KING SAUD UNIVERSITY College of Dentistry Department of Preventive Dental Sciences DIVISION OF ORTHODONTICS

431 PDS PRACTICAL MANUAL Part I

Prepared by: Dr. Eman Al-Kofide Dr. Hoda Al-Kawari Dr. Sahar Al-Barakati Dr. Hana Al-Balbeesi

Table of Contents

Topic

I.

Introduction

II.

Classification of Malocclusion 1. 2. 3. 4. Normal Occlusion Malocclusion Class I Malocclusion Class II Malocclusion: a. b. 5. Class II div. 1 Class II div. 2

Class III Malocclusion

III.

Radiographs: Orthopantomographs Occlusal Films Hand and Wrist Radiographs Cephalometrics

IV.

Model Analysis: 1. 2. Arch Perimeter Analysis: Moyers Analysis Arch Length Analysis: Nance Analysis
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3.

Tooth Size Discrepancy: Bolton Analysis

V.

Orthodontic Appliances

VI.

References

I. Introduction
Orthodontics is one of the most oldest branch in Dental Science. Orthodontics (Ortho = Straight, Dontic = Teeth), is that branch of dental science concerned with genetic variation, development and growth of facial form. It is also concerned with the manner in which these factors affect the occlusion of the teeth and the function of associated organs. Therefore we are not only concerned with straightening of the teeth, but also of the growth, development and function of the total orofacial complex. The lecture series of this course will deal with the above-mentioned aspects of orthodontics in more detail. The laboratory session of this course will teach the student the technical part of Orthodontics. The purpose of this manual is to introduce to the student the practical part of this course in a more simplified and understandable manner. Itwill cover the basics of Orthodontics from Classification of Malocclusion to Radiology in Orthodontics. The main objective of this part is to acquaint the student with proper Diagnosis in Orthodontics. This manual will aid the student during the study of the technical part of orthodontics. It is not considered a replacement of the required textbooks for the course, but as an adjunct to help the student during the laboratory session.

II. Classification of Malocclusion

1. Normal Occlusion Occlusion is considered to be normal when the dental arches are in correct alignment, with all the teeth in anatomically correct contact and in physiologically optimal occlusion with the corresponding teeth in the opposite dental arch. The development of normal occlusion passes through several continuous stages from birth to the development of the permanent dentition. The deciduous dentition begins to appear at around the age of 6 months with the eruption of the lower central incisors. The deciduous teeth are usually complete by the age of 2 years of age. At this stage there is often spacing between the teeth especially distal to the lower canines and mesial to the upper canines (primate spaces), with the distal surfaces of the second deciduous molars in line with each other (flush terminal plane). At 6 years of age the first molars start to erupt, and the permanent incisors develop lingual to the roots of the deciduous incisors. At this time also, the ugly duckling stage is evident. As the child continues to grow, he/she passes through the transition period from early mixed dentition to late mixed dentition, to the permanent dentition. Within these periods, there lies a discrepancy between the mesiodistal widths of the deciduous molars and the premolars which creates spacing and is termed the leeway space. This develops to allow the lower permanent molars to move forward

further than the upper molars and establish a Class I molar relationship (Class I; the mesiobuccal cusp of the maxillary first permanent molar occludes with the midbuccal groove of the lower first permanent molar).

2.

Malocclusion Malocclusion is defined as an irregularity of the teeth, OR Malrelationship of the Dental Arches The majority of

malocclusions are primarily hereditary in nature. (The various types of malocclusion will be discussed briefly here, the detailed description of each will be elaborated in the next section) The etiology of malocclusion is generally categorized into two causes: (1) Hereditary, such as jaw-teeth size discrepancy, and (2) Developmental, such as premature loss of teeth or habits (ex. thumb sucking or tongue thrusting).

Malocclusion may be associated with one or more of the following: A. Malposition of the Teeth This could be caused by: Tipped teeth which mean that the crown of a tooth is tipped or incorrectly positioned in comparison to the apex. Displaced teeth in this situation both the crown and the apex are displaced. Rotated teeth the tooth is rotated along its long axis. Teeth in infra-occlusion the tooth has not reached the occlusal level.
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Teeth in supra-occlusion the tooth has erupted pass the occlusal level. Transposed teeth two teeth have reversed their positions, for example a canine taking the place of first premolar.

B.

Malrelationship of the Dental Arches This could occur in any of the three planes of space: anteroposterior vertical or transverse. The antero-posterior

malrelationship is represented by the Angle Classification, which deals with the disproportion of the teeth in an anteroposterior plane. The vertical malrelationship is evident during the observation of overbite, while the transverse

malrelationship is presented in cases with crossbites. The most popular and world recognized classification of malocclusion is the one described by Angle, which deals with the arch malrelationship in the antero-posterior position.

Angles Classification This was the first useful orthodontic classification system that was developed in 1890, and it still used in our present date. Angles classification system was based on the upper first molars as being the Key to Occlusion and that the upper and lower molars should be related so that the mesiobuccal cusp of the upper molar occludes in the buccal grove of the lower molar. If this molar relationship existed and the teeth were arranged on a smoothly curving line of occlusion, then normal occlusion would result.
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Angle then described the three classes of malocclusion, based on the occlusal relationships of the first molars, which are as follows:

Class I - The lower first permanent molar is within one-half cusp width of its correct relationship to the upper first permanent molar (i.e. the mesiobuccal cusp of the maxillary first permanent molar occludes with the mid-buccal groove of the lower first permanent molar. This is sometimes termed neutro-occlusion. So basically

there is a normal relationship of the molars, but the line of occlusion is incorrect due to crowded, rotated, spaced teeth, or others.

Class II - The lower arch is at least one-half cusp width posterior to the correct relationship with the upper arch. This is also known as disto-occlusion. This type of malocclusion is further categorized into two divisions according to the relationship of the upper central incisors:

Class II Div. 1 - The upper central incisors are proclined or of average inclination with an increase in overjet. Class II Div. 2 - The upper central incisors are retroclined. The overjet is usually average but can be decreased or a little increased. Sometimes the upper laterals are proclined.

Class III - The lower arch is at least one-half cusp width too far forward in relation to the upper arch. This is also known as mesio-occlusion.

