431 PDS-Practical Manual

KingSaudUniversity CollegeofDentistry DepartmentofPreventiveDentalSciences
PreClinicalOrthodontics andDentofacialOrthopedics 431PDSCourse
PRACTICALMANUALI
Writtenby: Dr.EmanAlkofide Dr.HanaAlBalbeesi Dr.HudaAlKawari Dr.LailaBaidas Dr.SaharAlBarakati Reeditedby: Dr.EmanAlkofide 20052006 Reeditedby: AbdullahM.Aldrees,BDS,DMSc
AssistantProfessor,DivisionofOrthodontics DepartmentofPreventiveDentalSciences CollegeofDentistry,KingSaudUniversity
20082009
PreClinicalOrthodonticsCoursePracticalManualI Dr.AbdullahM.Aldrees,AcademicYear20082009
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TableofContents
I. Introduction
II. ClassificationofMalocclusion
1. NormalOcclusion 2. Malocclusion 3. ClassIMalocclusion 4. ClassIIMalocclusion a. ClassIIDiv.1 b. ClassIIDiv.2 5. ClassIIIMalocclusion
III. DiagnosticAids
1. StudyModels 2. Radiographs: i. OcclusalFilms ii. Orthopantomographs iii. HandandWristRadiographs iv. Cephalometrics 3. ModelAnalysis: i. ArchPerimeterAnalysis:MixedDentitionAnalysis ii. ArchLengthAnalysis:NanceAnalysis iii. ToothSizeDiscrepancy:BoltonAnalysis
IV.References

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Introduction
Orthodontics is the oldest specialty in the dental profession. Orthodontics (Ortho = Straight, Dontic = Teeth), is that branch of dental science concerned with genetic variation and 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 associatedorgans.Thereforewearenotonlyconcernedwithstraighteningoftheteeth, butalsothegrowth,development,andfunctionofthetotalorofacialcomplex. Duringthiscourse,thestudentwillbefamiliarizedwiththetermOrthodonticsthrougha seriesoflecturesandlaboratorysessions.Thelectureseriesofthiscoursewilldealwith the abovementioned aspects of orthodontics in more detail. The laboratory session of thiscoursewillteachthestudentthetechnicalpartofOrthodontics. The purpose of this manual is to introduce to the student the practical part of this courseinamoresimplifiedandunderstandablemanner. It is not considered a replacement of the required textbooks of the course, but as an adjuncttohelpthestudentduringthelaboratorysession.

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1. 2. 3. 4. NormalOcclusion Malocclusion ClassIMalocclusion ClassIIMalocclusion a. ClassIIdiv.1 b. ClassIIdiv.2 5. ClassIIIMalocclusion
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1. NormalOcclusion
Occlusionisconsideredtobenormalwhenthedentalarchesareincorrectalignment, with all the teeth in anatomically correct contacts, and in physiologically optimal occlusionwiththecorrespondingteethintheoppositedentalarch.Thedevelopmentof normal occlusion passes through several continuous stages from birth to the developmentofthepermanentdentition.Thedeciduousdentitionbeginstoappearat around the age of 6 months with the eruption of the lower central incisors. The deciduousteethareusuallycompletebytheageof2yearofage.Atthisstagethereis oftenspacingbetweentheteethespeciallydistaltothelowercaninesandmesialtothe uppercanines(primatespaces),withthedistalsurfacesoftheseconddeciduousmolars inlinewitheachother(flushterminalplane). At6yearsofagethefirstpermanentmolarsstarttoerupt,andthepermanentincisors develop lingual to the roots of the deciduous incisors. At this time also, the ugly ducklingstateisevident. Asthechildcontinuestogrow,he/shepassesthroughthetransitionperiodfromearly mixed dentition to late mixed dentition, to the permanent dentition. Within these periods, there lies a discrepancy between the mesiodistal widths of the deciduous molarsandthepremolarswhichcreatesspacingandistermedtheleewayspace.This developstoallowthelowerpermanentmolarstomoveforwardfurtherthantheupper molarsandestablishaClassImolarrelationship.
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2. Malocclusion
Malocclusionisdefinedasanirregularityoftheteeth(thevarioustypesofmalocclusion willbediscussedbrieflyhere;thedetaileddescriptionofeachwillbeelaboratedinthe futurelectures). The etiology of malocclusion is generally categorized into two causes: (1) Hereditary, such as jawteeth size discrepancy, and (2) Developmental, such as premature loss of teethorhabits(e.g.thumbsuckingortonguethrusting). Malocclusionmaybeassociatedwithoneormoreofthefollowing: A. MalpositionoftheTeeth Thiscouldbecausedby: Tipped teeth the crown of a tooth is tipped or incorrectly positioned in comparisontotheapex. Displacedteethinthissituationboththecrownandtheapexaredisplaced. Rotatedteeththetoothisrotatedalongitslongaxis. Teethininfraocclusionthetoothhasnotreachedtheocclusallevel. Teethinsupraocclusionthetoothhaseruptedpasstheocclusallevel. Transposedteethtwoteethhavereversedtheirpositions,forexampleacanine takingtheplaceoffirstpremolar. B. MalrelationshipoftheDentalArches This could occur in any of the three planes of space: anteroposterior, vertical, or transverse. The anteroposterior malrelationship is represented by the Angle Classification, which deals with the disproportion of the teeth in an anteroposterior plane.Theverticalmalrelationshipisevidentduringtheobservationofoverbite,while thetransversemalrelationshipispresentedincaseswithcrossbites. The most popular and world recognized classification of malocclusion is the one describedbyEdwardH.Angle,whichdealswiththearchmalrelationshipintheantero posteriordimension. 8|P a g e
AnglesClassification(MolarClassification): This was the first useful orthodontic classification system that was developed in 1890, and it is still used to our present date. Angles classification system was based on the upperfirstmolarsasbeingthe"KeytoOcclusion".AccordingtoAngle,themesiobuccal cuspoftheuppermolarshouldoccludeinthebuccalgroveofthelowerfirstmolar.If thismolarrelationshipexists,andtheteethwerearrangedonasmoothlycurvedlineof occlusion,thennormalocclusionwouldresult. Angle then described the three classes of malocclusion, based on the occlusal relationshipsofthefirstmolars,whichareasfollows: ClassIMalocclusion: The mesiobuccal cusp of the maxillary first permanent molar occludes with the mid buccalgrooveofthelowerfirstpermanentmolar(Fig.1).
