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Tran Ngoc Quang Phi
Angle classification Six keys Andrew Crown form Arch form Bolton analysis Golden proportion
Malposition → individual tooth
Buccal or labial, lingual, mesial, distal, torso (rotation), infra and supra. Impacted
Malocclusion → anteroposterior relationships of permanent first molars and canines. Canine relationship:
The upper canine fits distal to the lower canine
Class I: normal relationships → mesial buccal cusp UFM≡mesial sulcus LFM. Class II: distal buccal cusp UFM≡mesial sulcus LFM Class III: buccal cusp USP≡mesial sulcus LFM
Angle classification extension
Class II division 1:
Narrowing of the upper arch, lengthen and protruding UC. Abnormal function of the lips, nasal obstruction, mouth breathing.
Class II division 1 subdivision: class I on one side. Class II division 2:
Crownding, overlaping and lingual inclination UC Normal nasal and lip function
Class II division 2 subdivision: class I on one side. Class III subdivision: class I on one side. Mild class II: between class I and class II Mild class III: between class I and class III
Class I Molar or Class I Canine?
Four items that you "must complete" for successful orthodontic treatment
1. The teeth must be straight at the end of treatment. 2. There must not be any spaces between the front teeth. 3. There must not be any overjet (the patient refers to overjet as "overbite"). 4. The teeth must (generally) bite together at the end of treatment. It is OK to have a bicuspid out of occlusion, but the teeth must not be open molar to molar.
Six keys Andrew
Molar relationship :
Class I Angle Cusp‐embrasure relationship buccally Cusp‐fossa relationship lingually
All tooth crowns are angulated mesially (mesio‐distal tip)
Incisors are inclined labially Upper posterior teeth are inclined lingually, similarly from the canine to the premolars; upper molars are inclined slightly more than the canine and the premolars.
Angulation and inclination
Lower posterior teeth are inclined lingually, progressively from canine to molars
4. Rotations: Rotations are not present 5. Spaces Spaces are not present between teeth 6. Curve of Spee The plane is either flat or slightly curve
Curve of Spee
Anterior Crown form
Central incisor crown form:
•Triangular‐shaped incisors: need to be reshaped to avoid one‐ point contact (→ black triangle and unstable) •Rectangular‐shaped incisors: good esthetics •Barrel‐shaped incisors: do not provide ideal esthetics
Canine crown form
Relatively flat facial contour
Markedly curved facial contour
Narrow and pointed incisally
Wide and flattened incisally
Square Ovoid Tapered
The original arch form is considered the most stable position since this is the "in balance" position of the teeth and surrounding muscles: the neutral zone. Any alteration of this position may result in instability in retention. Relapse tendency after changing arch form (De La Cruz‐1995, Burke‐1998): inter‐canine width. Expansion the lower arch form: 10%.
Tapered Japaneses Caucasians 12% 44% Ovoid 42% 38% Square 46% 18%
Systemized management of arch form
Determine the arch form at the start of treatment
Template ♦ Computerized cast analysis @
Arch wire stocked:
Round arch wire (NiTi and SS): ovoid only .019/.025 (.018/.025 ) HANT: three shapes
45% ovoid 45% square 10% tapered
.019/.025 (.018/.025 ) SS: ovoid only →
Anterior Bolton analysis
Max 6: 40.0 – 54.5 (+0.5) Mand 6: 30.9 – 42.1 (+0.4)
Overall Bolton analysis
Max 12: 85 – 110 (+1) Mand 12: 77.6 – 100.4 (+ 0.9)
Ideal ratio → canine class I Determine distance between hooks or loop Bolton discrepancy → proper solution
Anterior Bolton analysis Full archBolton analysis
Ideal ratio in Bolton analysis
Maxillary 6 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 Maxillary 12 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
•Chose the T –loop arch wire •Adjust for the best fit occlusion
a + b a = = ϕ a b ϕ = 1 . 618
Orthodontic questionaire Clinical examination X‐rays : POG and CEP Models Pictures
Cephalometric analysis Model anlysis → Diagnosis: problem list
Under a physician's care at this time? Yes/No. Explain Taking any medication at this time? Yes/No. Specify Allergic to any medication? Yes/ No. Specify Any other allergies? Yes/No. Specify Need to be premedicated (antibiotics) for routine dental procedures? _Yes _No. Specify and reason
Following diseases or conditions? (If yes, explain and date): AIDS__ Bleeding disorder __ Anemia__ Lung disease__ Cerebral palsy__ Heart condition__ Arthritis__ Hepatitis__ Kidney disease__Rheumatic fever___ Asthma__ Diabetes__ Epilepsy__ Injury to face/head__ Tonsil/adenoid surgery__ Previous surgery__ Females: Is the patient pregnant? __ Yes __ No
Date of last dental examination Any injury to the face/teeth/gum? Explain and date. Any previous orthodontic treatment/consultation? Does the patient:
Grind his/her teeth at night? Bite his/her fingernails? Suck thumb, finger, pacifier, etc.?