In certain situations where early extraction of the first molars has occurred, the alternative to using the Angles classification of malocclusion is to use the position of the canine to determine which type of occlusion the patient has. Usually, in Class I relationships, the position of the upper canine is between the embrasure of the lower cuspid and first bicuspid.

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In Class II cases, we have a mesial movement of the upper canine and a distal movement of the lower canine. In Class III cases, the opposite is true. The upper canine is located more distal, with the lower canine migrating more mesial. Other systems have been developed to further aid in classifying a malocclusion. They are also used when the first molars are absent. In these cases, an Incisor classification has been

developed. Its benefit is also recognized during orthodontic treatment. Since one of the main objectives is to correct the incisor malrelationship during treatment, an understanding of incisor position is very important.

Incisor Classification: This does not usually follow the buccal segment relationship. It can be divided into: Class I - The lower incisor edges occlude with or lie immediately below the cingulum plateau (middle part of the palatal surface of the upper central incisors).

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Class II- The lower incisor edges lie posterior to cingulum plateau of the upper incisors.

There are two divisions Class II Div. 1 - The upper central incisors are proclined or of average inclination and there is an increased overjet. Class II Div. 2 - The upper central incisors are retroclined, sometimes the upper laterals are proclined.

Class III - The lower incisor edges lie anterior to the cingulum plateau of the upper incisors. The overjet may be either reduced or reversed.

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Class I Malocclusion
This is the most common of all the malocclusions. Dental Features Labial Segments The lower incisor edges should occlude with or lie directly below the cingulum plateau of the upper incisors. Meaning that there should be a normal antero-posterior relationship between them. Buccal Segments The upper and lower molars are in neutro-occlusion. Because of the order of eruption, if there is a crowded dental arch, the last tooth within the arch to erupt will often be impacted or crowded out of the line of the dental arch. In some cases there may be an associated crossbite of one or two teeth, anterior teeth crowding, spacing, deep overbite or openbite, irrelevant of the canine and molar Class I relationship.

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Skeletal Relationships Antero-posterior The skeletal pattern is usually a Class I, but it is possible to find a Class I malocclusion in association with a Class II or Class III skeletal pattern.

Vertical and Transverse They are usually within normal range.

Soft Tissue The soft tissue form and activity are usually within normal range.

Growth There is a harmonious growth between the upper and lower jaw, which accounts for the skeletal and facial balance.

class I Molar and jaw relationship

Growth pattern

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Class I Problems and Their Treatment 1. Crowding This may appear in the labial or buccal segments due to a small or narrow arch, or in the premolar region due to early loss and drifting of teeth. It can be classified into mild, moderate, or severe. There are two ways to measure the crowding:

According to the broken contact:

Mild = 1-2 broken contact Moderate = 3-5 broken contact Severe = more than 5 broken contacts

According to measurement by mms: Mild = 1-3 mm lack of space Moderate = 4-8 mm lack of space Severe = 8 mm

The treatment of crowding depends on the severity of the case. It can be treated by the following: 1. Stripping to minimize the width of the teeth mesiodistally. Used in mild, moderate cases of crowding. 2. Distallization applying forces to teeth to move them distally and create space. For example the use of headgears. crowding. 3. Expansion widen the arch (upper), also used in mild to moderate crowding cases.
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This is also used with mild

4.

Extraction usually the first premolars are removed when the crowding is moderate to severe.

2.

Spacing This could be localized or generalized.

Localized : such as Diastemas. Which could be caused by low frenal attachments, jaw-size discrepancy, or the presence of a mesiodens. TX: When the anterior teeth have narrow mesiodistal width, and the diastema is less than 5 mm, we can build up the teeth with a tooth colored material such as composite, to overcome the space. When the frenum attachment is low, the treatment of choice is a frenectomy in conjunction with appliance therapy.

Generalized Which is due to a jaw-size to teeth-size discrepancy. In this case fixed orthodontic appliance is the method of treatment.

3.Deep Bite Defined as the excessive vertical overlap of the incisors. Normally the lower incisal edges contact the

lingual surface of the upper incisors at or above the cingulum. It may cause traumatic occlusion and impingement of the palatal tissue. The treatment of this type of problem is
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usually by combination of removable and fixed orthodontic appliances, and in some cases orthognathic surgery.

4.Open Bite there is no vertical overlap of the incisors, and there is an evident vertical separation .

This could be due to: Dental Problems associated mainly with oral habits such as thumb sucking or mouth breathing. Skeletal Problems Arch deficiencies

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Treatment of these problems are by eliminating the habit if they are young in age, or by surgical procedures in adulthood.

5.Cross bite It could be lingual or buccal, anterior or posterior, unilateral or bilateral, involving one tooth or a group of teeth. If it present anterior, this could be due to a pseudo-Class III or a true Class III. If it is posterior, it is usually due to a narrow upper arch.

Normal Occlusion

Unilateral buccal Cross Bite

Bilateral buccal Cross Bite

Cusp relation tendency for crossbite [edge to edge] relationship

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Scissors Bite [lingual Cross Bite] (The upper buccal teeth are occluding buccaly to the lower teeth)

Its causes vary from thumb sucking habits to dental problems such as teeth inclinations, to skeletal problems. Treatment usually consists of appliance therapy, and may be surgery in the future.

6.Localized Teeth Problems Such as impacted or unerupted teeth. Most commonly observed in impacted cuspid cases.

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Class II Malocclusion
A. Class II Div. 1 Malocclusion
Dental Features Labial Segments The lower incisor edges lie posterior to the cingulum plateau of the upper incisors. There is an increased overjet which may be due to proclined upper incisors, retroclined lower incisors, or a skeletal problem. complete. Note: Overjet is defined as the horizontal overlap of the Usually the overbite is increased and

incisors. Normally the upper incisors are 2-3 mm ahead of the lower incisors. Buccal Segments The upper and lower first molars are in disto-occlusion, meaning that the mesiobuccal cusp of the upper first molar is anterior to the mid-buccal groove of the lower first molar.

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Skeletal Relationships Antero-posterior There is usually a Class II skeletal pattern. malocclusion cases, with poor skeletal In severe relationships,

orthodontic treatment alone is compromised. In other cases, the inclination of the lower teeth will compensate for the skeletal pattern and thus the overjet will be less than expected.

