Supplementary diagnostic aids

Essential diagnostic aids, as the name suggests are considered essential for the
diagnosis of an orthodontic case. Ideally before starting a case, a treating clinician
must possess these aids.
1. Case history
2. Clinical examination
3. Study models
4. Certain radiographs:
a. Periapical radiographs
b. Lateral radiographs
c. Orthopantomograms
d. Bite wing radiographs.
5. Facial photographs.
1. Specialized radiographs
a. Occlusal view of maxilla & mandible.
b. Selected lateral jaw views
2. Electromyographic examination
3. Hand-wrist radiographs
4. Computed axial tomography (CT scan)
5. Magnetic Resonance Imaging (MRI)
6. Endocrine tests and/or other blood tests
7. Estimation of the basal metabolic rate
8. Sensitivity (vitality) tests
9. Biopsy
Occlusal radiograph
Specialised radiographs
I.Maxillary occlusal projections

• Upper standard occlusal (standard occlusal)

• Upper oblique occlusal (oblique occlusal)

• Vertex occlusal (vertex occlusal)

II.Mandibular occlusal projections
• Lower 90 degrees occlusal (true occlusal)

• Lower 45 degrees occlusal (standard occlusal)

• Lower oblique occlusal (oblique occlusal)
Standard maxillary
Vertex occlusal
Oblique occlusal
Lower 90 degrees occlusal
Lower 45 degrees occlusal
Lower oblique occlusal
Special radiographs
•Lateral oblique
•Water’s view ( Sinus)
•Reverse townes.
•Temporomandibularjoint projections

Lateral oblique view
Water’s view projection
•Also known as sinus projection
•It’s similar to the posteroanterior projection Except that the center of
interest is focused on the middle third of the face.

To Evaluate the maxillary , frontal and ethmoid sinuses.
Townes view
Reverse townes
Submento vertex view
Main clinical indications
• Detection of the presence and position of
radiopaque calculi in the submandibular salivary
• Assessment of the bucco/lingual position of
unerupted mandibular teeth
• Evaluation of the bucco/lingual expansion of the
body of the mandible by cysts, tumours or

• Periapical assessment of the lower incisor
teeth, especially useful in adults and children
unable to tolerate periapical films
• Evaluation of the size and extent of lesions in
the anterior part of the mandible
• Assessment of displacement fractures of the
anterior mandible in the vertical plane
• Periapical assessment of the upper anterior teeth in
patients unable to tolerate periapical films

• Detecting the presence of unerupted canines,
supernumeraries and odontomes
• As the midline view, when using the parallax method
for determining the bucco/palatal position of
unerupted canines
• Evaluation of the size and extent of lesions
such as cysts or tumors in the anterior maxilla
• Assessment of fractures of the anterior teeth
and alveolar bone, especially useful for
• Clinical indications- assessment of the
bucco/palatal position unerupted canines
• Disadvantages:
- There is a lack of detail and contrast on the
film because of the intensifying screens, the
mass of tissues the X-ray beam has to
penetrate and the consequent scatter
18.05.2004 20
The instrument used for evaluating
the activity of the orofacial muscle is the
electromyograph. It is used to measure
the electrical activity .

Recording Methodology
• Electrical potential difference measured between two points
¬ bipolar electrode configuration used
• Bipolar Electrode Types
• Fine Wire
• Needle
• Surface

• Electrode Placement
• Overlying the muscle of interest in the direction of predominant fiber
• Subject is GROUNDED by placing an electrode in an inactive region of

18.05.2004 22
OAll types of the electrodes record the membrane
action potentials from the several to many fibers in a
single motor unit

O A flat metal plate is placed over the muscle to be
tested. Then, a thin sterile needle attached to wires of a
recording machine is inserted through the skin into the
muscle. The electrical activity of the muscle is
recorded at rest and during contraction. It is then
displayed as electrical waves on an oscilloscope and
amplified to produce sounds over an audio speaker.

OThis permits to study the behaviour of individual
units and how the units are recruited.
Fine Wire
Represented graphically ¬ electromyogram

The action potentials from the various units merge together and produce the
typical electromyogram.