If yes, at what age was the habit discontinued? __years Has another member of the family had orthodontic treatment? Whom?
Medical conditions to be considered in orthodontic treatment
Medical condition Asthma Allergies Coagulation disorders Diabetes Epilepsy, High blood pressure Implications Root resorption Allergic reaction Bleeding risk Periodontal disease Gingival hypertrophy Action Monitor every 6 mo for evidence of EARR Determine materials causing allergy Extraction? Monitor adequate control of diabetes Plaque control, gingivectomy if necessary Premedication when extraction, fitting bands Monitor TMJ Fluoride supplement
Heart valve conditions Endocarditis Rheumatoid arthritis Xerostomia TMJ degeneration Caries
PATIENT'S ATTITUDE AND MOTIVATION
Is the patient aware of the problem? Consultation here prompted by _________________ Patient's interest in having treatment is: __ Wants treatment ___ Willing if necessary __ Unwilling If the patient’s teeth were to be changed, how would you like them changed? _______________________________ If any features of the face could be changed, what would you like to see? ___________________________________
GROWTH STATUS: (child patients only)
Height__________ cm Weight _________kg Females: Has the patient started her menstruation? __ Yes __ No. If yes, at what age? ________ Males: Voice changes? __ Yes __ No Facial hair growth? __ Yes __ No Has the patient had any recent rapid growth? ___________ If so, how much?_______________
Rational for Orthodontic questionaire
Determine patient’s motivation, expectation
Medical and Dental history
Reveal the causes of problems Relation between the patient’s conditions and orthodontic treatment
Growth and development
Timing of orthodontic treatment
Macro esthetics: facial proportion Mini esthetics: tooth – lip relationships Micro esthetics: dental appearance
TMJ Occlusion Periodontal health Bad habit
Macro esthetics: facial proportion
Dolicofacial, brachyfacial, mesiofacial →
Proportion Chin height Lower face height
Proportion: rule of fifth
The lower third @
A. Increase face height:
Dolicofacial pattern Vertical maxillary excess (VME) ♦
High lip line: anterior teeth display too much Gummy smile Lip length: normal ≠ Short lip ♦
Excesssive chin height ♦ B. Decrease face height Brachyfacial pattern Vertical maxillary deficiency Mandibular defienciency ♦ Short chin height ♦
•Long and thin faces. Weak muscles of mastication that are not strong enough to hold the teeth together during orthodontic treatment. •Non extraction treatment of these cases may result in bite opening during the treatment. •When extraction, space closes quickly. Be careful when treating a protrusion case
•Mesiofacial is not long and thin facial features, and not short and square facial features. •In these cases you can extract and the extraction spaces will close "normally". •You can treat these case types non extraction and the teeth will remain in occlusion during treatment.
•Short, square faces with very strong muscles of mastication. •Short clinical crowns with some excess enamel wear on the occlusal surface of the teeth. •In these cases, if you extract, then the extraction spaces will close slowly.
Pre‐orthodontic Post‐ orthodontic@
Short lip: @
Philtrum height < commisure height Inverted lip
Upper midline asymmetry
Orthodontist : < 2mm Dentist : 2 – 4mm Non‐professional person: >4mm
Lower midline asymmetry Cause
Upper : missing tooth, impacted tooth, crowding… Lower: causes as upper arch, esp: TMJ
Always the tough cases
Proportion Convex, straight, concave Straight: anterior divergence, posterior divergence Mandibular plane angle Lower face
Maxillary projection Mandibular projection Chin projection
Lip posture and incisor prominence Lip fullness Labiomental sulcus
Chin – throat angle Throat length Submental contour
Be careful not to set the patient's expectations too high for reducing a convex profile: it takes 2‐3mm of tooth retraction to result in 1mm of lip retraction. Move the chin forward to reduce feeling convex Lefort I + BSSO for comprehensive treatment
Mini esthetics: Tooth – lip relationship
Philtrum height Commisure height Interlabial gap Incisal display at rest Smile analysis
Emotional smile and social smile Incisal display on smile Gingival display Smile arc Buccal coridor width Arch form Transverse cant
A: Philtrum height B: Commisure height C: Interlabial gap D: Incisal display at rest
A: Incisal display on smile B: Crown height and width C: Gingival display D: Smile arc
Emotional smile and social smile
Major zygomaticus muscle
The contour of the incisal edges of the maxillary anterior teeth relative to the curvature of the lower lip during a social smile
Crown lengthening Orthodontic treatment Lefort I Osteotomy Plastic surgery
gingival and dental appearance
Tooth proportion: crown height and width Width relationship and golden proportion Gingival height , shape and contour Connectors and embrasures Tooth shade and color
Crown height and width
The width of central upper incisor should be about 80% of it’s height. The disproportion should be done before orthodontic treatment is completed.