Vertical The anterior skeletal face height is usually average, although it may be high. A high angle or dolichofacial pattern is usually associated with an unfavorable facial profile with little chin prominence, hence complication orthodontic treatment.

Soft Tissue The lips are frequently incompetent, which leads to the uncontrolled proclination of the upper incisors. Sometimes a lip seal will be maintained but frequently there is a tongue-tolower-lip seal with the lower lip lying behind the upper incisors.

Growth Patients with a Class II div. 1 pattern exhibit more vertical growth, unlike patients with a Class II div. 2 pattern whom exhibit more mandibular horizontal growth. A typical Class II div. 1 case presents with a dolichofacial pattern or Long Face Syndrome, and has less favorable growth direction of the
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mandible than the brachyfacial patient or Square Jaw Patient in class II div. 2 cases.

classII
Molar and jaw relationship

Treatment: There are certain indications to treat a Class II div. 1 malocclusion, some of them are: To correct the anteroposterior relationship and gain a Class I. To correct the overjet and/or overbite. For proper esthetic appearance.

Treatment can be divided generally into non-extraction of teeth to correct the problem, or extraction. Non-extraction treatment is usually indicated for those cases with:
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 Favorable growth Mild overjet Acceptable esthetics Teeth are in good position

Extraction is usually indicated in those cases: Increased overjet and/or overbite Severe crowding Convex profiles Increased skeletal discrepancy Usually the first premolars are the teeth of choice for extraction. Fixed appliance is the choice of treatment.

If there is skeletal discrepancy, patients should be treated with the consideration of the growth spurt, so we can take advantage of growth and allow it to help the treatment.

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B. Class II Div. 2 Malocclusions

Dental Features Labial Segments The upper central incisors should be retroclined. The upper laterals may be proclined or retroclined when the upper laterals are proclined, they are usually mesially inclined and mesiolabially rotated. The lower anterior segment is frequently retroclined, which may lead to crowding of the lower incisor area. This increases the interincisal angle and hence has an effect on the amount of overbite. The overjet is usually not a problem here. There is an increase in the lower curve of Spee and the patient may appear with a gummy smile due to retroclination of the incisors. Buccal Segments Here the lower arch is at least one-half cusp width post normal to the upper arch, and there may be crowding due to early loss of the deciduous molars with a forward drift of the lower first molars.

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Skeletal Relationships Anteroposterior The profile is usually well balanced, with the chin in a good position with the rest of the face. In some cases, the skeletal discrepancy is sever. This may due to an increase in the length of the anterior cranial base, leading to a more distal positioning of the glenoid fossa and hence the mandible. Vertical The lower facial height is reduced or average. The Frankfort mandibular plane angle is often low. The lower anterior facial height may contribute to the depth of the overbite. Transverse In rare cases we may find a scissors bite, with the upper buccal teeth occluding outside the lowers.

Mandibular Positions and Paths of Closure Usually, the path of closure is a simple hinge movement and the habitual position of the mandible is the rest position. But in severe cases, the mandible is habitually postured downwards and forward. With true posterior displacements of the

mandible, and where there has been a loss of posterior teeth, patients will complain of pain in the early adult life, leading to TMJ problems.

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Soft Tissue The lip line here is usually high, with the lower lip covering more than the occlusal half of the upper incisors. There may be an accentuated

labiomental fold, and an increased nasiolabial angle with flattening of the upper lip profile.

Growth These patients exhibit a closing growth rotation, which contributes in part to the reduced facial height and the deep overbite. Treatment in these cases is difficult.

Oral Health In cases with severe overbite, direct trauma (traumatic bite) to the gingival mucosa may occur. This is due to the lower incisors occluding with the palatal mucosa and the upper incisors occluding with the labial mucosa. In these cases proper oral hygiene is a must and treatment of the traumatic occlusion is indicated.

Treatment This type of malocclusion is the most difficult to treat. Treatment modalities differ and can include any of the following: 1. No treatment: when the facial appearance is acceptable. 2. Upper removable appliance therapy. To reduce the overbite. 3. Fixed appliance therapy. For both upper and lower jaws.

4. Orthognathic surgery: It is indicated in the most severe forms of Class II div. 2, where the overbite is very deep and traumatic to the gingiva, and the facial profile is very poor.
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Class III Malocclusion

Dental Features Labial Segments There is a Class III incisor relationship when the lower incisor edges are lying anterior to the cingulum plateau of the upper incisors. The lower incisors may lie anterior to the uppers so that there is a reverse overjet. The upper incisors are often crowded and they are usually proclined. The lower incisors are usually spaced and frequently retroclined. This inclination

compensates the extent of the underlying sagital arch malrelationship.

Buccal Segments The lower arch is at least one-half cusp width too far forward relative to the upper arch. Usually the upper arch is crowded with canines buccally excluded, while the lower arch is well aligned. It is not

uncommon to observe a crossbite in the buccal segments because of a narrow maxilla, which may be unilateral or bilateral. A unilateral crossbite is usually associated with

lateral displacement of the mandible to obtain maximal intercuspation.

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Skeletal Relationships Anteroposterior There is a combination of factors which leads to this malrelationship. The mandible is usually large, with a short retrognathic maxilla. The patient will appear with a concave profile. There is a more forward position of the glenoid fossa on the skull base so that the mandible is more anteriorly positioned than usual, with a short anterior cranial base. In some cases, the dental pattern is a Class III while the skeletal pattern is a Class I.

Vertical The Frankfurt mandibular plane angle is usually high, with an associated reduced overbite or anterior open bite. intermaxillary height is an important factor to consider. The

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Transverse In most cases the maxillary base is narrow with a wide mandibular base. This transverse discrepancy is compensated for by a buccal inclination of the upper teeth and a lingual inclination of the lower teeth. It is common to see crossbites in the buccal segments due to a large mandible and a narrow maxilla.