EMG Uses

• Whether a muscle is active or not during a movement activity
• When the muscle turns ON/OFF during a movement activity
• Phasic relationship between muscles during a movement activity
• Does an increased EMG magnitude imply a higher muscular stress?
• Is the muscle fatigued?
Hand and wrist radiographs
• Chronological age- not sufficient for assessing the
developmental stage and the somatic maturity of the
• Assessment of the skeletal age is made with the help
of hand radiographs which can be considered as
biological clock

• Standard method for the evaluation of the
skeletal age

• Easily identifiable maturity indicators

• Reliable source of maturation process

• Serves as a useful diagnostic aid

Indications for hand & wrist radiographs
• Prior to rapid maxillary expansion
• When maxillomandibular changes are indicated
• Marked discrepancy b/w chronologic and dental age
• Orthodontic patients requiring orthognathic surgery
between 16 &20 yrs of age.
• Most commonly used, comprising of 28 – 30 separate
centers of bone growth and maturation

Anatomy of skeleton of the hand
Distal ends of long bones

Carpel bones:
I. Trapezium
II. Trapezoid
III. Capitate
IV. Hamate
V. Hamular processof the hamate
VI. Triquetral
VII. Pisiform
IX. Scaphoid
Atlas method of Greulich & Pyle
• Radiograph is compared with a standard series
of films, representative of normal children at
different chronological ages and for each sex.
Bjork, Grave & Browns method
• 9 developmental stages
• Area of ossification events
Area of phalanges
Carpel bones
• This method describes the relationship b/w the
epiphyses and the diaphysis in 3 stages
Stages of ossification
First stage
• PP2 = stage 1
• The epiphysis and
diaphysis of proximal
phalanx of index finger
are equai
• Occurs 3yrs before
prepubertal growth
Second stage:
• MP3 = stage
• The epiphysis and diaphysis of middle phalanx of the
middle finger are equal

Third stage

This stage is characterized
by presence of 3 areas
of ossification
a. The hamular process of
the hamate exhibits
b. Ossification of pisiform
c. The epiphysis and
diaphysis of radius are
Fourth stage
This stage marks the beginning
of the pubertal growth spurt
an is characterized by:
a. lnitial mineralization of the
ulnar sesamoid of the thumb
b. Increased ossification of the
hamular process of the
hamate bone

• Reach shortly before or at
the beginning of the
pubertal growth spurt
Fifth stage
This stage marks the peak of
the pubertal growth spurt.
Capping of diaphysis by
the epiphysis is seen in
a. Middle phalanx of the
third finger
b. Proximal phalanx of
c. Radius

• Marks the peak of
pubertal growth spurt
Sixth stage
DP3 U stage – constitues
the end of pubertal
• This stage signifies the
end of the pubertal
growth spurt and is
characterized by the
union between
epiphysis and diaphysis
of the distal phalanx of
the middle finger

Seventh stage
• PP3 U stage
• This stage is represented by the union of
epiphysis and diaphysis of the proximal phalanx
of the little fingers

Eighth stage
• MP3 U stage
• This stage is represented by the fusion between
the epiphysis and diaphysis of the middle
phalanx of the middle finger

Ninth stage
• This is the last stage and it signifies the end of skeletal
growth. It is characterized by fusion of epiphysis and
diaphysis of the radius
• Ossification of all the hand bones is completed and
skeletal growth is finished.
Singers method
• Julian Singer 1980,It involved six stages of
hand-wrist development
• Early,
• Pre pubertal
• Pubertal onset
• Pubertal
• Pubertal deceleration
• Growth completion

6 stages of hand & wrist developement
Stage 1(early)
Absence of pisiform,
Hook of hamate.
Epiphysis of proximal phalanx
Of second digit narrower than
Its shaft
Stage 2(prepubertal)
-Initial ossification of pisiform &
Hook of hamate.
-Proximal phalanx of second digit
And its epiphysis are equal in
• Stage 3( pubertal
• Beginning of
of ulnar sesamoid
×Increased ossification
of pisiform & hook of