Figure.1
This is sometimes termed neutroocclusion. There is the normal relationship of the molars,butthelineofocclusionisincorrectduetocrowding,rotations,spacingofthe teeth,orothermalpositions.
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ClassIIMalocclusion: The mesiobuccal cusp of the maxillary first permanent molar occludes anterior to the midbuccalgrooveofthemandibularfirstmolar.Thisisalsoknownasdistoocclusion. This type of malocclusion is further categorized into two divisions according to the inclinationoftheuppercentralincisors: ClassIIdiv.1Theuppercentralincisorsareproclinedorofaverageinclinationwithan increaseinoverjet(Fig.2a). ClassIIdiv.2Theuppercentralincisorsareretroclined.Theoverjetisusuallyaverage but can be decreased or a little increased. Sometimes the upper laterals are proclined(Fig.2b).
Figure.2a Figure.2b

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ClassIIIMalocclusion: Themesiobuccalcuspofthemaxillaryfirstpermanentmolaroccludesdistaltothemid buccal groove of the mandibular first permanent molar. This is also known as mesio occlusion(Fig.3).
Figure.3
In certain situations where early extraction of the first molars has occurred, the alternativetousingtheAnglesclassificationofmalocclusionistousethepositionofthe canine to determine which type of occlusion the patient has. Usually, in Class I relationship,theuppercanineoccludesintheembrasurebetweenthelowercanineand firstpremolar. InClassIIcases,wehaveamesialmovementoftheuppercanineandadistalmovement ofthelowercanine.InclassIIIcases,theoppositeistrue.Theuppercanineislocated moredistal,withthelowercaninemigratingmoremesial.
Othersystemshavebeendevelopedtofurtheraidinclassifyingamalocclusion.Theyare alsousedwhenthefirstmolarsareabsent.Inthesecases,anincisorclassificationhas been developed. Since one of the main objectives is to correct the incisor malrelationshipduringtreatment,anunderstandingofincisorpositionisveryimportant. 11|P a g e
IncisorClassification: Thisdoesnotusuallyfollowthebuccalsegmentrelationship.Itcanbedividedinto: Class I The lower incisor edges occlude with or lie immediately below the cingulumplateau(middlepartofthepalatalsurfaceoftheuppercentralincisors) (Fig.4a). Class II The lower incisor edges lie posterior to cingulum plateau of the upper incisors.Thetwodivisionsare: Class II div. 1 The upper central incisors are proclined or of average inclination andthereisanincreasedoverjet(Fig.4b). Class II div. 2 The upper central incisors are retroclined, sometimes the upper lateralsareproclined(Fig.4c). ClassIIIThelowerincisoredgeslieanteriortothecingulumplateauoftheupper incisors.Theoverjetmaybeeitherreducedorreversed(Fig.4d).
c d
b Figure.4
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III. DiagnosticAids
1. StudyModels 2. Radiographs: i. OcclusalFilms ii. Orthopantomographs iii. HandandWristRadiographs iv. Cephalometrics 3. ModelAnalysis: i. ArchPerimeterAnalysis:MixedDentitionAnalysis ii. ArchLengthAnalysis:NanceAnalysis iii. ToothSizeDiscrepancy:BoltonAnalysis
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III. DiagnosticAids
1.StudyModels
In order to properly diagnose an orthodontic case, several steps are required. These steps allow us to gather information pertinent to developing diagnosis, and hence, treatmentplanningofthecase. One aspect of orthodontic diagnosis that is part of the common knowledge of the profession,andyethasnotbeendescribedoftenintheliterature,isthefabricationof studymodels(Fig.5).