Mandibular Positions and Paths of Closure In patients with a mild Class III malocclusion in incisors meet edge to edge in centric relation, but in order for the mandible to obtain a position of maximal occlusion, there is a forward displacement of the mandible which accentuates the skeletal discrepancy. When there is a unilateral crossbite with the teeth in occlusion there will usually be an associated lateral displacement of the mandible on closure. In cases of skeletal disharmony, there will be a more pronounced anterior displacement of the mandible, and it will be more difficult if not impossible for the mandible to retrude to obtain maximal occlusion. In fact, the only way the lower arch can meet with the upper arch in maximum occlusion is through the forward displacement of the mandible.

Soft Tissue In cases where the lips are frequently incompetent, the anterior intermaxillary height is large. These cases usually present with
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an anterior open bite with an adaptive swallowing behavior, where the tongue comes forward into the gap between the incisors.

Growth Here any growth is unfavorable, since the mandible may grow more prognathic. When the height of the intermaxillary space is normal or reduced, growth may worsen the reverse overjet and the horizontal profile of the face. When the height of the intermaxillary space is increased with growth, the tendency to a skeletal anterior open bite may become greater.

Class III Molar and jaw relationship

Oral Health

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Mandibular displacements due to occlusal disharmonies eventually may be associated with muscle pain. Also when there is a premature contact in the incisor region there may be gingival recession around one or more lower incisors. And in cases with an anterior open bite, periodontal changes can be expected around the non-functional teeth.

Treatment Can be and is not limited to: 1. Removable appliance therapy, used for example in simple tipping movements of the upper incisors. 2. Functional Appliance. Can be used in mild cases. 3. Protraction headgears chin cup therapy, and maxillary expansion. This mode of treatment is usually used in young patients, with a narrow maxilla, and a straight or concave profile. 4. Fixed Appliances. For both upper and lower arches.

Treatment here can be done with extraction or nonextraction of teeth. If teeth are to be extracted, a

common approach is to extract the upper second premolars and tip the anterior teeth forward, and to extract the lower first premolars to tip back the lower anterior teeth, thus camouflaging the Class III pattern. 5. Orthognathic Surgery. Usually a combination of

mandibular setback and maxillary advancement.

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II. Radiographs
Radiographs are very important diagnostic aids in all aspects of the field, and especially in orthodontics.

There are two main types of radiographs: Intraoral Radiographs which includes periapicals, bitewings and occlusal films. Extraoral Radiographs includes orthopantomographs (OPG), hand-wrist radiographs, posteroanterior radiographs and lateral cephalometrics.

The following sections will cover extraoral radiographs in detail.

1. Orthopantomographs
Also termed panoramic radiography or rotational radiography. It is a radiographic procedure that produces a single image of the facial structures, including both the maxillary and mandibular arches and their supporting structures, such as the nasal cavity, maxillary sinuses and the temporomandibular joints. The principles of the panoramic radiography where first described by Numata in 1933 and Paatero in 1948. Originally the patient and the films rotated and the x-ray beam remained stationary. But this method was superceded by the

development of apparatus which have the tube and the film rotating around the patient.

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The x-ray source and film are simultaneously moved parallel to each other in opposite directions. While taking the radiograph, the

Frankfort Horizontal Plane (FHP), should be parallel to the floor, and the occlusal plane should be lower anteriorly by 20-30 degrees, with the patient biting on a bite block.

Caution should be taken on the position of the chin: If the chin is tipped too high to the horizontal plane, the mandible will be distorted. If the chin is tipped too low the hard palate will superimpose the roots of the maxillary teeth. To make sure of the distortion, we can check the width of the permanent mandibular teeth (molars) bilaterally. If one of them is wider than the other one by 20% the radiograph should be retaken.

Advantages of OPGs The film is extraoral, making it more comfortable for the patient. A broad anatomic region is imaged, which includes the maxilla and the mandible. It exposes the patient to less radiation. It is quick, convenient and easy for the assistant to take. It can be performed on patients who cannot open their mouths and cannot tolerate intraoral radiographs, especially edentulous patients or patients with a suspected pathosis.

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The time required for the procedure is short 3-4 min. including patient positioning and actual exposure. Accepted by patients during presentations and education. Gross lesions are visible.

Disadvantages Does not give the fine anatomic details such as the alveolar crest, margins of pathological lesions, bone pattern, caries, etc. The image may be distorted if the patient is situated outside the focus. Magnification, geometric distortion, overlapped images of teeth, especially premolar region. The projection can be taken only at one angle. The view of the temporomandibular joint is distorted. Expensive machine (3-4x more than the intraoral machine).

Indications for Usage To assess the patients dental age based on the development and progress of mineralization of the teeth, eruption time and exfoliation of the primary teeth. So a comparison of the

chronological and skeletal age can be done.

It used to evaluate: Teeth: Teeth present, missing congenitally or impacted, ectopic eruption, malpositioned teeth, the presence or absence of third molars, supernumeraries, quality of
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restorations, resorption pattern of deciduous teeth, calcification of permanent teeth, asymmetric resorption of deciduous molars, integrity of root structures. Bone: Alveolar bone, level of interdental crest, bone resorption (horizontal, vertical), infrabony pockets, trabecular pattern wide marrow space (esp. in young growing children), or narrow trabecular spaces (in older children and adults). Pathology: Pathological lesions, cysts, tumors, extensive or unique pathosis, ankylosis of deciduous teeth, susceptibility to caries, active carious lesions, root resorption.

2. Occlusal Films
It is required to visualize relatively large segment of dental arch, including the palate, floor of the mouth, and a reasonable extent of lateral structures.

It is indicated to: Locate roots, supernumerary, unerupted and impacted teeth especially cavities and third molars. Localize foreign bodies and stones in the salivary glands duct. Evaluate the integrity of the maxillary sinus outline. Provide information relative to the fractures of the mandible and maxilla.

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To determine to medial and lateral extent of pathosis (e.g. cysts).

3. Hand and Wrist Radiographs

Hand and wrist radiographs are one of the most important diagnostic aids when planning orthodontic treatment. Predicting the pattern of growth; that is the amount, direction, duration, location and timing of the onset of pubertal growth is important for the orthodontist when planning therapy and coordinating orthodontic treatment with the vital growth process. Estimation of the skeletal age of bones or bone age aids in determining the physical maturation status of the child. One of the indicators to verify the pubertal growth spurt is annual measurement of the body height, but this will only give a retrospective picture of what has happened. Whereas our interest is to know what will happen in the future to judge the development stage of the child in relation to the childs own growth curve, in order to decide whether the pubertal growth spurt has started or passed.

