24. Vertical facial proportions in the frontal and lateral views are best evaluated in
the context of the facial thirds, which the Renaissance artists noted were equal
in height in well-proportioned faces. In modern Caucasians, the lower facial
third often is slightly longer than the central third. The lower third has thirds :
the mouth should be one-third of the way between the base of the nose and the
chin. 24

25. FACIAL PROFILE :-
 The facial profile is examined by viewing the patient from the
sides.
 The facial profile helps in diagnosing gross deviations in the
maxillo-mandibular relationship.
 The profile is assessed by joining the following two reference
lines:
1. A line joining the forehead and the soft tissue point A( deepest
point in curvature of upper lip).
2. A line joining point A and the soft tissue pogonion (most
anterior point of the chin).
25

26. Profile convexity or concavity results from a disproportion in the size of the
jaws, but does not by itself indicate which jaw is at fault.
A convex facial profile( A) indicates a Class ll jaw relationship, which can
result from either a maxilla that projects too far forward or a mandible too
far back.
A concave profile( C) indicates a Class lll relationship, which can result from
either a maxilla that is too far back or a mandible that protrudes forward. 26

27. FACIAL DIVERGENCE :-
 Facial divergence is defined as anterior or posterior inclination of
the lower face relative to the forehead.
Facial divergence can be of 3 types :
a. Anterior divergence : a line drawn between the forehead and
chin is inclined anteriorly towards the chin.
b. Posterior divergence : a line drawn between the forehead and
chin slants posteriorly towards the chin.
c. Straight divergence : the line between the forehead and chin is
straight or perpendicular to the floor.
27

28. ASSESSMENT OF ANTERO – POSTERIOR
JAW RELATION :-
 Ideally the maxillary skeletal base is 2 – 3 mm forward of the
mandibular skeletal base when the teeth are in occlusion.
 Estimation is done by placement of the index and middle fingers
at the soft tissue point A and point B respectively.
Class I skeletal pattern
The hand is at an level
Class II skeletal pattern
The hands points upwards.
Class III skeletal pattern
The hand points downward
28

29. ASSESSMENT OF VERTICAL SKELETAL RELATION :-
 The vertical skeletal relationship can be assessed by studying the
angle formed between the lower border of the mandible and the
Frankfort horizontal plane.
 A markedly reduced lower facial height is associated with deep
bites while increased lower facial height is associated with
anterior open bites.
29

30. EXAMINATION OF LIPS :-
 Normally the upper lips covers the entire labial surface of upper
anterior except the incisal 2 – 3mm. The lower lip covers the
entire labial surface of the lower anterior and 2-3 mm of the
incisal edge of the upper anteriors.
 Classification :-
i. Competent lips
ii. Incompetent lips
iii. Potentially incompetent lips
iv. Everted lips
30

31. Competent lips Incompetent lips
Potentially incompetent lips
31

32. EXAMINATION OF THE NOSE :-
 Nose size : normally the nose is 1/3rd of the total facial height.
 Nasal contour : the shape of the nose can be straight, convex or
crooked as a result of nasal injuries.
 Nostrils : they are oval and should be bilaterally symmetrical.
32

33. EXAMINATION OF CHIN :-
 Mentolabial sulcus : the mento – labial sulcus is a concavity seen
below the lower lip.
 Mentalis activity : hyperactive mentalis activity is seen in some
malocclusion cases. It causes puckering of the chin.
Deep mento labial sulcus and hyperactive
mentalis activity in Class II div. 1
33

34. oLIP STEP ACCORDING TO KORKHAUS :-
Positive lip step Slightly negative lip step Marked negative lip step
34

35. oNASOLABIAL ANGLE :-
•It is the angle formed between the lower border of the nose and a line
connecting intersection of nose and upper lip with the tip of the lip
(labrale superius).
•This angle is normally 110◦ .
•It reduces in patients having proclined upper anteriors or prognathic
maxilla.
•It increases in patients with retrognathic maxilla or retroclined maxillary
anteriors.
35

36. oEXAMINATION OF TONGUE :-
•Abnormalities of the tongue can upset the muscle
balance and equilibrium leading to malocclusion.
•Presence of excessively large tongue is indicated by
scalloping on the lateral margins of the tongue.
•The lingual frenum should be examined for tongue
–tie as it alters the resting tongue position and
impairs the tongue movement.
36

37. EXAMINATION OF THE PALATE :-
 The palate should be examined for the following findings :
• Variation in palatal depth
• Presence of swelling
• Mucosal ulceration and indentations
• Presence of clefts
37

38. oEXAMINATION OF GINGIVA :-
•The gingiva should be examined for inflammation, recession and other
mucogingival lesions.
•Presence of poor oral hygiene is usually associated with generalized
marginal gingivitis.
•Anterior marginal gingivitis can be seen in mouth breathers due to dryness
of the mouth caused be the open lip posture.
•Bleeding on probing indicates active disease, which must be brought under
control before treatment is undertaken.
38