• Stage 4(pubertal)
• Calcified ulnar
• Capping of shaft of
middle phalanx of
third digit by its
• Stage 5(pubertal
• Ulnar sesamoid fully
• DP3u stage
• All phalanges and carpals
fully calcified
• Epiphyses of radius and ulna
not fully calcified with
respect to shafts
• Stage 6(growth
• No remaining growth
Fishman method
This system uses;
- Only four stages of
- Six anatomic sites
located on the thumb,
third finger, fifth finger

11 discrete adolescent SMIs

System of SMA


-relatively simple

Cervical vertebrae
Lateral ceph.
Dens(odontoid process)
Body of C3
Body of C4

C2 C1
CATEGORY 1(initiation)

• Corresponds to SMI 1&2.

• 80-100% of growth expected

• Inferior borders of C2,C3 & C4
were flat

• Vertebrae wedge shaped

• Tapered from post. to Ant.
Six categories of CV maturation
CATEGORY 2 (acceleration)

• Corresponds to SMI 3&4
• 65-85% of growth
• Inferior borders of C2,C3-
concavities developing
• Inf. Border C4 flat
• C3 &C4 bodies rectangular

CATEGORY 3 (transition)
• Corresponds toSMI 5& 6
• Distinct concavities-C3&C4
• Concavity begins to develop-C4
• C3 &C4 rectangular.

• Corresponds to SMI 7&8.

• 10-25% growth expected

• Distinct concavities- C2, C3&C4.

• C3&C4-becoming square in shape.

CATEGORY 5(maturation)
• Corresponds to SMI 9 & 10

• 5-10% growth expected.

• Accentuated concavities-C2,C3 &C4.

• C3 &C4 almost square in shape.
• Corresponds toSMI 11

• Adolescent growth complete

• Deep concavities-C2, C3 &C4.

• Vertebral bodies greater vertically
than horizontally.
•Orthodontists have always relied on 2-
dimensional X-rays for diagnosis, treatment
planning and patient education
•But the introduction of 3-dimensional imaging
systems like computerized tomograms have
radically altered the ability of the orthodontist in
making diagnosis and treatment planning
Parts of the Equipment;
1. Scanner ( movable x
ray table + gantry)
2. Computer system
3. A display console
Radiation dosage 1.536 rad for
a single section

1.8432 rad for
multiple sections
Estimated dose to the centre of the condyle
with CT is 180mR
Cleft of the upper lip
Skeletal and soft tissue abnormalities can also be seen
Airway analysis
A recent study conducted on 11 subjects using lateral cephalograms
and CBCT’s showed moderate variability in airway dimension
Assessment of alveolar bone height and volume