Advantages of the Hand and Wrist Radiographs It differentiates the certain developmental stages towards full physical development. The sequence of such developmental or morphological changes is equal in all humans. It is technically simple to make roentgenograms of the hand. An individual will pass through a regular series of changes in

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size and shape of the ossification centers of bone during their progress towards maturity. Several systems have been

developed to evaluate these series of growth changes. One which will be described in detail here, is a system produced by Leonard Fishman. Fishmans analysis is based on skeletal

maturation assessment (SMA). This system uses four stages of bone maturation located at six anatomic sites: the thumb, third finger, fifth finger and radius. In these six sites eleven

maturational indicators (SMIs) are found to cover the entire adolescent development period.

Sites of Skeletal Maturity Indicators Which are related to: widening of the epiphyseal discs in one of the phalanges on the third or fifth finger, visibility of the ulnarmetacarpophalangeal sesamoid on the first finger (thumb), capping of selected epiphyses over their diaphyes, and the fusion of selected epiphyses and diaphyses. In addition to that ossification of the hook of the hamate and pisiform bone is also taken into consideration.

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The development or maturation stage for the individual patient can be plotted on the growth curve:

The best treatment time for orthodontic patients is 1-2 years before the growth spurt, after that time usually no growth will occur. Hence, the advantage of growth will be missed and treatment might be compromised.

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For ease of interpretation, the first step is to determine the presence or absence of the adductor sesamoid of the thumb

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4. Cephalometrics
Cephalometrics was first introduced to the world by Hofrath in Germany and Broadbent in the United States. Cephalometric

radiography means measuring the head in the living individual through the use of radiographs. The original purpose of

cephalometrics was to conduct research on growth patients in the craniofacial complex, but was soon used afterwards as a method to evaluate dentofacial proportions and clarify the anatomic basis for a malocclusion. Nowadays, lateral cephalometric radiographs are

routinely used in orthodontic practices. A cephalograph, which is a standardized radiograph of the head (cranium and face), is taken for the patient by the use of a machine termed the Cephalostat (cephalus meaning the skull or head, and stat meaning fixed or static position). The basic equipment required to obtain a cephalometric view consists of an x-ray source, an adjustable cephalostat, a film cassette with radiographic intensifying screens, and a film cassette holder.

Components of the Cephalostat The cephalostat consists of the following:

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Ear Rods: Two in number, one right and one left. These are tightened into the external auditory meatuses so that the patient is maintained in the mid-sagittal plane. Each ear rod has a metal ring of the same dimension, and in a correctly aligned cephalostat the radiograph shows a single ring. If two rings are seen it indicates an improperly aligned cephalostat. Nasal Pointer: Which rest on the bridge of the nose (usually at the soft tissue nasion). Orbital Pointer: This optional, and if present it is fixed at the orbital region. A Metal Millimeter Scale: This is fixed vertically to the nasal pointer to indicate the amount of magnification or distortion.

The patient is placed within the cephalostat using the adjustable bilateral ear rods placed within each auditory meatus, usually while the patient is in a standing position. The mid-sagittal plane of the patient is vertical and perpendicular to the x-ray beam. It is also parallel to the film plane, which in turn is also perpendicular to the xray beam. The patient Frankfort plane (line-connecting the superior border to the external auditory meatus and the infraorbital rim) is oriented parallel to the floor. The distance between the x-ray source and the mid-saggital plane of the patients head is kept at a minimum of 5 feet (150 cm), so reduce magnification.

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A fast Kodak blue brand 8 x10 film is used. The film is exposed for 4/10 of 7/10 sec. at 90 KVP and 10MA, to penetrate the hard tissue and provide good details of both the hard and soft tissue.

Two views can be used with this type of radiographic method 1. Posteroanterior View: It shows the vertical and transverse dimensions of the head The primary indication for obtaining a posteroanterior cephalometric film is the presence of facial asymmetry. A tracing is made and vertical planes are used to illustrate transverse asymmetrics. Lines are drawn through the angles of the mandible and the outer borders of the maxillary tubersity. Vertical asymmetry can be observed by drawing transverse occlusal planes (molar to molar) at various vertical levels and observing their vertical orientation.

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2. Lateral Head or Profile View(lateral cephalometrics): It shows the vertical and anteroposterior or saggital dimensions. This type is most commonly used during orthodontic diagnosis.

Uses of Cephalometrics An Aid to Diagnosis 1. Classify the type of face. 2. Show the relationship between the basal parts of the maxilla and the mandible. 3. Evaluate the soft tissue profile. 4. Evaluate the position of the incisors in relation to the basal parts and the soft tissue profile.

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 A pre-treatment record prior to the placement of appliance, particularly where movement of the upper and lower incisor is planned. Monitoring the Progress of Treatment 1. Anchorage requirements and incisor inclinations. 2. Movement of unerupted teeth. 3. Movement of treated teeth and their inclination. To make a growth prediction when the orthodontic treatment is to be conducted during the growth period. Research Purposes Information about growth and development by longitudinal studies (serial cephalometric radiographs from birth to the late teens). Detecting for any abnormalities or pathology e.g. a pituitary tumor of patency of the airway as enlarged adenoids. Tracing Technique Certain materials are used for this purpose, which are: Tracing paper 3 H drawing pencil Gum eraser Transparent millimeter ruler

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 Transparent triangle Scotch tape Template View box

Method of Tracing 1. Place the cephalograph on the table with the profile facing to your right hand. 2. Place the tracing paper over the film (the dull surface facing you), with the lower border of the paper extending about one inch below the chin point. 3. Tape the upper corners of the tracing paper to the radiograph. 4. The tracing should be carried out in a dark room on a light-viewing box. 5. Trace the soft tissue profile, then the hard tissue profile, and then the dentition according to the following tracing procedure. 6. If bilateral structures are present, draw both of them and take the average of the two. 7. Trace the reference points.