Figure.5 The following section describes in detail the process of constructing study models as advisedbytheAmericanBoardofOrthodontics: 1.Impressions: Standardaluminumtraysshouldbeusedtoobtainaccurateimpressionsofthedentition andassociatedsoftandhardtissuestructures.Theedgesofthetraysusuallyarelined with a border of wax that prevents the edge from impinging on the soft tissue. Care shouldbetakentoensurethatthetraysareneithertoowidenortoonarrow,sothat minimalsofttissuedistortionoccurs.Theareasoftissueattachment,particularlyinthe areaofthelabialfrenumandinareasofsofttissueattachmentadjacenttotheupper firstpremolars,shouldbereproducedintheimpression.Obtainingaproperimpression
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of the hard and soft tissue of the dentoalveolar region is critical for the proper fabricationofdiagnosticcasts. Aftertheimpressionhavebeenmade,itshouldbecheckedthoroughly.Theimpression shouldappearsmoothwithnomajorvoids,andthebordersoftheimpressionshouldbe rolledwithgoodextensionintothevestibularareas.Theimpressionalsoshouldextend posteriorly in the palatal area and lingually in the mandibular region. Lastly, the impression should be checked for the presence of any large air bubbles, especially on theocclusalsurfacesoftheteeth. 2.WaxBiteRegistration: Clinicians use a wide variety of substances to record the orientation of the upper and lowerdentalarches.Normally,thebiteregistrationistakenincentricocclusion,atooth guidedposition.Ininstancesinwhichthereisasubstantialdifferencebetweencentric occlusionandcentricrelation,anadditionalbiteregistrationshouldbetakenincentric relation as well. The clinician then must decide whether the study models are to be trimmedincentricocclusionorcentricrelation.Ininstancesinwhichacentricrelation registration is desired, it is often useful to mount the articulated model on an appropriatearticulator,utilizingafacebowtransfer. Forroutineprocedures,oneortwothicknessesofyellowbiteregistrationwaxareused. Thehorseshoeshapedwafersofwaxaresoftenedfirstinwarmwaterandthenplaced onthemaxillarydentalarch.Thepatientthencloseshisorhermouthsothatthelower teethbiteintothesoftenedwax.Thepatientshouldbeinstructedtobitethroughthe wax,toavoidproducingstudymodelsthatrockorareunstablewhentrimmed.Using fingerpressure,theclinicianthenwillpressthewaxagainsttheteethtoachieveathree dimensionalregistrationofthebite.Somecliniciansadvocatekeepingthelabialsurfaces oftheupperandloweranteriorteethfreeofwax.Theincisaledgescanberegisteredin thewax,butthemidlinesarestillvisiblesothatthelateralorientationofthewaxbite (usingthemidlines)canbedetermined. After the impression and wax bite have been taken, they are wrapped in moistened papertowelingandplacedinsealableplasticbag. 15|P a g e
3.DisinfectingtheImpressions: Athoroughrinsingofimpressionsreducesthenumberofmicroorganismsonthesurface of the impressions, removing plaque and secretions. The impressions should be immersedinBiocideandthenallowedtostandforapproximately10minutes.A1:100 solution of chlorine bleach and water also can be used as disinfecting solution. Impressions then are rinsed in lukewarm water and rebagged until the time they are poured. 4.PouringtheImpressions: Thefirststepinpouringtheimpressionsistofillintheareaoccupiedbythetonguein themandibularimpression.Thiscanbeaccomplishedbyfirstplacingathumborpieceof moistenedpapertowelortissueinthetonguespace.Onescoopofalginateismixedto normal consistency and placed in the area normally occupied by the tongue. As the alginatebeginstoharden,smoothenthealginatewithfingerpressure.Aftertheinitial set is completed, the impression is put aside until a final set is completed. After that time, the impression should be checked for accuracy, making sure that the alginate addition does not obstruct the anatomical structures in the lingual region of the mandibularimpression. The impressions are poured using white orthodontic stone or plaster. The impression shouldhavebeenrinsedpreviously;notonlytoeliminatetheresidueofthedisinfectant but also to eliminate traces of saliva that otherwise might affect the integrity of the finishedsurfaceofthestone.Thestoneismixedinavacuummixertoeliminatebubbles thatotherwisewouldbetrappedinthestone.Thestoneispouredinthetoothportion oftheimpressionfirst,usingavibratorandawaxinginstrumentorspatula.Additional stoneisaddedwiththespatulatocompletetheanatomicalportionoftheimpression. After the pouring of the anatomical portion of the impression is completed, the remaining stone is poured into a large base former, again using the vibrator. The impression tray is turned upside down and pushed into the stone in the base former. Care should be taken to verify that the occlusal surface of the impression remains paralleltothebottomsurfaceofthebaseformer.Also,theimpressiontrayshouldnot bepushedintotheplasterinthebaseformer.Iftheimpressiontraybecomestrappedin
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the plaster, difficulties will be encountered in removing the tray, and the vertical thicknessofthestudymodelmaybereduced. Theimpressiontrayisremovedfromthepouredstoneafteritishardened.Ordinarily,a wait of 3060 minutes after the onset of the mix is adequate to make sure that the orthodonticstoneisset.Careshouldbetakeninremovingtheimpressionfromtheset stone so that the teeth (particularly the upper and lower incisors) are not fractured duringtrayremoval. 5.TrimmingtheStudyCasts: Thetrimmingneedstobedoneslowlyandcarefully.Asafirststepintheprocedure,a laboratory knife is used to remove any large or small chunks of plaster that interfere with the occlusion of the cast. Such interferences include bubbles on the occlusal surfacesaswellaslateralextensionsintheposteriorregions,particularlybehindthelast eruptedmolar. RoughTrimmingtheMaxillaryModel The maxillary model is trimmed symmetrically with the top of the model trimmed paralleltotheocclusalplane(Fig.6).Thebackofthemodelistrimmedperpendicularto the midline of the palate as indicated by the orientation of the midline palatal raphe. Rough trimming of the stone bases first can be accomplished freehand, using the platformonthemodeltrimmerasaguide. Afterthemodelisroughtrimmed,themodelisplacedonitsbacksothatthetopofthe castcanbetrimmed.Theteethrestagainsttheattachmentofthemodeltrimmerthat slides into the groove on the trimming platform. The top surface of the model is trimmedsothatitisparalleltotheocclusalplaneoftheteeth(Fig.6). Theanatomicalbaseofthemaxillarymodelshouldbeabout1.5cmthick(about13mm) (fig.7).Ifthemaxillarybasehasbeenpouredtoaninadequatethickness,orifthebase hasbeentrimmedexcessively,thefinishedstudymodelswilllookuneven. Thetotalheightofeachcastshouldmeasure3.54.0cmfromtheocclusalsurfacetothe topofthemodel.