ªFor implant placement
ªAssessing the height, width of the bone
TMJ morphology
Computerized Tomography
ª Computerized Tomography was developed by sir
Godfrey Hounsfield in 1967
ª Since its evolution it has gone through 5
ª The method of organization of these systems
depends on the individual moving parts and physical
motion of the beam in capturing the data
ª Consists of a single radiation source and a single detector
ª The second generation made use of multiple detectors arranged in the
same plan but they need not be continuous
ª The third generation CT’s made use of laarge detectors there by
reducing the need for the beam to translate around the object
ª They were also known as fan beam CT’s
ª Disadvantage was ring artefacts seen in the image thus distorting
the 3D image
ª Fourth Generation CT’s counteracted the problem of ring artefacts
ª They consisted of a moving radiation source but a fixed detector ring
ª Scattered radiation was more
ª The Fifth Generation CT’s were developed to overcome motion or scatter effects
ª The detector is stationery and the electron beam is swept around in a semicircular
tungsten strip anode .X-rays are produced when the electrons hit the anode and rotate
around a patients head with no translational components or moving parts
ª The X-ray tube rotates around the patient as the table is translated through the
gantry , net effect being that the X-ray tube traveling in a helical path around the
ª Multiple detector arrays are used
ª Detectors are closely packed
Disadvantages of conventional CT’s
ª Requires more space
ª Expensive than conventional radiographic
ª Images captured are made up of multiple slices
and therefore the ‘stacked’ image is time
consuming and less cost efficient
ª Radiation exposure is more so limited only to
complex craniofacial problems
ª Cone Beam Computerized Tomography
(CBCT) was introduced in 1990’s
ª Evolutionary process resulting from the
demand for three dimensional information
information obtained from conventional
ª Custom built CBCT’s are in the market
specifically for use in dentistry
ª The object to be evaluated is captured as the radiation source falls on a 2-
dimensional detector
ª An entire region of interest can be obtained with a single rotation of the
X-ray source
ª The cone beam produces a more focused beam, so less scatter radiation
ª Significant increase in X-ray utilisation and reduces tube required for
volumetric scanning
ª Total radiation exposure is approximately 20% of conventional CT’s
ª Nearly equal to a full mouth periapical radiographic exposure
ª Less expensive and smaller, so can fit in dental office
CBCT Acquisition systems
ª New Tom 3G - Quantitative radiology, Verona, Italy
ª i-CAT - Imaging sciences International,USA
ª CB MercuRay – Hitachi, Japan
ª 3D Accuitomo - Kyoto, Japan
ª CBCT technology in dentistry
ª Patient in supine position or sitting position
ª Scan takes place in 36 seconds
ª 3 possible fields of view
ª 0.125mm voxel resolution
ª 12 BIT Gray Scale
ª Higher resolution for all views
ª 0.125 mm voxel resolution
ª Good contrast
Amorphous silicon flat panel image sensor

Views possible with CBCT
ª periapical
ª panoramic
ª Cephalogram
ª occlusal view
ª TMJ series
ª separate axial views
Orthodontic implications of CBCT’s
ª Impacted canines and abnormalities
ª Airway analysis
ª Assessment of alveolar bone height and
ª TMJ morphology
Impacted canines and abnormalities
2 D View
3D CBCT View
ª The quality of TMJ images is comparable to
conventional CT’s
ª Radiation exposure is less
ª Image taking faster
ª Less expensive
• The New Tom 9000 Volume scan has been extremely valuable for
investigating impacted teeth, temporo mandibular joints, implant
planning, and pathology.
• Three-dimensional scans can give valuable information about
areas of the dentition, such as the position of the maxillary
incisor roots relative to the lingual cortical border of the palate to
plan retraction, the amount of bone in the posterior maxilla
available for distalization, the amount of bone lateral to the
maxillary buccal segments available for dental rather than skeletal
expansion, airway information on the pharynx and nasal
passages, maxillary root proximity to the maxillary sinus, and the
position of the mandibular incisor roots in bone.
• These scans also allow 3D visualization of bony
defects and supernumerary teeth in patients with
cleft lips or palates.
• axially corrected tomograms of the temporo
mandibular joints can be obtained from the same

Magnetic Resonance Imaging
Magnetism is a dynamic invisible
phenomenon consisting of discrete
fields of forces.
Magnetic fields are caused by
moving electrical charges or
rotating electric charges.
Images generated from protons of
the hydrogen nuclei.
Essentially imaging of the water in
the tissue.
Magnetic Resonance Imaging
· The technique is based on the presence of specific magnetic
properties found within atomic nuclei containing protons and
· Inherent property of rotating about their axis
· Causes a small magnetic field to be generated around the
electrically charged nuclei.
· When dipoles exposed within a strong electric field
· Orientation in response to the field
· Depending on density and spatial relation
· Signal interpreted and image produced

When images are displayed; intense signals show as
white and weak ones as Black and Intermediate as
shades of gray.
Cortical bone and teeth with low presence of hydrogen
are poorly imaged and appear black.

