A short presentation on orthodontic diagnosis for the general practitioner

1. Tournée de l’Ordre 2012
• Dr Jean-Marc Retrouvey
• Dr Donald Taylor

2. Objectives of the Day
• Discuss the different modalities necessary to
obtain an adequate diagnosis
• Revisit the basic principles of interceptive
orthodontics and understand the importance
of early intervention
• Determine the importance of the use of
orthodontics to optimize the dental health of
adults
• Discuss Invisalign

3. Orthodontic
Diagnosis
Dr Donald Taylor
Dr Jean-Marc Retrouvey

4. Objectives
1. Review the fundamental principles of
diagnosis
2. How to prepare proper orthodontic record
3. The importance of differential diagnosis
4. The selection of cases that can be treated in
your office

5. 1. Review of fundamental principles
• Screenings of
malocclusions (children
and adults)
• Orthodontic evaluation
1. Observation-Reevaluation
2. Intervention
3. Treatment
4. When to refer to the
orthodontist

6. Brief History of Diagnosis in
Orthodontics
Akerman Profitt 1970- New approach
Angle’s Classification 1980: more information
1920’s. Based on molar based on skeletal and “Outside in ”:
relationship dento-alveolar Importance of facial
relationships harmony

7. Diagnosis-Differential Diagnosis
• Important to differentiate the severity of the
malocclusion

8. Orthodontic Record
• It is imperative to create an orthodontic record for
each patient!

9. The orthodontic record is
composed of two sections
1. Collection of Information
1. Medical and Dental History
2. 2.Extraoral Examination
Extraoral Examination
3. Functional examination
(TMJ, orofacial muscles, tongue position, respiration,
habits)
4. Intraoral Examination and Study Models
5. Radiographs
• panoramic
• cephalometric

10. Orthodontic Record: 2nd Section
2. Interpretation of the findings
The collection of the findings is not sufficient.
You must Interpret these findings to allow
you to arrive at a precise diagnosis.
This interpretation must be written in the
chart and must be in a logical order that can
be understood by others.

11. 1. Collection of Information
1. Medical and Dental History
2. Extraoral Examination
3. Functional Patient’s History
1. examination
(TMJ, orofacial muscles, tongue position, respiration,
habits)
4. Intraoral Examination and Study Models
5. Radiographs
• panoramic
• cephalometric

12. History
• Chief complaint:
– It is really important to write the reason for the
visit in the terms described by the patient
• Ex: I have an overbite….
• Ex: My teeth are crooked..
• Medical, Dental and Familial History
– This allows you to detect problems which are
environmental and or genetic

13. 1. Collection of Information
1. Medical and Dental History
2.Extra-oral Examination
2. Extraoral Examination
3. Functional examination
(TMJ, orofacial muscles, tongue
position, respiration, habits)
4. Intra-oral Examination and
Study Models
5. Radiographs
• panoramic
• cephalometric

14. WHY PERFORM AN EXTRAORAL
EXAMINATION ?

15. • Determine the harmony of facial structures
• Judge facial symmetry
• Analyze the smile
• Evaluate the position of the teeth in relation
to the soft tissue of the face

16. Facial Type
Has an important influence on the
prognosis of the result of
orthodontic treatment

17. Normocephalic
• The length and width of
the face are in ideal
proportions
• The growth pattern is
most probably favorable

18. Brachycephalic Dolychocephalic
Facial Types deviate from
ideal and the growth
pattern is not favorable

19. Brachycephalic Dolichocephalic
Tendency for a deep bite Tendency for an open bite

20. Analysis of the Profile
The angle Glabella,
Subnasale et Pogonion
gives a good idea of the
relationship of the skeletal
bases in relationship to
the soft tissues of the face

21. Facial profile and soft tissues
A pleasant profile is not measurable: It is an esthetic judgment

22. 1. Collection of Information
1. Medical and Dental History
2. Extraoral Examination
3. Functional Examination
3. Functional examination
(TMJ, orofacial muscles, tongue position, respiration,
habits)
4. Intraoral Examination and Study Models
5. Radiographs
• panoramic
• cephalometric

23. 1. Verify the medical and dental history

24. 2. Palpate the TM Joints and Perioral
musculature

25. 3. Record mandibular movements and
excursions

26. Functional Examination
A malocclusion whose
origin is skeletal with
joint degeneration.
It can be seen that the
condyle on the left is
actively resorbing

27. 1. Collection of Information
1. Medical and Dental History
2. Extraoral Examination
4. Intra oral examination and
3. Functional examination
(TMJ, orofacial muscles,
study models
tongue position, respiration,
habits)
4. Intraoral Examination and
Study Models
5. Radiographs
panoramic
cephalometric

28. Intra-oral Photographs
(obligatory and of diagnostic quality)

29. Study models
Study models must be of good
quality to allow proper study

30. When to mount a case in CR

31. 1. Molar Classification
• Angle determined that this relationship was
essential in order to have a functional
occlusion and optimal esthetics…….with a full
compliment of teeth
• One of the goals of orthodontic treatment is
to achieve a class I molar relationship. There
are exceptions

32. Is there a problem with this
classification?
Even though Class I is very
important , it does not take into
account the denture position in
relation to facial structures
It is not guaranteed that a Class I
molar relationship is the only
mark of success of orthodontic
treatment
It is vertical problems which cause
us miseries

33. Two malocclusions which present with
a Class I malocclusion (or almost)
Are the problems skeletal or dento alveolar?
The Angle classification has nothing to do with the
complexity of the cases

