Dr.

TranNgocQuang Phi

Backgrounds
y Angleclassification y SixkeysAndrew y Crownform y Archform y Boltonanalysis y Goldenproportion

AngleClassification
y Malposition individualtooth y Buccal orlabial,lingual,mesial,distal,torso(rotation),infra andsupra. y Impacted y Malocclusion anteroposterior relationshipsof permanentfirstmolarsandcanines. y Caninerelationship: y Theuppercaninefitsdistaltothelowercanine y Molarrelationship y ClassI:normalrelationships mesial buccal cusp UFMmesial sulcus LFM. y ClassII:distalbuccal cuspUFMmesial sulcus LFM y ClassIII:buccal cuspUSPmesial sulcus LFM
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Angleclassificationextension
y ClassIIdivision1: y Narrowingoftheupperarch,lengthenandprotrudingUC. y Abnormalfunctionofthelips,nasalobstruction,mouth breathing. y ClassIIdivision1subdivision:classIononeside. y ClassIIdivision2: y Crownding,overlaping andlingualinclinationUC y Normalnasalandlipfunction y ClassIIdivision2subdivision:classIononeside. y ClassIIIsubdivision:classIononeside. y MildclassII:betweenclassIandclassII y MildclassIII:betweenclassIandclassIII
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ClassIMolarorClassICanine?

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Fouritemsthatyou"mustcomplete"for successfulorthodontictreatment
1. Theteethmustbestraightattheendoftreatment. 2. Theremustnotbeanyspacesbetweenthefront teeth. 3. Theremustnotbeanyoverjet (thepatientrefersto overjet as"overbite"). 4. Theteethmust(generally)bitetogetherattheend oftreatment.ItisOKtohaveabicuspidoutof occlusion,buttheteethmustnotbeopenmolarto molar.
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SixkeysAndrew
1.

Molarrelationship:
y ClassIAngle y Cuspembrasurerelationshipbuccally y Cuspfossa relationshiplingually

2. 3.

Crownangulation:
y Alltoothcrownsareangulatedmesially (mesiodistaltip)

Crowninclination:
y Incisorsareinclinedlabially y Upperposteriorteethareinclinedlingually,similarlyfrom

thecaninetothepremolars;uppermolarsareinclined slightlymorethanthecanineandthepremolars.
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Angulation andinclination

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Lowerposteriorteethareinclinedlingually, progressivelyfromcaninetomolars

4. Rotations: y Rotationsarenotpresent 5. Spaces y Spacesarenotpresentbetweenteeth 6. CurveofSpee y Theplaneiseitherflatorslightlycurve

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CurveofSpee
YesNo

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AnteriorCrownform
Centralincisorcrown form:
Triangularshaped incisors:needtobe reshapedtoavoidone pointcontact( black triangleandunstable) Rectangularshaped incisors:goodesthetics Barrelshapedincisors:do notprovideidealesthetics
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Caninecrownform

Relativelyflatfacialcontour

Markedlycurvedfacialcontour

Narrowandpointedincisally

Wideandflattenedincisally

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Archform
SquareOvoidTapered

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y Theoriginalarchformisconsideredthemoststable positionsincethisisthe"inbalance"positionofthe teethandsurroundingmuscles:theneutralzone. y Anyalterationofthispositionmayresultininstability inretention. y Relapsetendencyafterchangingarchform(DeLa Cruz1995,Burke1998):intercaninewidth. y Expansionthelowerarchform:10%.

Tapered Japaneses Caucasians 12% 44% Ovoid 42% 38% Square 46% 18%

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Systemizedmanagementofarchform
y Determinethearchformatthestartoftreatment y Template y Computerizedcastanalysis@ y Archwirestocked: y Roundarchwire(NiTi andSS):ovoidonly y .019/.025(.018/.025)HANT:threeshapes
y y y

45%ovoid 45%square 10%tapered

.019/.025(.018/.025)SS:ovoidonly
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Boltonanalysis
y AnteriorBoltonanalysis y Max6:40.0 54.5(+0.5) y Mand 6:30.9 42.1(+0.4) y OverallBoltonanalysis y Max12:85 110(+1) y Mand 12:77.6 100.4(+0.9) y Idealratio canineclassI y Determinedistancebetweenhooksorloop y Boltondiscrepancy propersolution
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AnteriorBoltonanalysisFullarchBolton analysis