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Figure.6 TrimmingtheBackoftheModels Oncethetopofthecasthasbeentrimmedflat,thecastisplacedwiththetopofthe castagainstthetrimmingplatform.Thecastthenisorientedsothatthepalatalrapheis perpendiculartothewheelofthemodeltrimmer.Itisadvisabletousethepalatalraphe asaguidesincethedentalmidlinesoftenarenotcoincidentwiththeskeletalmidlines. The cast is trimmed so that thereis about 5 mm of stone distal to the most posterior tooth.IninstancesofsevereClassIImalocclusion,additionalspaceshouldbeallottedin theposteriorregionuntilthefinalocclusionisdetermined. EstablishingtheInterarchRelationship The upper and lower casts are placed together, and the operator checks for any interferencethatmightpreventaproperocclusionfrombeingestablished.Thewaxbite registrationisplacedonthemaxillarycast,andthemandibularcastisoccludedintothe waxindentations. Themodelsthenareplacedonthetrimmingtablewiththecastsinocclusionandthe maxillarymodelonthebottom,withthebacksofthecastsfacingthetrimmingwheel. Thecastsareheldfirmlytogether,andthebacksurfacesofthemodelsaretrimmed.At this point, only the mandibular cast touches the trimming wheel. The casts should be heldgentlybutfirmlytogetherasthecastsarepushedintothecoarsegrindingwheel. Trimmingcontinuesuntilboththeupperandlowercastsaretouchingthetrimmer. 18|P a g e
Afterithasbeendeterminedthatthebacksofthecastshavebeentrimmedinaparallel fashion,themodelsareremovedfromthetrimmer,andthebacksofthecastsplacedon aflatsurface.Atthispoint,themodelsshouldlieflushonthesurfacewiththewaxbite inplace.Ifthisisnotthecase,themodelsshouldbeplacedbackinthetrimmerwiththe waxbiteinplaceandretrimmeduntilbothsurfacesareflushagainstthetrimmer. Thewaxbiteisremovedandthecastsoccludedinahandheldfashion.Onceagain,the modelsshouldbecheckedfortheappropriatebiteorientationbyplacingthebacksof the models on a flat surface. If the backs of the models are not flush, they should be retrimmed without the wax bite in place. If there is any uncertainty concerning the accuracyofthewaxbite,anewbiteshouldbetaken.
Figure.7 RoughTrimmingtheMandibularModel With themodels in occlusion and the wax bite in place, the modelsare placed on the trimmingtablewiththelowerbaseagainstthetrimmingwheel.Usingtheperpendicular attachmentofthetrimmingtableagainstthetopsurfaceoftheuppercast,thebottom ofthelowercastistrimmedparalleltothetopoftheuppercast.Thecastistrimmedso thatthebaseofthelowermodelisequalinthicknesstothatoftheuppermodel(figs.6 and7).Thetotalheightofbothcastsinocclusionshouldbeabout77.5cm. 19|P a g e
6.FinalTrimming: MaxillaryModel Thepreciseangulationsofthestudymodelsaredeterminedusinganangulatorthatcan bescrewedintothetrimmingtable.Theangulatorallowstheoperatortosetthecorrect angle for each surface. By placing the back of the cast against the flat surface of this device, an angle is formed between the surface of the cast and the trimming wheel surface that allows for the correct angulations to be determined. The screw on the angulatorshouldbetightenedfirmlytopreventslippingofthedevicethatcouldresultin trimming errors. First, the angulator is set at 70 (Fig. 8). The cast is placed in the appropriatepositionandthefirstsidetrimmeduntilthedeepestextentofthevestibule isreached.Thethicknessoftheinitialtrimshouldberoughlythethicknessofastandard woodenpencil.Itisbesttobecautiousatthispoint,becauseitis,ofcourse,possibleto retrimanysurface.Theoppositesidealsoistrimmedat70.Theangulatorthenissetto 25andthefrontofthemaxillarycasttrimmedsothatbothsidesmeetanteriorly.The tipofthecastshouldapproximatethemidlineasdeterminedbythepalatalraphe.The anteriorbordersofthemaxillarycastareequalinlength.