1. The Gantry ;houses the
patient. Patient is
surrounded by
magnetic coils
2. Operating console ;
where the operator
controls the computer
and scanning procedure
3. Computer room

The objectives of MRI imaging of the TMJ are;
- Determine relationship between the disc and Temporal and
mandibular components of the TMJ
- Detect inflammation, hematoma and effusion for the soft
tissue components

- MRI clearly differentiates the soft tissue components .
- Short and long echo imaging of the TMJ enables identification
of the positional relationships between the disc and the
- The contrast and appearance of images can be varied by
selecting the field strength and other factors.
- Special head holders have been designed which facilitates
orientation of the patient and reduces patient movement
during imaging

Magnetic forces and radio waves - not know to produce any
biological side effects in man.
Non invasive technique and can be used in most patients.
× Patients with cardiac pacemakers.
× Patients with cerebral metallic aneurysm clips. Slight movement
of the clip could produce bleeding
× Stainless steel and other metals produce artifacts ; obliterate
image details of the facial area.*

- Assessing diseases of the TMJ
- Cleft lip and palate
- Tonsillitis and adenoiditis
- Cysts and infections
- Tumors
/Short comings
× Inability to identify ligament tears or perforations
× Dynamics of tissue joint not possible
× Cannot be used in patients suffering from claustrophobia.

Hormones – in Greek means “I excite
or arouse”, was introduced by Starling
in 1905.
DEFINITION : Secretory product of
Endocrine glands released directly into
the circulation in small amount in
response to specific stimulus.On
delivery in circulation it produces response
on the target cells or organs.
Endocrine tests
× Protein hormone, secreted by acidophills
of anterior pitutary
× Secretion is more during strenuous excercises
and deep sleep.
× No specific target organ.
× Anabolic harmone.
× No direct action on bone but act thru
substance called STOMATOMADIN.

1. Insulin like growth factor(IGF-1)
2. Insulin like growth factor(IGF-2)

GH carries almost all the metabolic activity with
IGF-1 .

Normal concentration of GH ;
2 – 4 ng/ml in growing child

×Children with big skull with babyish face
×Cephalometric studies :
Small size of ant. & post. Cranial base
Smaller mandibular dimensions
Small post. Facial height & mand.

× Study done on 13 pts. with pitutary deficiency,
Cephalometric finding were low as compared to normal



Occur during adolescence before
epiphysial closure.
× Tall stature
× Bilateral gynaecomastia
× Large hand and feet
× Associated features like:coarse hair,loss of libido,etc.


Occur during adulthood after epiphyseal closure.
Usually a result of benign pitutary tumor.

Features :
×Broad,thick nose
×Thickening of the skin
×Prominent brow
×Coarsening of facial features
×Prognathism : elongation and
widening of mandible (class 3 malocclution)
×Serum level of IGF-1 was 10 times high.
×Development of cross bite

Mandibular growth in Acromegaly results from
appositional growth and hypertrophic changes
in the condylar cartilage.
×It has no specific target organ
×Regulates the pace of metabolism thru interactions
with mitochondrial,nuclear & extra mitochondrial
Prenatal hypothyroidism
×Development of bone & teeth are retarded
×Later enamel defects in prenatally developed teeth are seen.
×Some degree of mental retardation is seen.
After birth
×Growth of cranium is retarded – brachycephalic faces develop
×Increased mental retardation.

×TH important for synthesis of IGF-1
×Reduced facial height seen in children hypothyroidism
of long duration.
Orthodontic consideration
TH administration leads to :

×Increased bone remodelling
× Increased bone resorptive
×Reduced bone density
This result in increased tooth
movement during ortho. treatment.
(study done by

×Polypeptide hormone,secreted by parathyroid glands.
×It mobilizes calcium and phosphorous from bones
×It increases serum calcium level, and decreases
serum phosphorous.

Study done by Anthony and Richard on rats:
×50U in 0.5cc solution injected in distal aspect of left central incisor
of 6 rats.
×After 5
day- appliance fitted(1 ounce force)
day animal sacrificed and maxilla removed and examined.

Lat. Incisor treated with PTH moved more than the right lat. Incisor

Result ; PTH enhance ortho. Tooth movement if applied locally.

×Peptide hormone, secreted by intra follicular or C- cells
in the thyroid gland.also called Thyrocalcitonin.

×It flows in bloodstream and attracts Ca to bone, thus reducing
Serum calcium
×It reduces bone resorption by reducing the no. of osteoclasts.