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IdealratioinBoltonanalysis
Maxillary6 40.0 40.5 41.0 41.5 48.0 48.5 51.5 52.0 54.5 Mandibular 6 30.9 31.3 31.7 32.0 37.1 37.4 39.8 40.1 42.1 Maxillary12 85 86 88 89 90 91 96 97 103 104 106 107 Mandibular 12 77.6 78.5 80.3 81.3 82.1 83.1 87.6 88.6 94.0 95.0 96.8 97.8
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Application?
ChosetheTlooparchwire Adjustforthebestfitocclusion

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Goldenproportion

a + b a = = a b = 1 . 618

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DIAGNOSIS
y Collectdata y Orthodonticquestionaire y Clinicalexamination y Xrays:POGandCEP y Models y Pictures y Cephalometric analysis y Modelanlysis Diagnosis:problemlist

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OrthodonticQuestionaire
MEDICALHISTORY
y Underaphysician'scareatthistime?Yes/No.Explain y Takinganymedicationatthistime?Yes/No.Specify

Allergictoanymedication?Yes/No.Specify
y Anyotherallergies?Yes/No.Specify y Needtobepremedicated (antibiotics)forroutinedental

procedures?_Yes_No.Specifyandreason
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Followingdiseasesorconditions?(Ifyes,explainand date):
y AIDS__Bleedingdisorder__Anemia__ y Lungdisease__Cerebralpalsy__Heartcondition__ y Arthritis__Hepatitis__Kidneydisease__Rheumatic

fever___Asthma__Diabetes__Epilepsy__
y Injurytoface/head__ y Tonsil/adenoidsurgery__Previoussurgery__ y Females:Isthepatientpregnant?__Yes__No
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DENTALHISTORY
y Dateoflastdentalexamination y Anyinjurytotheface/teeth/gum?Explainanddate. y Anypreviousorthodontictreatment/consultation? y Doesthepatient:
y Grindhis/herteethatnight? y Bitehis/herfingernails? y Suckthumb,finger,pacifier,etc.?

y Ifyes,atwhatagewasthehabitdiscontinued?__years y Hasanothermemberofthefamilyhadorthodontic treatment?Whom?

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Medicalconditionstobeconsideredin orthodontictreatment
Medicalcondition Asthma Allergies Coagulationdisorders Diabetes Epilepsy,Highblood pressure Implications Rootresorption Allergicreaction Bleedingrisk Periodontaldisease Gingival hypertrophy Action Monitorevery6moforevidence ofEARR Determinematerialscausing allergy Extraction? Monitoradequatecontrolof diabetes Plaquecontrol,gingivectomy if necessary Premedication whenextraction, fittingbands MonitorTMJ Fluoridesupplement
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Heartvalveconditions Endocarditis Rheumatoidarthritis Xerostomia TMJdegeneration Caries

PATIENT'SATTITUDEANDMOTIVATION
y Isthepatientawareoftheproblem? y Consultationherepromptedby_________________ y Patient'sinterestinhavingtreatmentis: y __Wantstreatment___Willingifnecessary__Unwilling y Ifthepatientsteethweretobechanged,howwouldyou

likethemchanged?_______________________________
y Ifanyfeaturesofthefacecouldbechanged,whatwould

youliketosee?___________________________________
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GROWTHSTATUS: (childpatientsonly)
y Height__________cm

Weight_________kg

y Females:Hasthepatientstartedhermenstruation? __Yes__No.Ifyes,atwhatage?________ y Males:Voicechanges?__Yes__No Facialhairgrowth?__Yes__No y Hasthepatienthadanyrecentrapidgrowth?___________ Ifso,howmuch?_______________

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RationalforOrthodonticquestionaire
y Chiefcomplaints y Determinepatientsmotivation,expectation y MedicalandDentalhistory y Revealthecausesofproblems y Relationbetweenthepatientsconditionsand orthodontictreatment y Growthanddevelopment y Timingoforthodontictreatment

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CLINICALEXAMINATION
y Estheticanalysis y Macroesthetics:facialproportion y Miniesthetics:tooth liprelationships y Microesthetics:dentalappearance y Functionalanalysis y TMJ y Occlusion y Periodontalhealth y Badhabit
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Macroesthetics:facialproportion
y Generalview y Dolicofacial,brachyfacial,mesiofacial y Frontalview y Vertical
y y y