Tracing Procedures 1. Trace the soft tissue profile starting with the forehead, then nose, then lips, then chin till the throat angle beyond the chin.

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2. Trace hard tissue profile, start with the forehead and the frontal sinus. 3. Trace the nasal bone. 4. Trace the anterior nasal spine and the anterior contour of the maxilla up to the interdental alveolar crest between the central incisors. 5. Trace the floor of the nose and the roof of the palate. Trace the posterior nasal spine. 6. Trace the anterior contour of the mandible starting from the interdental crest between the lower incisors. 7. Trace the outline of the chin up to the symphysis. 8. Trace the lower border of the mandible from the symphysis to the angle of mandible. 9. Trace the posterior border of the ramus. 10. Trace the orbit from the supra orbitale ridge to the most inferior portion on the lower border of the orbit known as orbitale. 11. Trace the zygomatic bone from the lateral contour of the orbit down to the triangular image. The lowest projection of the triangular image is called key ridge. 12. Trace the pterygomaxillary fissure which is seen as an inverted tear drop shape just above the posterior nasal spine. The anterior contour of the fissure represents the posterior surface of the maxilla and its posterior contour represents the pterygoid bone. 13. Trace the shadow of the external acustic meatus. It appears as an oval radiolucency or opaque ring shadow due to ear
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rods and it lies behind the upper most surface of the condylar head. 14. Trace the sella turcica (saddle shaped pituitary fossa). 15. Trace the most prominent upper central incisor from crown to root. 16. Trace the most prominent lower central incisor.. 17. Trace the occipital bone. Note: Use the template to trace the central incisors

Anatomic Points (Landmarks) of the Cephalometric

A. Cranial Base 1. Nasion (N) The most anterior point on the fronto nasal suture. 2. Sella (S) The mid-point of sella turcica.

B. Mid-Face 1. Orbitale (or) The most inferior point on the lower margin of the orbit. 2. Porion (po) The most superior point on the bone external auditory (acustic) meatus. In case of metal ring, it located 4.5 mm above the center of the metal ring.

C. Maxilla 1. Anterior Nasal Spine (ANS) The tip of anterior process of the maxilla or the most anterior point on the maxilla at the level floor of the nose.
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2. Posterior Nasal Spine (PNS) The most posterior point on the maxilla at the level floor of the nose. 3. Point A (A) The deepest point on the anterior contour of the maxilla between ANS and alveolar crest usually it is approximately 2 mm anterior central incisor. to the apices of maxillary

D. Mandible 1. Point B (B) The deepest point on the anterior contour of the mandible between the chin and alveolar crest. 2. Pogonion (pog) The most anterior point on the curvature of bony chin. 3. Menton (Me) The most inferior point on the mandibular symphysis. 4. Gonion (Go) The most inferior posterior point on the angle of the mandible.

E. Soft Tissue 1. Upper Lip Point (UL) The most anterior point of upper lip profile. 2. Lower Lip Point (LL) The most anterior point of lower lip profile. 3. Soft Tissue Pogonion (pog) - The most anterior point on the profile of soft tissue chin.

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Cephalometric Horizontal Planes and Lines SN Line This line, connecting the mid-point of sella turcica with nasion, is taken to represent the cranial base. Frankfort Plane This I the line joining porion and orbitale. Maxillary Plane The line joining anterior nasal spine with posterior nasal spine. Mandibular Plane the line joining gonion and menton.

Cephalometric Analysis:
Angular and Linear Measurements A series of angles in degree and a few linear distances in millimeter are measured and compared normal values. The differences from the normal are noted as plus or minus. When the differences are below or above the normal ranges, they are considered as abnormal. The angles used in cephalometric analysis are formed at the junction of two planes, could be horizontal or vertical planes.

The whole cephalometric analysis can be divided into three parts. 1. Skeletal relationship 2. Dental relationship 3. Soft tissue relationship

Skeletal Analysis
A. Antero-Posterior Relationship
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SNA: Measured at the

junction of SN line and NA line.It evaluates the

antero-posterior position of the maxilla in relation to the anterior cranical base.The normal average is 813 (normal or orthognathic maxilla). When this angle is above the normal range it would be interpreted as protruded or prognathic maxilla, and when it is below the normal range, retruded or retrognathic maxilla.

SNB: Measured at the

junction of SN line and NB line. It evaluates

the antero-posterior position of the mandible in relation to the anterior cranial base.The normal average is 783 (normal or orthognathic mandible). When this angle is above the normal range, it would be interpreted as protruded or prognathic mandible, and when it is below the normal range, retruded or tetrognathic mandible.

ANB: This angle is the difference between SNA and SNB angle and indicates the amount of skeletal discrepancy between maxilla and mandible in antero-posterior position.The normal average is 33 (skeletal Class I).A larger than normal angle would indicate of skeletal Class II and smaller than 1 angle skeletal Class III.

B. Vertical Relationship: SN-Mxpl: Measured at the intersection of SN line to maxillary plane and expresses the vertical inclination of the maxilla in relation to the anterior cranial base. The mean value is 83 (normal inclined

maxilla) value greater than normal indicate a posterior inclination of the maxilla, smaller values indicate an anterior inclination of maxilla.

FH-Mnpl:

Measured at the intersection of Frankfort plance and

mandibular plane and expresses the inclination of the mandible. The mean value is 284 (normal inclined mandible). Angles greater than normal indicate the mandible is growing downward and backward or the mandible is steep (posterior inclination of the mandible). Angles less than normal indicate

anterior inclination of mandible, mandible is growing forward and upward (mandible is horizontal)

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MMpA:

Measured at the intersection of maxillary plane with

mandibular plane and relates the inclination of the mandible and the maxilla to each other. The mean value is 274 (normal interbasal angle). If the angle exceeds the normal there is skeletal open bite, whereas an angle less than the mean indicates skeletal deep bite.

Facial Proportion (FP): This is the ratio of the lower facial height to the total anterior facial height and it is calculated as a percentage according to this equation lower facial height FP = ---------------------- x 100 Total facial height Total facial height = lower facial height +upper facial height. Lower facial height: This is a linear measurement from menton

perpendicular to maxillary plane. Upper facial height: This is a linear distance is measured from Nasion perpendicular to maxillary plane. In normal faces this index has a value of about 50% 2% (normal lower height). A larger than this ratio will indicate increased lower facial height, smaller than this value will indicate decreased lower facial height.