×It is used in the treatment of Hypercalcemia and Osteoporosis.

Ortho consideration

It inhibit tooth movement and consequently delays
orthodontic treatment .
×Vit. D3 with parathyroid and cacitonin hormone
regulates the amount of Ca and phosphorous in human body.

×It promotes interstitial Ca and phosphorous absorption

×Vit.D3 increases the bone mass and thus reduces fractures
in osteoporosis .

×It can be assumed that they can inhibit tooth movement.
×They are steroidal hormone.

×At puberty, the increase in GH and IGF-1 production is
sex hormone dependent.

×Promotes protein synthesis in the body.

×They regulate normal bone metabolism
(after menopause- osteoporosis)

Role of sex hormone in dental & craniofacial development

× delayed facial growth in Hypogonadism .
× Estrogen directly stimulates the bone forming activity of osteoblasts.
× Androgens also inhibit bone resorption &also modulate
growth of muscle system.

× In Athletes excess use of drugs may effect the length
and the results of orthodontic treatment.
×HYPERGLUCOCORTICOIDISM leads to short stature
and developed bone maturation.

×Very small amount may decrease growth rate.

×Skeletal IGF-1 synthesis decreased by Cortisol.

×Cortisol has inhibitory effect on bone collagen synthesis

×Cortisone accelerate the tooth eruption.
They act by increasing number of osteoclasts and activating
already existing osteoclasts on application of mechanical stress.
×Certain “CRITICAL PERIOD” exist during development of organ
PHASES.Any dietary deficiency during these phases may cause
irreversible changes like growth retardation & orofacial alteration in
humans like:

1. Cleft lip and Palate
2. Reduced dental arch dimensions with inadequate spaces
3. Insufficient dental eruption
4. Short root and interosseous rotation of per. Teeth
5. Shorter mandible in ant. And post. Direction
6. Reduction in ascending ramus
7. Dentoalveolar inclinations in the incisor region
8. Reduction in mesio – distal dimension of 3
Biopsy is the removal of tissue from the living organism
for the purpose of microscopic examination and diagnosis.

The total excision of a small lesion for microscopic study
is called excisional biopsy.

A small section is removed for examination which is
termed as incisional biopsy.


+ Surgical excision by a scalpel
+ Surgical removal by cautery or high frequency cutting knife.
+ Removal by biopsy forceps or biopsy punch.
+ Aspiration through a needle with a large lumen
+ Exfoliative cytology.


* Cleansing the surface of the oral lesion of debris & mucin &
scraping the entire surface of lesion several times with a metal
cement spatula or moistened tongue blade.

* Collected material is the quickly spread over a microscopic
slide & fixed immediately.

* Fixative may be 95% Alcohol or equal parts of alcohol & ether.

* After the slide is flooded with fixative it should be allowed to
stand for 30 Min to Air dry.

Classification :
+Class I : (Normal) – Indicates that only normal
cells present
+Class II : ( Atypical) – Indicates presence of
Atypia but no malignant changes.
+Class III : ( Indeterminate) – This is an in
between Cytology that seperates cancer from Non-
Cancer Diagnosis.
+Class IV : (Suggestive of cancer) – A few cells
malignant characteristics
+Class V: (+For cancer)
+The instruments include a scalpel handle & blade (No:15,
Forceps, a Needle holder, sutures & L.A.

+Few drops L.A are placed at periphery of the lesion

+An elliptical or wedge incision is then made that includes both
normal & Abnormal tissue with in the lesion.

+Grasp the tissue with a forceps & then circumscribe the area
while under tension.

+Once the sample is removed, it is placed in fixative (10%

+The sample along with description is sent for histologic

+Hemostasis can be accomplished by direct pressure, suture or
placement of a periodontal pack.
Healing of Biopsy wound :
The healing of biopsy wound of oral cavity may be
classified as primary healing or secondary healing.

The nature of healing process depends upon
whether the edges of wound can be brought in to
apposition often by suturing or whether the lesion
fill in gradually with granulation tissue.

Sign up to vote on this title
UsefulNot useful