Proportion Chinheight Lowerfaceheight Proportion:ruleoffifth

y y

Horizontal
y

Midlineasymmetry

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Verticalproportion

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Horizontalproportion

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Thelowerthird@
A. Increasefaceheight: y Dolicofacial pattern y Verticalmaxillaryexcess(VME) y Highlipline:anteriorteethdisplaytoomuch y Gummysmile y Liplength:normal y Shortlip y Excesssive chinheight B. Decreasefaceheight y Brachyfacial pattern y Verticalmaxillarydeficiency y Mandibular defienciency y Shortchinheight
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Dolicofacial
Longandthinfaces.Weak musclesofmasticationthatare notstrongenoughtoholdthe teethtogetherduring orthodontictreatment. Nonextractiontreatmentof thesecasesmayresultinbite openingduringthetreatment. Whenextraction,spacecloses quickly. Becarefulwhentreatinga protrusioncase
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Mesiofacial
Mesiofacial isnotlongand thinfacialfeatures,andnot shortandsquarefacial features. Inthesecasesyoucanextract andtheextractionspaceswill close"normally". Youcantreatthesecasetypes nonextractionandtheteeth willremaininocclusion duringtreatment.
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Brachyfacial
Short,squarefaceswith verystrongmusclesof mastication. Shortclinicalcrownswith someexcessenamelwearon theocclusal surfaceofthe teeth. Inthesecases,ifyou extract,thentheextraction spaceswillcloseslowly.

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PreorthodonticPost orthodontic@

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@@

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Shortlip:@
Philtrum height<commisure height Invertedlip

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Asymmetry
y Uppermidlineasymmetry y Orthodontist:<2mm y Dentist:2 4mm y Nonprofessionalperson:>4mm y Lowermidlineasymmetry y Cause y Upper:missingtooth,impactedtooth,crowding y Lower:causesasupperarch,esp:TMJ y Alwaysthetoughcases
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y Profil view y Proportion y Convex,straight,concave y Straight:anteriordivergence,posteriordivergence y Mandibular planeangle y Lowerface

y y y

Maxillaryprojection Mandibular projection Chinprojection

y Lip y Lippostureandincisorprominence y Lipfullness y Labiomental sulcus y Throatform y Chin throatangle y Throatlength y Submental contour
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Profil view

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Blackpattern

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Convextreatment?
y Becarefulnottosetthepatient'sexpectationstoo highforreducingaconvexprofile:ittakes23mmof toothretractiontoresultin1mmoflipretraction. y Movethechinforwardtoreducefeelingconvex y Lefort I+BSSOforcomprehensivetreatment

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Miniesthetics:Tooth liprelationship
y y y y y

Philtrum height Commisure height Interlabial gap Incisal displayatrest Smileanalysis

y y y y y y y

Emotionalsmileandsocialsmile Incisal displayonsmile Gingivaldisplay Smilearc Buccal coridor width Archform Transversecant
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Verticalmeasurements

A:Philtrum height B:Commisure height C:Interlabial gap D:Incisal displayatrest

A:Incisal displayonsmile B:Crownheightandwidth C:Gingivaldisplay D:Smilearc

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Emotionalsmileandsocialsmile

Majorzygomaticus muscle

Risorius muscle

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Smilearc
y Thecontouroftheincisal edgesofthemaxillaryanterior teethrelativetothecurvatureofthelowerlipduringa socialsmile

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Transversecant

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Gummysmile
y y y y

Crownlengthening Orthodontictreatment Lefort IOsteotomy Plasticsurgery

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Microesthetics:
gingivalanddentalappearance
y y y y y

Toothproportion:crownheightandwidth Widthrelationshipandgoldenproportion Gingivalheight,shapeandcontour Connectorsandembrasures Toothshadeandcolor

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Crownheightandwidth
y Thewidthofcentral upperincisorshouldbe about80%ofitsheight. y Thedisproportion shouldbedonebefore orthodontictreatmentis completed.

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Widthrelationshipandgoldenproportion

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Gingivalshapeandcontour
Gingivalshapeofupper centralincisorsandcanines ismoreelliptical. Gingivalshapeofupper lateralincisorsand mandibular incisorsisa symmetrichalfovalorhalf circularone. Thegingivalzenithof centralandcanineislocated distaltothelongitudinal axis. Thegingivalzenithoflateral incisorscoincideswiththe longitudinalaxis.
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Connectorsandembrasures
Connector#contactpointarea: Includetheareasaboveandbelow thecontactpoint. Greatestbetweenthecentralincisors anddiminishfromthecentralstothe posteriors. Embrasures:triangularspacesincisal andgingivaltotheconnector. Gingivalembrasuresarefilledby interdental papillae. Shortinterdental papillae black triangle. Taperedcrownform blacktriangle
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Clinicalconsiderations
y y y y y