Figure.8 Thelastportionsofthemaxillarycasttobetrimmedarethebackedges.Theseedges are trimmed perpendicular to a line drawn from the intersection of the lateral and posterior borders of the cast and the intersection point of the lateral and frontal surfaces of the cast on the opposite side (Fig. 7). The length of the corner segments shouldbe1315mm.Careshouldbetakentoavoidtrimmingthisareatooquickly,or excessstonemayberemoved. 20|P a g e
MandibularMode Theangulatorissetat65wheninitiallytrimmingthelowermodel(Fig.9).Eachsideis trimmed to the depth of the vestibule, again using the width of a standard wooden pencilasaninitialguide. Thenextstepintrimmingistoestablishtheposterioranglesofthemandibularcast.As with the maxillary model, the posterior edges of the mandibular model is trimmed perpendiculartoalinebisectingtheangleformedbythelateralaspectofthecastand the posterior aspect ofthe cast (Fig. 9). The length of this posterior surface should be 1315mm(Fig.10).Theanteriorpartofthecastisnotangledbutratherisrounded.The determinationofthecurvatureisaccomplishedfreehandthroughgentlemovementof thecastinasmootharcingfashion.Theanteriorcurvatureistrimmedtothedepthof thevestibuleinmostinstances.Ininstancesofdentoalveolarprotrusion,caremustbe takentoavoiddamagingtheteethduringthetrimmingprocess. 7.FinishingProcedures: FillingVoids The casts are inspected carefully and any remaining bubbles removed with a cleoid discoidinstrumentoranywaxinginstrument.Particularattentionispaidtothegingival marginaswellastoothersofttissueareas.Anyairholesorvoidsarefilledwithstone andthesurfacesmoothedcarefully,usingeitherafingerorsmallbrushtoaddplasterto the model. All voids are filled, regardless of whether they are on the anatomical or artisticportionsofthemodel.
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Finishing Theedgesofthedentalcastaresmoothedslightlywithalaboratoryknifesothatthey aresmoothandeven.Ifthereareobviousasymmetriesintheextensionofthevestibule thatareduetoimpressiontechniqueratherthananatomicalvariation,theseareasmay bemodifiedusingaplasterknifeorarotaryinstrument. Thefinepolishingoftheartisticportionsofthedentalcastisinitiatedusingapieceof finegrained sand paper. The edges of the study models are smoothed under warm water. Also, the flat surfaces of the model are smoothed in areas of voids that previouslyhavebeenfilledwithplaster. Theedgesofthemodelsshouldnotberounded.Thefinishedmodelsshouldhavesharp angles but should be generally smooth in appearance. The models are set aside in an areatodryatleast24hours. PolishingtheCasts Thecastsareplacedinasoapingsolutionforonehour.Thecaststhenareremovedfrom thesoapbathtoberinsedunderwarmwaterandallowedtodryforapproximately20 minutes.Usingasoftrag,thebasesarebuffeduntilthecastsaresmoothandshiny.The castsarelabeledintheappropriatemanner,notingthenameandageofthepatient,as wellasthedateoftheimpressions.
Figure.10
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2. Radiographs
Radiographs are very important diagnostic aids in all aspects of the field of dentistry, andespeciallyinorthodontics. Therearetwomaintypesofradiographs: IntraoralRadiographsThisincludesPeriapicals,BitewingsandOcclusalfilms. ExtraoralRadiographsIncludesOrthopantomographs(OPG),HandWristradiographs, PosteroanteriorradiographsandLateralCephalometrics. The following sections will cover the radiographs that are used mainly for orthodontic purposes.
i.OcclusalFilms:
It is required to visualize relatively large segments of the dental arch, including the palate,floorofthemouth,andareasonableextentoflateralstructures.
Itisindicatedto: Locate roots, supernumerary, unerupted and impacted teeth especially cavities andthirdmolars. Localizeforeignbodiesandstonesinthesalivaryglandsduct. Evaluatetheintegrityofthemaxillarysinusoutline. Provideinformationrelativetothefracturesofthemandibleandmaxilla. Todeterminetomedialandlateralextentofpathosis(e.g.cysts). 23|P a g e
ii.Orthopantomographs(OPG):
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,maxillarysinusesandthetemporomandibularjoints. The principles of the panoramic radiography where first described by Numata in 1933 andPaateroin1948. Originally the patient and the films rotated andthexraybeamremainedstationary.But this method was superseded by the development of apparatus which have the tube and the film rotating around the patient. The xray source and film are simultaneously moved parallel to each other in opposite directions. While taking the radiographs, the Frankfort Horizontal Plane (FHP), should be parallel to the floor, and theocclusalplaneshouldbeloweranteriorlyby2030degrees,withthepatientbiting onabiteblock. Cautionshouldbetakenonthepositionofthechin: Ifthechinistippedtoohightothehorizontalplane,themandiblewillbedistorted.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 mandibularteeth(molars)bilaterally.Ifoneofthemiswiderthantheotheroneby20% theradiographshouldberetaken. AdvantagesofOPG: Thefilmisextraoral,makingitmorecomfortableforthepatient. Abroadanatomicregionisimaged,whichincludesthemaxillaandthemandible. It exposes the patient to less radiation. It is quick, convenient and easy for the assistanttotake. It can be performed on patients who cannot open their mouths and cannot tolerate intraoral radiographs, especially edentulous patients or patients with a suspectedpathosis. 24|P a g e