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Note:The MMpA reflects both posterior lower facial height and anterior lower facial height. Therefore in the case of patient who has an increased MnpA but average facial proportion it would appear that the posterior facialheight is reduced (opposed to an increased lower facial height which result in creased MMpA). This would be noticed when there is a discrepancy between the measurements of the facial proportion and the maxillary mandibular plane angles (MMpA).

Dental Relationship: Uinc-Mxpl: Measured at the intersection of the long axis of the upper central incisor with the maxillary plane. It evaluates the antero-posterior inclination of the most prominent maxillary central incisor. This angle averages 1096 (normal inclination of upper incisor). A larger than normal angle would indicate proclination of the upper central incisor and smaller than normal angle would indicate retroclination of maxillary incisors.

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Uinc-NA: This is a linear distance measured in millimeter from the most prominent incisal edge of the upper incisor perpendicular to NA line.It averages 42 mm (normal position of upper incisor) A larger than normal angle would indicate protrusion of upper central incisor and a smaller than normal angle would indicate retrusion of the central incisor.

Linc to MnPL: Measured at the intersection of the long axis of the lower central incisor with mandibular plane. It evaluates the anteroposterior inclination of the most prominent mandibular central incisor.A larger than normal angle would indicate proclination of lower incisor and a smaller than normal angle would indicate retroclination of the mandibular incisor.

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Linc-NB: This is a linear distance measured in millimeter from the most prominent incisal edge of the lower incisor perpendicular to NB line. It averages 42 mm (normal position of lower incisor). A larger than normal angle would indicate protrusion of lower central incisor and a smaller than normal angle would indicate retrusion of the mandibular incisor.

Linc to A-Pog: This is a linear distance measured in millimeter from the incisal edge of the lower incisor perpendicular to A-Pog line.This measurement averages +12 mm (normal position of lower incisor). A larger than normal angle would indicate protrusion of lower central incisor and a smaller than normal angle would indicate retrusion of the mandibular incisor.
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To have a pleasing facial appearance, the tip of lower incisor lay on or just in front of this line.

Uinc-Linc: The interincisal angle measured at the junction of the long axis of upper central incisor with the lower central incisor. It averages 1355 (normal proclination of upper and lower central incisors). The angle decreases with proclination of upper and lower incisors and increase with retroclination of incisors.

Soft Tissue Relationship:

Upper Lip-EL: This is a linear distance measured from the most anterior point on the upper lip perpendicular to esthetic plane (tip of the nose to the soft tissue pogonion).It averages 2 to 4 (normal position of upper lip which is inside the line). A larger angle indicates

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the protrusion of the upper lip and a smaller angle indicates the retrusion of the upper lip.

Lower LipEL: This is a linear measurement from the most anterior point on the lower lip perpendicular to esthetic plane. It averages form 0 to 2 inside the esthetic line (normal position of the lower lip).A larger angle indicates the protrusion of the lower lip and a smaller angle indicates the retrusion of the lower lip.

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IV. Model Analysis

The practical evaluation of the study model is an important step during the diagnosis and treatment planning of an orthodontic case. This includes observing the model in three different views: lateral, frontal and horizontal.

Lateral View: We can observe from this view the following: Angle classification Incisal classification Overjet (horizontal relationship) Overbite (vertical relationship), lateral overbite or

supraeruption. Curve of Spee Inclination of the front teeth, primary evaluation (best done on cephalometrics)

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Frontal View: The following can be seen: The midline, upper or lower. We can determine the palatal midline by using a symmetroscope Deviating axial inclination, meaning the mesial, distal buccal or lingual tipping of the front teeth. Crossbite, unilateral or bilateral, including one tooth or a group of teeth. Scissors bite, also unilateral or bilateral, individual or a group of teeth. Diastemas, we should determine the amount in millimeters.

Horizontal View: Determine the following: Eruption stage, deciduous/mixed permanent. Width of the alveolar process. Shape of the dental arch, ellipsoid/parabolic. Width of the dental arch, the intercanine and intermolar distance. Deviation in tooth morphology, ex. Peg. Shape

lateral/fusion. Space condition, Moyers analysis, Nance Anaylsis/Boltons Analysis

One of the most important aspects when viewing the study models is to observe the amount of space required for the eruption of teeth, also termed the space condition, as mentioned above. In order to estimate

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if there is any arch discrepancy and space available, and whether we need to extract, the following analysis Model Analysis has been developed:

Plaster Model Analysis:

The most common analysis used are: 1. Mixed dentition analysis, termed Moyers Analysis 2. Arch length analysis, termed Nance Analysis 3. Tooth size analysis, termed Boltons Analysis

1. Mixed Dentition Analysis, Moyers Analysis This analysis is based on measurement of the mandibular permanent incisors. A quantitative assessment of crowding may be obtained by this mixed dentition analysis. The space available in each dental arch is measured on the study models and the sum of the mesio-distal dimension of the unerupted teeth is determined by measuring the mesio-distal dimensions of the four erupted mandibular permanent incisors, and predicting the combined sizes of the unerupted canine and premolars from the table. The following diagrams show the method used step by step:

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How to apply Moyers Analysis

1. Determine the maximum mesiodistal width of each of the four lower permanent incisors in the study model. Calculate their sum. 2. From the incisors value determine: a. The predicting size for unilateral upper 3, 4 and 5 (cuspid, first and second bicuspid). This can be found from the probability charts on the following page. The upper half of the chart is for the upper teeth, and the lower half is for the lower teeth, this value is termed the space required. b. The predicting size for unilateral lower 3, 4 and 5 from the lower probability chart (this value is termed the space required).

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3. Calculate the space available after alignment of upper and lower incisors each arch separately. This value determines the space available needed to accommodate 3, 4 and 5. 4. Space available space required = will give the space adequacy or inadequacy for the non-erupted 3, 4 and 5.