Openbite Tonguethrust Functionalshift Missingtooth LowerAnteriorTissueThickness

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Openbite
Principle:Teetheruptuntiltheyhitsomething. y Openbite:thelower incisordoesnotcontact theupperincisor.There areobviousopenbite caseswheretheteethare separatedintheanterior. y InsomeclassIIcases wheretheamountof overlapoftheupper incisorvs.thelower incisorisnormal(1/3 coverage),butthelower incisordoesnotcontact thetoothnorthepalate.
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Tonguethrust
y Atestforanteriortonguethrustisto: y Takeasmallsipofwater. y Closetheteethtogetherwiththelipsopen. y Swallow. y Apatientwithananteriortonguethrustwilleither: y Notbeabletokeephis/herlipsopen. y Willtilthis/herheadbackforgravitytokeepthewaterfromsquirting forward. y Willsquirtthewaterbetweentheteethforwardontotheirshirt (child patient). y Agoodexercisetogiveapatientwithananteriortonguethrust

(especiallyinthepresenceofopenbiteorexcessanterioroverjet)is: y Takeasmallsipofwater. y Closetheteethtogetherwiththelipsopen. y Swallowwiththethroatmuscles.Tellthepatienttoholdtheirhand ontheirthroatastheylearnthisexercisetofeelthemuscle contraction.

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FunctionalShift
y Forwardfunctionalshift y Lateralfunctionalshift y Unilateralcrossbite y Dentalmidlinesnot centered. y Theasymmetricface fromthefrontalview.

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MissingTooth
y Thisseemsveryobvious,butinmanycaseswherea toothhasbeenlost,thespacehasclosed spontaneouslybydentaldrifting.Itisveryeasytonot noticeamissingtoothinadentalarchwhendoing yourexamination. y Becertainthatyoucount4incisors,2canines,4 bicuspids,etc.ineacharch,beforechecking"none."

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LowerAnteriorTissueThickness
Principle:Thelowerarchisconsideredthelimiting archinedgewisediagnosis. y Toaligncrowdedteeth,advancement(forward movement)oftheteethwillinevitablyoccur. y Iftheadvancementofthelowerincisorsissignificant, thenaperiodontaldefect(strippingofgingivaltissue isthemostcommon)canoccur. y Advancementofincisorswith"thintissue"hasmore riskthanadvancementwith"thicktissue"labialtothe lowerincisors. Astheteethadvance,thetissuewill becomethinner.
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Cephalometric analysis:lanmarks

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Planes

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Growthdirection

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SNB Mandibleisprotrusiveif>83 Mandibleisaverageif76 82 Mandibleisretrusive if<75

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Cephalometric analysis Skeletal

Description
Pal.planetoMd.Plane:Skeletal Open/closed Md.Planeangle:SkeletalOpen/closed Y AxisVert/Hor Growth MaxillatoCranium MaxillatoCranium MandibletoCranium MandibletoCranium MaxillatoMandible Wits

Measurement
ANSPNStoMd.plane FH MA:Child Adult SGN FH N A SNA N Po:Child Adult SNB ANB A,B Occlusal plane

Mean
280 260 220 590 +1mm 820 7mm 1mm 790 20 0mm

Range
Closed240 330 Open Closed200 300 Open 240 330 Hor.570 620 Vertical Retruded 1to+3Protruded Retruded 760 830 Protruded Retruded 10to4Protruded 4to1 Retruded 750 830 Protruded ClassI:+20 to+4.50 ClassIIItendency:+0.50 to+1.50 ClassI:1to+2
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Cephalometric analysis Dental

Description
Interincisal Angle LowerIncisal Inclination LowerIncisal Protrusion LowerIncisal Protrusion UpperIncisal Inclination UpperIncisal Protrusion UpperIncisal Protrusion

Measurement 1
1
to

Mean
1300 920 +4mm +2mm 1030 5mm 4mm

Range
Bestfinish1250 1300 Retroclined 890 980 Proclined Retruded +1to+6Protruded Retruded 0to+4Protruded Retroclined 990 1060 Proclined Retruded +2to+7Protruded Retruded +2to+6Protruded

1 1
1
1 1 1

toMP toNB toAPo toSN toAPo toAvertical (toFH)

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Castanalysis

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Castanalysisbysoftware

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Advantagesofcomputerizedanalysis
y Accurate y Easy y Moreinformation: y Archform y Loopdistance(Boltonanalysis) y DetermineasymmetricArch y Spaceanalysis y Rotation y Prediction
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DETERMINETHEPROBLEMS
y Kindofproblems: y Dentalproblems y Skeletalproblems y Facialproblems y Occlusal problems y TMJproblems y Periodontalproblems y Causativefactors y Degreeofproblems
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AckermanandProffit diagram
y y y y y