Thetimerequiredfortheprocedureisshort34minincludingpatientpositioning andactualexposure. Acceptedbypatientsduringpresentationsandeducation. Grosslesionsarevisible. Disadvantages: Does not give the fine anatomic details such as the alveolar crest, margins of pathologicallesions,bonepattern,caries,etc. Theimagemaybedistortedifthepatientissituatedoutsidethefocus. Magnification, geometric distortion, overlapped images of teeth, especially premolarregion,allcanoccur. Theprojectioncanbetakenonlyatoneangle. Theviewofthetemporomandibularjointisdistorted. Expensivemachine(34xmorethantheintraoralmachine). IndicationsforUsage: a. To assess the patients dental age based on the development and progress of mineralizationoftheteeth,eruptiontimeandexfoliationoftheprimaryteeth.So acomparisonofthechronologicalandskeletalagecanbedone. b. To evaluate present teeth, missing congenitally or impacted, ectopic eruption, malpositioned teeth, the presence or absence of third molars, supernumeraries, quality of restorations, resorption pattern of deciduous teeth, calcification of permanent teeth, asymmetric resorption of deciduous molars, integrity of root structures. c. To determine the level of alveolar bone, the 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 andadults). d. To note the presence of any pathological lesions, cysts, tumors, extensive or unique pathosis, ankylosis of deciduous teeth, susceptibility to caries, active cariouslesions,rootresorption. 25|P a g e
iii.HandandWristRadiographs:
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 withthevitalgrowthprocess.Handandwristradiographs canaidwiththisprocessofgrowthestimation. This estimation of the skeletal age of bones or bone age, aids in determining the physical maturation status of the child.Oneoftheindicatorstoverifythepubertalgrowthspurtisannualmeasurement ofwhathashappened.Whereasourinterestistoknowwhatwillhappeninthefuture tojudgethedevelopmentstageofthechildinrelationtothechildsowngrowthcurve, inordertodecidewhetherthepubertalgrowthspurthasstartedorpassed. AdvantagesoftheHandandWristRadiographs: It differentiates the certain developmental stages towards full physical development. The sequence of such developmental or morphological changes is equalinallhumans. It is technically simple to make roentgenograms of the hand. An individual will pass through a regular series of changes in size and shape of the ossification centersofboneduringtheirprogresstowardsmaturity. Severalsystemshavebeendevelopedtoevaluatetheseseriesofgrowthchanges.One which will be described in detail here, is a system produced by Leonard Fishman. Fishmansanalysisisbasedonskeletalmaturationassessment(SMA).Thissystemuses four stages of bone maturation located at six anatomic sites: the thumb, third finger, fifthfingerandradius.Inthesesixsiteselevenmaturationalindicators(SMIs)arefound tocovertheentireadolescentdevelopmentperiod.
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SitesofSkeletalMaturityIndicators Whicharerelatedto:wideningoftheepiphysealdiscsinoneofthephalangesonthe 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 selectedepiphysesanddiaphyses(Figs.11ad,&Table).
a.WidthofEpiphysis
b.Ossification
c.CappingofEpiphysis
d. Fusion Figure.11
SitesofSkeletalMaturityIndicators Radiographicidentificationofskeletalmaturityindicators(Fig.11) 1.Epiphysisequalinwidthtodiaphysis. 2. Appearanceofadductorsesamoidofthethumb. 3. Cappingofephiphysis. 4. Fusionofepiphysis.
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SMI
D.S.
Description
Female Age
Male Age
Diagram
Theepiphysesanddiaphysesinthe SMI1 PP3 proximalphalynxofthethirdfingerare equallywide. Theepiphysesanddiaphysesinthemiddle SMI2 MP3 phalynxofthethirdfingerareequally wide. 10 11 9 11
Theepiphysesanddiaphysesinthemiddle SMI3 MP5 phalynxofthefifthfingerareequallywide. 10.8 12
Ossificationoftheulnarmetacarpo phalangealsesamoidonthefirstfinger. SMI4 S Thisstageisfoundbeforemaximalgrowth, butcanalsobefoundtogetherwith maximumgrowth. Theepiphysesformacaparoundthe SMI5 DP3 cap diaphysesonthedistalphalynxofthe middleorthirdfinger. Theepiphysesformacaparoundthe SMI6 MP3 cap diaphysesonthemiddlephalynxofthe thirdfinger. Theepiphysesformacaparoundthe SMI7 MP5 cap diaphysesonthemiddlephalynxofthe fifthfinger. 12.3 14.3 12 13.7 11.6 12.9 11 12.3
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Ossificationoftheepiphysisinthedistal SMI8 DP3u phalynxonthethirdfinger. 13 15
Ossificationoftheepiphysisinthe SMI9 PP3u proximalphalynxonthethirdfinger. 13.9 15.5
Ossificationoftheepiphysisinthemiddle phalynxonthethirdfinger.Thisstage: SMI 10 MP3u DP3U+PP3u+MP3u=allthesestagesare foundafterthestageofmaximumgrowth isreached,mostoftenfrom14yearsafter. Completeunionofepiphysisanddiaphysis SMI 11 oftheradius.Theossificationofallthe R handbonesiscompleteandskeletal growthisfinished. (D.S.=DevelopmentalStage) 16 17 14.7 16.4
Note: The best treatment time for orthodontic patients is 12 years before the growth spurt,afterthattimeusuallynogrowthwilloccur.Hence,theadvantageofgrowthwill bemissedandtreatmentmightbecompromised.
Figure.12 ElevenSkeletalMaturityIndicators(SMIs) 29|P a g e
HANDWRISTOBSERVATIONSCHEME
Figure.13 An observational scheme for assessing SMIs on a handwrist radiograph (For ease of interpretation, the first step is to determine the presence or absence of the abductor sesamoidofthethumb).