Width relationship and golden proportion
Gingival shape and contour
Gingival shape of upper central incisors and canines is more elliptical. Gingival shape of upper lateral incisors and mandibular incisors is a symmetric half‐oval or half‐ circular one. The gingival zenith of central and canine is located distal to the longitudinal axis. The gingival zenith of lateral incisors coincides with the longitudinal axis.
Connectors and embrasures
Connector # contact point area: Include the areas above and below the contact point. Greatest between the central incisors and diminish from the centrals to the posteriors. Embrasures: triangular spaces incisal and gingival to the connector. Gingival embrasures are filled by interdental papillae. Short interdental papillae → black triangle. Tapered crown form → black triangle
Open bite Tongue thrust Functional shift Missing tooth Lower Anterior Tissue Thickness
Principle: Teeth erupt until they hit something. Open bite: the lower incisor does not contact the upper incisor. There are obvious open bite cases where the teeth are separated in the anterior. In some class II cases where the amount of overlap of the upper incisor vs. the lower incisor is normal (1/3 coverage), but the lower incisor does not contact the tooth nor the palate.
A test for anterior tongue thrust is to: Take a small sip of water. Close the teeth together with the lips open. Swallow. A patient with an anterior tongue thrust will either: Not be able to keep his/her lips open. Will tilt his/her head back for gravity to keep the water from squirting forward. Will squirt the water between the teeth forward onto their shirt (child patient). A good exercise to give a patient with an anterior tongue thrust (especially in the presence of open bite or excess anterior overjet) is: Take a small sip of water. Close the teeth together with the lips open. Swallow with the throat muscles. Tell the patient to hold their hand on their throat as they learn this exercise to feel the muscle contraction.
Forward functional shift Lateral functional shift
Unilateral crossbite Dental midlines not centered. The asymmetric face from the frontal view.
This seems very obvious, but in many cases where a tooth has been lost, the space has closed spontaneously by dental drifting. It is very easy to not notice a missing tooth in a dental arch when doing your examination. Be certain that you count 4 incisors, 2 canines, 4 bicuspids, etc. in each arch, before checking "none."
Lower Anterior Tissue Thickness
Principle: The lower arch is considered the limiting arch in edgewise diagnosis. To align crowded teeth, advancement (forward movement) of the teeth will inevitably occur. If the advancement of the lower incisors is significant, then a periodontal defect (stripping of gingival tissue is the most common) can occur. Advancement of incisors with "thin tissue" has more risk than advancement with "thick tissue" labial to the lower incisors. As the teeth advance, the tissue will become thinner.
Cephalometric analysis: lanmarks
SNB Mandible is protrusive if > 83 Mandible is average if 76 – 82 Mandible is retrusive if <75
Cephalometric analysis – Skeletal
Pal. plane to Md. Plane: Skeletal Open/closed Md. Plane angle: Skeletal Open/closed Y – Axis Vert/Hor Growth Maxilla to Cranium Maxilla to Cranium Mandible to Cranium Mandible to Cranium Maxilla to Mandible Wits
ANS‐PNS to Md. plane FH – MA: Child Adult SGN ‐ FH N ⊥ A SNA N ⊥ Po : Child Adult SNB ANB A, B ⊥ Occlusal plane
280 260 220 590 +1mm 820 ‐7mm ‐1mm 790 20 0 mm
Closed 240 – 330 Open Closed 200 – 300 Open 240 – 330 Hor. 570 – 620 Vertical Retruded ‐1 to +3 Protruded Retruded 760 – 830 Protruded Retruded ‐10 to ‐4 Protruded ‐4 to ‐1 Retruded 750 – 830 Protruded Class I : + 20 to +4.50 Class III tendency: +0.50 to +1.50 Class I : ‐1 to +2
Cephalometric analysis – Dental
Interincisal Angle Lower Incisal Inclination Lower Incisal Protrusion Lower Incisal Protrusion Upper Incisal Inclination Upper Incisal Protrusion Upper Incisal Protrusion
1300 920 +4mm +2mm 1030 5mm 4mm
Best finish 125 0 – 1300 Retroclined 890 – 980 Proclined Retruded +1 to +6 Protruded Retruded 0 to +4 Protruded Retroclined 990 – 1060 Proclined Retruded +2 to +7 Protruded Retruded +2 to +6 Protruded
1 1 1
to MP to NB to APo to SN to APo to A vertical (to FH)
