Supplementary diagnostic aids

B.SRINIVASAN
KIDS
ESSENTIAL 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.
NONESSENTIAL / SUPPLEMENTAL
DIAGNOSTIC AIDS
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
occlusal
Vertex occlusal
Oblique occlusal
Lower 90 degrees occlusal
Lower 45 degrees occlusal
Lower oblique occlusal
Special radiographs
Lateral oblique
Waters view ( Sinus)
Townes
Reverse townes.
Submentovertex
Temporomandibularjoint projections

Lateral oblique view
Waters view projection
Also known as sinus projection
Its similar to the posteroanterior projection Except that the center of
interest is focused on the middle third of the face.

Purpose:
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
ducts
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
osteodystrophies


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
children
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
direction
Subject is GROUNDED by placing an electrode in an inactive region of
body

http://www.hhdev.psu.edu/atlab/EMG.jpg

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
patient
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
Carpals
Metacarpals
Phalanges

Carpel bones:
I. Trapezium
II. Trapezoid
III. Capitate
IV. Hamate
V. Hamular processof the hamate
VI. Triquetral
VII. Pisiform
VIII.Lunate
IX. Scaphoid
carpals
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
Radius
This method describes the relationship b/w the
epiphyses and the diaphysis in 3 stages
1976
(
)
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
spurt
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
ossification
b. Ossification of pisiform
c. The epiphysis and
diaphysis of radius are
equal
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
thumb
c. Radius

Marks the peak of
pubertal growth spurt
Sixth stage
DP3 U stage constitues
the end of pubertal
growth
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
width
Stage 3( pubertal
onset)
Beginning of
calcification
of ulnar sesamoid
Increased ossification
of pisiform & hook of
hamate

Stage 4(pubertal)
Calcified ulnar
sesamoid
Capping of shaft of
middle phalanx of
third digit by its
epiphysis-MP3cap.
Stage 5(pubertal
decelaration)
Ulnar sesamoid fully
calcified
DP3u stage
All phalanges and carpals
fully calcified
Epiphyses of radius and ulna
not fully calcified with
respect to shafts
Stage 6(growth
completion)
No remaining growth
sites
Fishman method
This system uses;
- Only four stages of
maturation
- Six anatomic sites
located on the thumb,
third finger, fifth finger
radius.

11 discrete adolescent SMIs

System of SMA

-organized

-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
expected
Inferior borders of C2,C3-
concavities developing
Inf. Border C4 flat
C3 &C4 bodies rectangular


CATEGORY 3 (transition)
Corresponds toSMI 5& 6
25-65% GROWTH EXPECTED
Distinct concavities-C3&C4
Concavity begins to develop-C4
C3 &C4 rectangular.


CATEGORY4(DECELERATION)
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.
CATEGORY 6 (COMPLETION)
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
COMPUTED TOMOGRAPHY
Parts of the Equipment;
1. Scanner ( movable x
ray table + gantry)
2. Computer system
3. A display console
RADIATION DOSAGE FOR CT
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 CBCTs showed moderate variability in airway dimension
Assessment of alveolar bone height and volume