39. oEXAMINATION OF FRENAL ATTACHMENTS :-
•A heavy maxillary labial frenum may be cause of a midline
diastema.
•An abnormally high attachment of the mandibular labial frenum
can cause recession of the gingiva in that area.
•Abnormal frenal attachments are diagnosed by a blanch test
where the upper lip is stretched upwards and outwards for a period
of time.
39

40. ASSESSMENT OF THE DENTITION :-
 The dentition is examined and the following details are recorded :
 Status of dentition i.e. erupted and missing teeth.
 Presence of caries, restorations, malformations, hypoplasia,
wear and discoloration.
40

41. Antero – posterior relation :
Angle’s class I (neutrocclusion, normal antero-posterior relationship)
Angle’s class II div. 1 ( distoclusion with labioversion of the maxillary incisors)
41

42. Angle’s class II div. 2 (distoclusion with linguo-version of the upper incisors)
Angle’s class III (mesioclusion)
42

43. Over jet and overbite :
Transverse malrelations, like cross bite and shift of midline :
43

44. Individual tooth irregularities such as rotations, displacements,
intrusion and extrusion.
Rotation Transposition
Arch form and symmetry.
44

45. FUNCTIONAL EXAMINATION :-
 Improper functioning of the stomatognathic system can result in
various malocclusions.
 The functional examination should include :
a. Assessment of postural rest position and inter occlusal space
b. Path of closure
c. Assessment of respiration
d. Examination of TMJ
e. Examination of swallowing
f. Examination of speech
45

46. ASSESSMENT OF POSTURAL REST POSITION AND
INTER – OCCLUSAL CLEARANCE :-
 The postural rest position is the position of the mandible at which
the muscles that close the jaws and those that open them are, in a
state of minimal contraction to maintain the posture of the
mandible.
 At the postural rest position, a space exist between the upper and
lower jaws. This space is called the inter occlusal clearance or the
freeway space.
 Normally the freeway space is 3mm in canine region.
 Methods :
• Phonetics : ‘m’ or ‘c’ or ‘Mississippi’
• Command method : e.g. swallowing
• Non command method : e.g. visual examination 46

47. Measurement of inter occlusal clearance;
•Direct intra oral procedure : vernier caliper
•Direct extra oral procedure
•Indirect extra oral procedure : e.g. radiographs, Kinesiography
47

48. EVALUATION OF PATH OF CLOSURE :-
 The path of closure is the movement of the mandible from rest
position to habitual occlusion.
a. Forward path of closure : occurs in patients with mild skeletal
prenormalcy or edge to edge incisor contact.
b. Backward path of closure : class II div.2 cases exhibit
premature incisor contact due to retroclined maxillary incisors.
c. Lateral path of closure : it is associated with occlusal
prematurity and a narrow maxillary arch.
48

49. ASSESSMENT OF RESPIRATION :-
 Humans may exhibit 3 types of breathing : nasal, oral and oro-
nasal.
 Tests to diagnose the type of respiration :
a. Mirror test
b. Cotton test
c. Water test
d. observation
49

50. EXAMINATION OF T.M.J. :-
 The patient is examined for symptoms of temporo mandibular
joint problems such as clicking, crepitus, pain in the masticatory
muscles, limitation of jaw movement, hyper mobility and
morphological abnormalities.
 The maximum mouth opening is determined by measuring the
distance between the maxillary and mandibular incisal edges
with the mouth wide open.
 The normal inter – incisal distance is 40 – 45 mm.
50

51. oSPEECH :-
Certain malocclusions may cause defects in speech due to interference
with movement of the tongue and lips.
51

52. EVALUATION OF SWALLOWING :-
 The persistence of the infantile swallowing can be a cause for
malocclusion.
 The persistence of infantile swallow is indicated by the presence
of the following features :
a. Protrusion of the tip of the tongue.
b. Contraction of perioral muscles during swallowing.
c. No contact at the molar region during swallowing.
52

53. ORTHODONTIC STUDY MODEL :-
 Orthodontic study models are accurate plaster reproduction of the
teeth and their surrounding soft tissues.
 Uses of the study models :-
• They enable the study of the occlusion from all aspects.
• They enable accurate measurements to be made in a dental arch.
• They help in assessment of treatment progress by the dentist as
well as the patient.
• They help in assessing the nature and severity of malocclusion.
• They help in motivation of the patient.
• It makes it possible to simulate treatment procedures on the cast.
• Useful in transfer of records. 53

54. ORTHODONTIC STUDY MODEL
Frontal view Side view
54

55. DIAGNOSTIC SET UP :-
 The diagnostic set up was first proposed by H. D. Kesling.
 The diagnostic cast is made from an extra set of trimmed and
polished study model.
 Uses of diagnostic set up :-
• It is useful in visualizing and testing the effects of complex tooth
movements and extractions on occlusion.
• The patient can be motivated by simulating the various corrective
procedures on the cast.
• Tooth size – arch length discrepancies can be visualized.
55

56. DIAGNOSTIC SET UP
56

57. FACIAL PHOTOGRAPHS :-
 Facial photographs offer a lot of information on the soft tissue
morphology and facial expression.
 The extra oral photographs :-
These are taken by positioning the patient in such a manner that
the F – H plane is parallel to the floor.
Frontal view Profile view Oblique view
57