Cast analysis by software
Advantages of computerized analysis
Accurate Easy More information:
Arch form Loop distance (Bolton analysis) Determine asymmetric Arch Space analysis Rotation Prediction
DETERMINE THE PROBLEMS
Kind of problems:
Dental problems Skeletal problems Facial problems Occlusal problems TMJ problems Periodontal problems
Causative factors Degree of problems
Ackerman and Proffit diagram
Aligment (spacing and crowding) Profile (convex, straight, concave) Sagittal deviation (Angle class) Vertical deviation (deep bite, open bite) Transsagittal deviation (combine Angle class and cross bite) Sagittovertical deviation (combine Angle class and deep bite or open bite) Verticotransverse deviation (combine cross bite and deep bite or open bite) Transsagittovertical deviation (combine of problems in three planes of space)
Intra‐arch problems Inter‐arch problems Causative factors Degree of the dental problems
Protrusion or retrusion of incisors Malposition Impaction
Rotation Angulation Inclination:
Procline or recline
Spacing or crowding
Curve of Spee
Class I, II, III
Class I, II, III
Overbite, deep bite, open bite
Overjet, end‐to‐end, anterior crossbite. Posterior crossbite
Upper and lower incisor angulation Inter‐arch discrepancy Midline relationship:
Large jaw Small teeth Missing teeth Lateral over‐expansion of arches or forward proclination of anterior teeth.
Small or constricted arches Large teeth Retroclination Mesial drift of posterior teeth
Bad habit: thumb sucking, finger sucking or pacifier using, tongue thrush, lip habit. High tongue posture Airway obstruction: allergies, enlarged tonsils, adenoids, septum problem… Intracapsular TMJ problems Skeletal growth abnormalities
Diagnosis of Impacted Teeth
Impacted Teeth : not erupted for 2 years following the normal eruption age. The eruption path is blocked, or if the eruption stops after the tooth strays to a position labial or lingual to another tooth. The most common impaction: the upper canine. DIAGNOSIS OF AN UPPER IMPACTED CANINE Panoramic x‐ray: Any overlap of the canine crown with the lateral incisor roots → impaction?. Palatal or labial?
Palpate the labial tissue Occlusal x‐ray
Crowding and impacted tooth
The "impacted tooth" may be BLOCKED OUT of the arch because of crowding: in a good position but cannot erupt due to a lack of space →blocked out. Evaluate the root formation to determine eruption potential: incomplete root formation → eruption potential. Tx: space is made with open coils or extraction and a deadline # 12 months is set to wait for its eruption.
Consideration in impacted tooth
Position: labial (good) or palatal Angulation: the more vertical the more success Space available: enough? The path to the correct position? The age: best under 25 The risk:
Ankylosis Damage the adjacent teeth
Degree of problems: Diagnostic Parameters
Canine and molar relationships: RM, RC, LM, LC Angle classification Overbite Overjet Stage of dental development Presence of crossbite: with or without functional shift 7. Space analysis 8. POG interpretation 9. CEP interpretation
1. 2. 3. 4. 5. 6.
Canine and molar relationships: RM, RC, LM, LC
a. b. c. d.
Class I Class II* Class III* Not fully erupted
2. Angle classification a. Class I malocclusion b. Class II malocclusion, division 1, 2 and subdivision* c. Class III malocclusion, subdivision*
a. b. c. d. e.
Normal (5 % ‐ 20%) Moderate deep bite (20% ‐ 50%) Severe deep bite ( > 50%)* Edge to edge Anterior open bite
4. Overjet a. Normal (1 – 3mm) b. Excessive ( > 3mm)* c. Edge to edge d. Underjet (negative overjet)
Stage of dental development
a. b. c. d.
Deciduous dentition Early Mixed dentition Late Mixed dentition Permanent dentition
6. Presence of cross bite: with or without functional shift a. None b. Anterior c. Posterior d. Both
a. b. c. d. e.
Adequate arch length ( +1 to ‐1mm) Mild crowding (‐2 to ‐3mm) Moderate crowding (‐4 to ‐6mm) or Severe (> ‐6mm) Mild spacing (1 – 3mm) Moderate spacing (4 to 6mm) or Severe (> 6mm)
8. POG interpretation a. Normal b. Abnormal: missing, supernumerary, ectopic, impacted tooth) 9. CEP interpretation a. Normal b. Beyond the normal range: 1 SD c. Beyond the normal range: 2 SD d. Beyond the normal range: 3 SD
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