34. 2. Overbite
1. Etiology of exaggerated deep
bite
– Over eruption of the incisors The chief complaint
– Under eruption of the molars of the patient was:
« I have a crooked
– Skeletal dysplasia tooth »
– Deep Curve of Spee

35. The etiology greatly helps to determine the modalities
of treatment
• Supra erupted incisors • Intrusion with fixed
• Under erupted molars braces
• Deep Curve of Spee • Level Curve of Spee
• Hypoplastic Mandible • Orthognathic surgery

36. 2.Open Bite
• Possible etiologies of open bite
– Anterior position of the tongue( habits)
– Genetic factors
– Sleep apnea

39. 3.Overjet
• The etiology was
multifactorial
• Dentoalveolar
• Skeletal
• A combination of the
above

40. Overjet
 The incisors seem to
be very protrusive
 Equally, the mandible is very
retrusive

41. 4. Midlines
• Skeletal
• Dental

42. Midlines
• We use the reference line
Reference
to determine the different
line
midlines- maxillary and
mandibular

43. Midlines
1. Midline reference line
2. Maxillary midline
3. Mandibular midline
If there is a facial deviation,
how is it corrected?
If a dental deviation is it
skeletal or functional?

44. 6. Tooth size/Arch size
Small lateral incisors Large teeth

45. Width of the teeth
Bolton analysis – Normal: 77%
Tooth Upper right Upper left Ideal
Central incisor 8.85
Lateral incisor 6.9
Canine 7.88
Tooth Lower right Lower left Ideal
Central incisor 5.5
Lateral incisor 6
Canine 6.95
• UA (Σ 13-23) = mm
• LA (Σ 33-43) = mm
• ( 35.3 / 43.3 ) x 100 = %

46. The Boley Gauge of
Dr. Retrouvey
He as developed a computer program to calculate Bolton
Discrepancy

47. 7.Number of teeth and sequence of
dental eruption
• What is normal?
• Can we take advantage of the sequence of
eruption? Yes (E space)
• Is the timing early or late?
Patient age 16 years: slow eruption and multiple impacted teeth

48. Curve of spee
• Flat (normal) • Deep. Probably a skeletal
malocclusion

49. 8.Curve of Spee
Very important to evaluate
• Flat or moderate: good prognosis
• Accentuated curve: Prognosis les positive
– Do we level?
– How much space is necessary?
– We need to analyze the cephalogram. Helps with
differential diagnosis

50. 9. Amount of Crowding
• There are different factors
to consider
• Difference between the
mixed dentition and the
permanent dentition
(Leeway Space)
• Inclination of the lower
incisors (Curve of Spee)
• Non-apparent available
space ( non anatomic
restorations)

51. Is this crowding a concern?

52. Mixed dentition
The control and utilization of the
Leeway space is really important

53. The Boley Gauge of
Dr. Retrouvey
He has developed a computer program to calculate E space

54. If leeway space is not adequate
• Normally, extractions
will be required
• Sometimes we can
expand the arches
• Depends on the amount
of attached gingiva at
labial of the lower
incisors and facial
features

55. 1. Collection of Information
1. Medical and Dental History
2. Extraoral Examination
3. Functional examination
5.Radiographs
(TMJ, orofacial muscles, tongue position, respiration,
habits)
4. Intraoral Examination and Study Models
5. Radiographs
• panoramic
• cephalometric

56. Analysis of Pantographic radiograph

57. Analysis and interpretation of the cepalogram
Mandatory when contemplating all orthodontic treatment!
Analysis:
– Skeletal (values as normal as possible)
– Dentoalveolar
– Pearl: The cases where the mandibular plane angle
is normal typically gives the best prognosis

58. Cephalometric analysis
Angles Ceph. Normal
Values
The skeletal measurements give
us the relationship of the osseous Skeletal Measurements
bases relative to the cranial base SNA 79.5 81 ± 3
SNB 75.0 78 ± 3
ANB 4.5 3±2
Witts -4.0 2 mm ± 2mm
Facial 86.0 88 ± 4
MPAST 38.0 32 ± 3
Y axis 60.0 60 ± 4
Dental Measurements
(UI,NA) 16.0 23 ±6
(LI,NB) 23.0 27.5 ±5
(UI,LI) 135.0 130 ± 7
(LI,MP) 91.0 91.4 ± 4
Pre-Treatmen

59. Diagnosis of the malocclusion
• Write the most significant
elements
• Example
– Class II division I
malocclusion
– Severe retrusion of the
mandible
– Increased overbite
– Moderate crowding of the
upper arch
– Upper right canine
palatally impacted

60. Problem list
Problem Resolution Comments
Class II molar x Maintain There are potential
Correct skeletal problems
Improve
Mandibular retrusion x Correct
Reevaluate in 6 months
Overjet Maintain
Correct
x Improve
Impacted canine Consultation with surgeon May need to be
su Wait 6 months
x Surgically exposed
Crowding Rapid palatal expansion
Extraction
Arch development

61. Conclusions
Identify the malocclusion presented and arrive to a proper
diagnosis is the most important aspect in orthodontic
treatment.
Then the formulation of the objectives and establishment
of a feasible treatment plan are indispensable in
establishing the path to follow in treatment
Observe, wait, treat or refer, but above all be sure that you
inform the patient and parent of the diagnosis and
options of treatment so that THEY make an informed
decision to chose the best course for the to follow.