30|P a g e
iv.Cephalometrics
CephalometricswasfirstintroducedtotheworldbyHofrathinGermanyandBroadbent intheUnitedStates.Cephalometricradiographymeansmeasuringtheheadintheliving individualthroughtheuseofradiographs.Theoriginalpurposeofcephalometricswas researchongrowthpatternsinthecraniofacialcomplex,butwasusedafterwardsasa method to evaluate the dentofacial proportions and clarify the anatomic basis for a malocclusion. Nowadays, lateral cephalometric radiographs are routinely used in orthodonticpractices. Acephalograph,whichisastandardizedradiographofthehead(craniumandface),is taken for the patient by the use of a machine termed the Cephalostat (cephalus meaningtheskullorhead,andstatmeaningfixedorstaticposition). The basic equipment required to obtain a cephalometric view consists of an xray source,anadjustablecephalostat,afilmcassettewithradiographicintensifyingscreens, andafilmcassetteholder. ComponentsoftheCephalostat: Thecephalostatconsistsofthefollowing: 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 midsagittal 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 indicatesanimproperlyalignedcephalostat. Nasal Pointer: Which rest on the bridge of the nose (usually at the soft tissue nasion). OrbitalPointer:Thisisoptional,andifpresentitisfixedattheorbitalregion. AMetalMillimeterScale:Thisisfixedverticallytothenasalpointertoindicatethe amountofmagnificationordistortion. 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 (Fig.14).Themidsagittalplaneofthepatientisverticalandperpendiculartothexray beam.Itisalsoparalleltothefilmplane,whichinturnisalsoperpendiculartothexray 31|P a g e
beam.Thepatient'sFrankfortplane(lineconnectingthesuperiorbordertotheexternal auditorymeatusandtheinfraorbitalrim)isorientedparalleltothefloor.Thedistance between the xray source and themidsagittal plane of the patientshead is kept at a minimumof5feet(150cm),soreducemagnification.
Figure.14 AfastKodakbluebrand8x10filmisused.Thefilmisexposedfor4/10of7/10sec.at 90 KVP and 10MA, to penetrate the hard tissue and provide good details of both the handandsofttissue. Twoviewscanbeusedwiththistypeofradiographicmethod: 1.PosteroanteriorView Itshowstheverticalandtransversedimensionsofthehead.Theprimaryindicationfor obtaining a posteroanterior cephalometric film is the presenceoffacialasymmetry. A tracing is made and vertical planes are used to illustrate transverse asymmetry. Lines are drawn through the angles of the mandible and the outer borders of the maxillary tuberosity (Fig. 15). Vertical asymmetry can be observed by drawing transverse occlusal planes (molar to molar) at various levels and observingtheirverticalorientation. 32|P a g e Figure.15
2.LateralHeadorProfileView(lateralcephalometrics) It shows the vertical and anteroposterior or sagittal dimensions. This type is most commonlyusedduringorthodonticdiagnosis. UsesofCephalometrics: 1. Classifythetypeoftheface. 2. Showtherelationshipbetweenthebasalpartsofthemaxillaandthemandible. 3. Evaluatethesofttissueprofile. 4. Evaluate the position of the incisors in relation to the basal parts and the soft tissueprofile. 5. A pretreatment record prior to the placement of appliances, particularly where movementoftheupperandlowerincisorisplanned. 6. Monitoringtheprogressoftreatment. 7. Tomakeagrowthpredictionwhentheorthodontictreatmentistobeconducted duringthegrowthperiod. 8. Research purposes e.g. information about growth and development by longitudinalstudies(serialcephalometricradiographsfrombirthtothelateteens). 9. Detecting for any abnormalities or pathology e.g. a pituitary tumor or enlarged adenoids. TracingTechnique Certainmaterialsareusedforthispurpose,whichare: 33|P a g e Tracingpaper 3Hdrawingpencil Gumeraser Millimeterrule Transparenttriangle Protractor Scotchtape Viewbox
MethodofTracing 1. Placethecephalographonthetablewiththeprofilefacingtoyourrighthand. 2. Placethetracingpaperoverthefilm(thedullsurfacefacingyou),withthelower borderofthepaperextendingaboutoneinchbelowthechinpoint. 3. Tapetheuppercornersofthetracingpapertotheradiograph. 4. Thetracingshouldbecarriedoutinadarkroomonalightviewingbox. 5. Trace the soft tissue profile, then the hard tissue profile, and then the dentition accordingtothefollowingtracingprocedure. 6. Ifbilateralstructuresarepresent,drawbothofthemandtaketheaverageofthe two. TracingProcedures(Fig.16) 1. Tracethesofttissueprofilestartingwiththeforehead,thennose,thenlips,then chintillthethroatanglebeyondthechin. 2. 3. 4. Tracehardtissueprofile;startwiththeforeheadandthefrontalsinuses. Tracethenasalbone. Tracetheanteriornasalspineandtheanteriorcontourofthemaxillauptothe interdentalalveolarcrestbetweenthecentralincisors. 5. Tracethefloorofthenoseandtheroofofthepalate.Tracetheposteriornasal spine. 6. Trace the anterior contour of the mandible starting from the interdental crest betweenthelowerincisors. 7. 8. Tracetheoutlineofthechinuptothesymphysis. Trace the lower border of the mandible from the symphysis to the angle of mandible. 9. Tracetheposteriorborderoftheramus.
10. Tracetheorbitfromthesupraorbitalridgetothemostinferiorportiononthe lowerborderoftheorbitknownasorbitale. 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.