58. oThe intra oral photographs :-
Frontal view Right lateral view Left lateral view
Maxillary occlusal view Mandibular occlusal view
58

59. ELECTROMYOGRAPHY :-
 Electromyography is a procedure used for recording the electrical
activity of the muscles.
 The electromyograph is a machine that is used to receive, amplify
and record the action potential during muscle activity.
 The action potential is picked up by electrodes that are of two
types : a) surface electrodes and b) needle electrodes
 EMG is used to detect the abnormal muscle activity in certain
forms of malocclusion.
For e.g. in severe class II, div. 1 malocclusion the upper lip is hypo-
functional, Abnormal buccinator activity.
• EMG can be carried out after orthodontic therapy to see if
muscle balance is achieved.
59

60. RADIOGRAPPHIC EXAMINATION :-
 A valuable tool in orthodontic diagnosis.
 Uses of radiographs in orthodontics –
i. To assess general development of the dentition, presence,
absence and state of eruption of the teeth.
ii. To establish the presence or absence of supernumerary teeth.
iii. To determine the extent of root resorption of deciduous teeth.
iv. To study the extent of root formation of the permanent teeth.
v. To confirm the presence and extant of pathological and
traumatic conditions
vi. To study the character of alveolar bone.
vii. To confirm the axial inclination of the roots of teeth.
viii. To assess morphologically abnormal teeth. 60

61. o Radiographs routinely used for diagnosis in orthodontics
can be classified into two groups :-
1. Intra oral radiographs –
• Intra oral periapical radiographs
• Bitewing radiographs
• Occlusal radiographs
61

62. 2. EXTRA ORAL RADIOGRAPHS :-
a. Panoramic radiographs –
b. Cephalometric radiographs –
62

63. 3. Other radiographs :-
Hand wrist radiographs
63

64. RECENT ADVANCES IN DIAGNOSTIC AIDS :-
1. XERORADIOGRAPHY :-
• Xeroradiography is a completely dry, non – chemical process
that makes use of the electrostatic process as in Xerox machine.
• It was invented by Chaster f. Carlson in 1937.
• It makes use of an aluminium plate that is coated with a layer
of vitreous selenium.
• The unique feature of it is that it is possible to have both
positive and negative image.
• It exhibit high edge contrast due to a phenomenon called edge
enhancement.
• The xeroradiographic image is on paper and is viewed in
reflected light. 64

65. 65
2. DIGI GRAPH :-
•The digi graph is a synthesis of video imaging, computer technology and
sonic digitizing.
•The digi graph enables the clinician to perform non – invasive and non
– radiographic cephalometric analysis.
•The system allows cephalometric evaluation and treatment progress as
often as necessary without radiographic exposure.
3. MRI (Magnetic Resonance Imaging) :-
•MRI makes use of two fundamental properties of protons, i.e. spin and
small magnetic movement.
•The advantages of MRI are:
It does not have hazards as it uses non ionizing electromagnetic
radiation.
Anatomical details are good as in CT scan.
Greater tissue characterization is possible.
Imaging of blood vessels, blood flow, visualization of thrombus is
possible.

66. 66
4. TOMOGRAPHY :-
•In some situations superimposition of objects interferes with an
observer’s ability to clearly discover the objects of interest.
•In these instances tomography can be used to visualize a section or slice
of the object and thereby eliminate undesirable overlap.
•Tomography can be conventional or computed tomography.
5. OCCLUSOGRAMS :-
•It is a tracing of a photograph or a photocopy of a dental arch.
•It is used for the following purposes :
To estimate occlusal relationship.
To estimate arch length & width.
To estimate the required tooth movement in all 3 planes of space.
To estimate anchorage requirements.

67. 67
6. DIGITAL SUBTRACTION RADIOGRAPHY :-
•Subtraction radiography addresses many of the limitations in the
detection of radiographic changes by decreasing the amount of
distracting background information and by allowing the eye to focus
on the actual change that has occurred between two images.
•Technically this is an image enhancement method that removes the
structured noise from the image.
7. LASER HOLOGRAPHY :-
•Holography is a photographic technique for recording and
reconstructing images in such a way that the 3 dimensional aspect of
an object can be obtained. The recorded image is called a hologram.

68. CONCLUSION :-
 The problem-oriented approach to diagnosis and treatment
planning has been widely advocated in medicine and dentistry as
a way to overcome the tendency to concentrate on only one part
of a patient's problem. The essence of the problem-oriented
approach is the development of a comprehensive database of
pertinent information so that no problems will be overlooked.
From this database, the list of problems that is the diagnosis is
abstracted.
68

69. REFERENCES :-
 Contemporary orthodontics 4th edition by proffit
 Orthodontic diagnosis by Thomas Rakosi, Irmtrud Jonas, Thomas
M. Graber
 Orthodontics – the art and science, 4th edition by S. I. Bhalajhi
 Orthodontics - Current principles and technique (Graber) 2000
 Dentistry for the child – Mc Donald
69

70. 70