Aligment (spacingandcrowding) Profile(convex,straight,concave) Sagittal deviation(Angleclass) Verticaldeviation(deepbite,openbite) Transsagittal deviation(combineAngleclassandcross bite) y Sagittovertical deviation(combineAngleclassanddeep biteoropenbite) y Verticotransverse deviation(combinecrossbiteanddeep biteoropenbite) y Transsagittovertical deviation(combineofproblemsin threeplanesofspace)
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DENTALPROBLEMS
y y y y

Intraarchproblems Interarchproblems Causativefactors Degreeofthedentalproblems

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Intraarchproblems
y Position: y Protrusionorretrusion ofincisors y Malposition y Impaction y Rotation y Angulation y Inclination: y Procline orrecline y Spaces: y Spacingorcrowding y CurveofSpee
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Interarchproblems
y Molarrelationship y ClassI,II,III y Caninerelationship y ClassI,II,III y Verticalrelationship: y Overbite,deepbite,openbite y Horizontalrelationship: y Overjet,endtoend,anteriorcrossbite. y Posteriorcrossbite y Upperandlowerincisorangulation y Interarchdiscrepancy y Midlinerelationship: y Midlineasymmetry
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Causativefactors
y Spacing y Largejaw y Smallteeth y Missingteeth y Lateraloverexpansionofarchesorforwardproclination of anteriorteeth. y Crowding y Smallorconstrictedarches y Largeteeth y Retroclination y Mesial driftofposteriorteeth
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y Openbite y Badhabit:thumbsucking,fingersuckingorpacifier using,tonguethrush,liphabit. y Hightongueposture y Airwayobstruction:allergies,enlargedtonsils, adenoids,septumproblem y Intracapsular TMJproblems y Skeletalgrowthabnormalities

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DiagnosisofImpactedTeeth
y ImpactedTeeth: noteruptedfor2yearsfollowingthe normaleruptionage. y Theeruptionpathisblocked,oriftheeruptionstopsafter thetoothstraystoapositionlabialorlingualtoanother tooth. y Themostcommonimpaction:theuppercanine. y DIAGNOSISOFANUPPERIMPACTEDCANINE y Panoramicxray:Anyoverlapofthecaninecrownwiththe lateralincisorroots impaction?. y Palatalorlabial? y Palpatethelabialtissue y Occlusal xray
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Crowdingandimpactedtooth
y The"impactedtooth"maybeBLOCKEDOUT ofthe archbecauseofcrowding:inagoodpositionbut cannoteruptduetoalackofspaceblockedout. y Evaluatetherootformationtodetermineeruption potential:incompleterootformation eruption potential. y Tx:spaceismadewithopencoilsorextractionanda deadline#12monthsissettowaitforitseruption.

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Considerationinimpactedtooth
y y y y y y

Position:labial(good)orpalatal Angulation:themoreverticalthemoresuccess Spaceavailable:enough? Thepathtothecorrectposition? Theage:bestunder25 Therisk:

Ankylosis y Damagetheadjacentteeth
y

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Degreeofproblems: DiagnosticParameters
Canineandmolarrelationships:RM,RC,LM,LC Angleclassification Overbite Overjet Stageofdentaldevelopment Presenceofcrossbite:withorwithoutfunctional shift 7. Spaceanalysis 8. POGinterpretation 9. CEPinterpretation
1. 2. 3. 4. 5. 6.
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1.

Canineandmolarrelationships:RM,RC,LM,LC
a. b. c. d.

ClassI ClassII* ClassIII* Notfullyerupted

2. Angleclassification a. ClassImalocclusion b. ClassIImalocclusion,division1,2andsubdivision* c. ClassIIImalocclusion,subdivision*

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3.

Overbite
a. b. c. d. e.

Normal(5% 20%) Moderatedeepbite(20% 50%) Severedeepbite(>50%)* Edgetoedge Anterioropenbite

4. Overjet a. Normal(1 3mm) b. Excessive(>3mm)* c. Edgetoedge d. Underjet (negativeoverjet)

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5.

Stageofdentaldevelopment
a. b. c. d.

Deciduousdentition EarlyMixeddentition LateMixeddentition Permanentdentition

6. Presenceofcrossbite:withorwithoutfunctionalshift a. None b. Anterior c. Posterior d. Both

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7.

Spaceanalysis
a. b. c. d. e.

Adequatearchlength(+1to1mm) Mildcrowding(2to3mm) Moderatecrowding(4to6mm)orSevere(>6mm) Mildspacing(1 3mm) Moderatespacing(4to6mm)orSevere(>6mm)

8. POGinterpretation a. Normal b. Abnormal:missing,supernumerary,ectopic,impacted tooth) 9. CEPinterpretation a. Normal b. Beyondthenormalrange:1SD c. Beyondthenormalrange:2SD d. Beyondthenormalrange:3SD

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