For implant placement
Assessing the height, width of the bone
TMJ morphology
Conventional
Computerized Tomography
Computerized Tomography was developed by sir
Godfrey Hounsfield in 1967
Since its evolution it has gone through 5
generations.
The method of organization of these systems
depends on the individual moving parts and physical
motion of the beam in capturing the data
FIRST GENERATION
Consists of a single radiation source and a single detector
The second generation made use of multiple detectors arranged in the
same plan but they need not be continuous
The third generation CTs made use of laarge detectors there by
reducing the need for the beam to translate around the object
They were also known as fan beam CTs
Disadvantage was ring artefacts seen in the image thus distorting
the 3D image
Fourth Generation CTs counteracted the problem of ring artefacts
They consisted of a moving radiation source but a fixed detector ring
Scattered radiation was more
The Fifth Generation CTs were developed to overcome motion or scatter effects
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
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
patient
Multiple detector arrays are used
Detectors are closely packed
Disadvantages of conventional CTs
Requires more space
Expensive than conventional radiographic
machines
Images captured are made up of multiple slices
and therefore the stacked image is time
consuming and less cost efficient
Radiation exposure is more so limited only to
complex craniofacial problems
Cone Beam Computerized Tomography
(CBCT) was introduced in 1990s
Evolutionary process resulting from the
demand for three dimensional information
information obtained from conventional
CTs
Custom built CBCTs are in the market
specifically for use in dentistry
CBCT
The object to be evaluated is captured as the radiation source falls on a 2-
dimensional detector
An entire region of interest can be obtained with a single rotation of the
X-ray source
The cone beam produces a more focused beam, so less scatter radiation
Significant increase in X-ray utilisation and reduces tube required for
volumetric scanning
Total radiation exposure is approximately 20% of conventional CTs
Nearly equal to a full mouth periapical radiographic exposure
Less expensive and smaller, so can fit in dental office
CBCT Acquisition systems
New Tom 3G - Quantitative radiology, Verona, Italy
i-CAT - Imaging sciences International,USA
CB MercuRay Hitachi, Japan
3D Accuitomo - Kyoto, Japan
CBCT technology in dentistry
Patient in supine position or sitting position
Scan takes place in 36 seconds
3 possible fields of view
0.125mm voxel resolution
12 BIT Gray Scale
Higher resolution for all views
0.125 mm voxel resolution
Good contrast
Amorphous silicon flat panel image sensor

Views possible with CBCT
periapical
panoramic
Cephalogram
occlusal view
TMJ series
separate axial views
Orthodontic implications of CBCTs
Impacted canines and abnormalities
Airway analysis
Assessment of alveolar bone height and
volume
TMJ morphology
Impacted canines and abnormalities
2 D View
3D CBCT View
The quality of TMJ images is comparable to
conventional CTs
Radiation exposure is less
Image taking faster
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
scan.

Magnetic Resonance Imaging
Principles:
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
neutrons,
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.

Equipment;
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
network.

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
condyle
- 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


/Complications;
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.
/Contraindications;
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.*


/Indications
- 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
GROWTH HORMONE (GH)
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.

TWO TYPES:
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
GH DEFICIENCY

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

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

HYPERSECRETION OF GH
1. GIGANTISM
2. ACROMEGALY


GIGANTISM

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


ACROMEGALY

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

ELONGATION AND WIDENING OF MANDIBLE IN
ACROMEGALY
Mandibular growth in Acromegaly results from
appositional growth and hypertrophic changes
in the condylar cartilage.
THYROXINE HORMONE (TH)
It has no specific target organ
Regulates the pace of metabolism thru interactions
with mitochondrial,nuclear & extra mitochondrial
processes.
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
activity
Reduced bone density
This result in increased tooth
movement during ortho. treatment.
(study done by
Sherazi,Dehpour,Jafari)

PARATHORMONE(PTH)
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
th
day- appliance fitted(1 ounce force)
6
th
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.


CALCITONIN
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 .
VITAMIN D - 3
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.
SEX HORMONES
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.
)
CORTICOSTEROIDS
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.
PROSTAGLANDINS(PG)
They act by increasing number of osteoclasts and activating
already existing osteoclasts on application of mechanical stress.
ROLE OF VITAMINS IN GROWTH AND
DEVELOPMENT
Certain CRITICAL PERIOD exist during development of organ
characterized by HYPERPLASTIC AND HYPERTROPHIC GROWTH
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
rd
molar.
BIOPSY
DEFINITION :
Biopsy is the removal of tissue from the living organism
for the purpose of microscopic examination and diagnosis.

TYPES :
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.

METHODS :

+ 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.

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)
BIOPSY TECHNIQUE :
+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%
formalin)

+The sample along with description is sent for histologic
Examination

+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.
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