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2. Arch Length Analysis, Nance Method

The amount of space available is determined by adapting a length of 0.025 inch diameter brass wire to fit from the mesial marginal ridge of the left first permanent molar around the arch to the mesial marginal ridge of the right mandibular first permanent molar. The brass wire should pass over the imagined correct position of the cuspid, the center of the occlusal surfaces of the bicuspids and the incisal edge of the most labial of the incisor teeth. The wire should be a smooth arch, free from kinks and should simulate the desired arch form. Adjustment to the arch form should be made if a mandibular buccal or lingual crossbite is present. The length of the brass wire, determined in millimeter, is regarded as the available space for the total complement of the dentition. Which consists of: the 1st and 2nd bicuspids, cuspids and lateral and central incisors of both the right and left sides of the mandibular arch. It is important to recognize that the available space may or may not be adequate for the proper alignment of the teeth. The required space is determined by measuring the mesiodistal width of each tooth from the right 2nd bicuspid to the left 2nd bicuspid, then calculating the sum. The space available space required = will give us the space adequacy or inadequacy to accommodate the teeth.

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3. Tooth Size Analysis, Bolton Analysis

The determination of tooth size ratios between the maxillary and mandibular teeth is essential for proper orthodontic diagnosis, treatment planning and result prediction. This relation determines: Teeth interdigitation Excessive overbite Overjet Spacing between teeth

The desirable ratio is necessary to attain an optimum interarch relationship. If the analysis indicates a marked deviation, it can give an insight into the required pattern of treatment and extraction. The Bolton procedure is used in this case to determine the overall ratios. It is as follows: a. The sum of the mesiodistal diameter of the 12 maxillary teeth and the sum of the mesiodistal diameter of the 12 mandibular teeth including the first molar is calculated, this called the overall ratio: Sum of 12 mandibular teeth Overall ratio =---------------------------------- x 100 = 91.3% Sum of 12 maxillary teeth b. If the overall ratio is less than 91.3%, then the maxillary tooth material is excessive. We can determine from the table the desired size of the mandibular 12 teeth, appropriate for the actual size of

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the maxillary 12 teeth. The value represents the excessive amount of mandibular tooth material. c. We can use the same equation for the anterior 6 teeth only from canine to canine. This called the Anterior Ratio:

Sum of 6 mandibular teeth Anterior Ratio = ----------------------------- x 100 = 77.2% Sum of 6 maxillary teeth Again if the ratio is less than 77.2%, the maxillary teeth are excessive:

How to apply the Boltons Analysis 1. If the overall ratio of the 12 mandibular and 12 maxillary teeth is more than 91.3%, then the teeth that are at fault are the 12 mandibular teeth, meaning that they are excess in size. From the table in the following page, we determine what the corrected sum of the 12 mandibular teeth should be (this is achieved by locating our actual sum of the 12 maxillary teeth which we have already the chart, this is termed the corrected mandibular. 2. If the overall ratio is less than 91.3%, then the teeth that are at fault are the 12 maxillary teeth, meaning that they are excess in size. The same procedure is done, but here we take the actual sum of the 12 mandibular teeth instead, and locate our corresponding maxillary value from the chart. 3. When determining the anterior ratio, the same procedure as above is used, calculations are done when the amount is more than 77.2% or less than 77.25.
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V. Orthodontic Appliances
There are three basic types of orthodontic appliances:

1. Removable Orthodontic Appliances:

These are generally used to

correct minor malocclusions where only a tipping movement is necessary. The forces are produced by various types of springs formed from arch wires. These type of appliances are also used to stabilize or retain treatment results at the end of treatment of fixed appliances.

2. Functional Appliances: Are also removable appliances, but contrary to the ordinary orthodontic device which acts in one jaw only, and where the force arises from a spring, the functional appliances influence both jaws and the force system is created by the jaw musculature. During function (mainly swallowing) the muscle forces are transmitted to the teeth through the appliance and thereby initiate tooth movement. Functional appliances may even produce some orthopedic changes. A typical example of a functional appliance is the activator.

3. Fixed Appliances: The term fixed appliances is usually used for a full bonding/banding appliance system with tubes and brackets attached to most of the teeth. There are numerous types of brackets and tubes. The principles, however, are the same. The brackets and tubes that are

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rigidly attached to the teeth, enable the different qualities of the orthodontic wires to be transferred to the teeth, and in addition, they may have built in qualities which are released when the orthodontic wires are placed into the tubes and bracket slots. The fixed appliance systems are designed for active treatment, but some fixed elements may even be used to stabilize results of active treatment, such as lingual retainers.

Basic Elements of Orthodontic Fixed Appliances Various types of brackets are used as attachments on incisors, canines and premolars, whereas tubes are used on the molars. The brackets and tubes may be attached directly to the tooth by bonding the bracket base directly o the tooth surface using the acid etch technique, or they may be welded to orthodontic bands which are cemented on the tooth. There are also many additional attachments such as lingual buttons, eyelets, hooks, etc., that are used to supplement the basic bands, brackets and tubes. Replaceable arch wires are used as the basic elements of fixed appliances. These arch wires engage the tubes and the slots in the brackets. It is along these arch wires that the teeth move when

orthodontic treatment is undertaken. In order to suit the whole range of working routines experienced throughout a course of orthodontic treatment, the characteristics of such arch wires must be specially adapted to meet such varied demands. One therefore finds that there is a whole range of wires with varied cross-sectional diameters and different degrees of hardness and elasticity.

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Some Standard Orthodontic Pliers The following are some pliers used in an orthodontic practice: 1. Bird peak plier: used for forming loops in rectangular wires.

2. Orthodontic cutter: used for cutting wires.

3. Adams plier: Adams clasps.

used for construction and adjustment of

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VI. References:
1. Proffitt, W.R. and Fields, HW. Contemporary Orthodontics. Second

edition, Mosby Yearbook Inc., St. Louis Missouri, 1993. 2. Thilander, B. and Ronning, O. Introduction to Orthodontics. Fifth edition, Printed by Minab/Gotab, Stockholm, 1985. 3. Walther, D.P. and Houston, W.J. Orthodontic Notes. Fifth edition,

Butterworth-Heinemann Ltd., Oxford, 1994. 4. Wisth, P. Introduction to the Edgewise Technique, A Technical Manual, University of Bergen, Norway, 1985.

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