34|P a g e
12. Tracethepterygomaxillaryfissurewhichisseenasaninvertedteardropshape just above the posterior nasal spine. The anterior contour of the fissure represents the posterior surface of the maxilla and its posterior contour representsthepterygoidbone. 13. Trace the shadow of the external acoustic meatus. It appears as an oval radiolucencyoropaqueringshadowduetoearrodsanditliesbehindtheupper mostsurfaceofthecondylarhead. 14. Tracethesellaturcica(saddleshapedpituitaryfossa). 15. Tracethemostprominentuppercentralincisorfromcrowntoroot. 16. Tracethemostprominentlowercentralincisor. 17. Tracetheupperandlowerpermanentfirstmolars. 18. Tracetheoccipitalbone.
Figure.16 35|P a g e
AnatomicPoints(Landmarks)oftheCephalometricRadiograph(Fig.16): 1. CranialBase a. Nasion(N):Themostanteriorpointonthefrontonasalsuture. b. Sella(S):ThemidpointofSellaTurcica. 2. Maxilla a. AnteriorNasalSpine(ANS): Themostanteriorpointonthemaxillaatthelevel floorofthenose. b. PosteriorNasalSpine(PNS):Themostposteriorpointonthemaxillaatthelevel floorofthenose. c. PointA(A):Thedeepestpointontheanteriorcontourofthemaxillabetween ANSandalveolarcrest,usuallyitisabout2mmanteriortotheapexofmaxillary centralincisor. 3. Mandible a. PointB(B):Thedeepestpointontheanteriorcontourofthemandiblebetween thechinandalveolarcrest. b. Pogonion(Pog):Themostanteriorpointonthecurvatureofbonychin. c. Menton(Me):Themostinferiorpointonthemandibularsymphysis. d. Gonion(Go):Themostinferiorposteriorpointontheangleofthemandible. 4. SoftTissue a. UpperLipPoint(UL)Themostanteriorpointofupperlipprofile. b. LowerLipPoint(LL)Themostanteriorpointoflowerlipprofile. c. SoftTissuePogonion(Pog):Themostanteriorpointontheprofileofsofttissue chin.
36|P a g e
CephalometricPlanesandLines(Fig.17): SNLineThisline,connectingthemidpointofSellaTurcicawithNasion,istaken torepresentthecranialbase. MaxillaryPlaneThelinejoininganteriornasalspinewithposteriornasalspine. MandibularPlaneThelinejoiningGonionandMenton. EstheticLineThelineconnectingthetipofthenosetothesofttissuePogonion.
CephalometricAnalysis: AngularandLinearMeasurements: Aseriesofanglesindegreeandafewlineardistancesinmillimetersaremeasuredand comparedtonormalvalues.Thedifferencesfromthenormalvaluesarenotedasplusor minus.Whenthedifferencesarebeloworabovethenormalranges,theyareconsidered asabnormal. The angles used in cephalometric analysis are formed at the junction of two planes, whichcouldbehorizontalorverticalplanes. Thecephalometricanalysiscanbedividedintothreeparts:Skeletalrelationship,Dental relationshipandSofttissuerelationship
1.SkeletalRelationships: a.SagittalRelationship SNA:MeasuredatthejunctionofSNlineand NA line (Fig. 18). It evaluates the antero posteriorpositionofthemaxillainrelationto theanteriorcranialbase.Thenormalaverage is 813 (normal or orthognathic maxilla). Whenthisangleisabovethenormalrangeit would be interpreted as prognathic maxilla, and when it is below the normal range, retrognathicmaxilla.
Figure.18
SNB:MeasuredatthejunctionofSNlineand NB line (Fig. 19). It evaluates the antero posteriorpositionofthemandibleinrelation 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 prognathic mandible, and when it is below thenormalrange,retrognathicmandible. 38|P a g e Figure.19
ANB:ThisangleisthedifferencebetweenSNAand SNB angle and indicates the amount of skeletal discrepancy between maxilla and mandible in anteroposterior position (Fig. 20). The normal range is 32 (skeletal Class I). A larger than normalanglewouldindicateaskeletalClassII,and smaller than 1 angle reflects a skeletal Class III relationship. Figure.20 b.VerticalRelationship SNMxpl: Measured at the intersection of SN line to maxillary plane (Fig. 21). It expresses the vertical inclination of the maxilla in relation to the anterior cranial base. The mean value is 83 (normally inclined maxilla), values greater than normalindicateaposteriorinclinationof the maxilla (clockwise rotation), and smaller values indicate an anterior inclination of maxilla (counterclockwise rotation). Figure.21
MaxPlMnPl:Measuredattheintersectionof themaxillaryplanewiththemandibularplane and relates the inclination of the mandible and the maxilla to each other (Fig. 22). The mean value is 274 (normal interbasal angle). If the angle exceeds the normal there is a skeletal open bite, whereas an angle less thanthemeanindicatesskeletaldeepbite. Figure.22 39|P a g e
FacialProportion(FP):Thisistheratioofthe lower facial height to the total anterior facial height and it is calculated as a percentage accordingtothisequation: FP= lowerfacialheight X100 totalfacialheight
Totalfacialheight=Lowerfacialheight+ Upperfacialheight. Figure.23 Lowerfacialheight:ThisisalinearmeasurementfromMentonperpendicularto maxillaryplane. Upper facial height: This is a linear distance is measured from Nasion perpendiculartomaxillaryplane(Fig.23). Innormalfacesthisindexhasavalueofabout55%2%(normallowerheight).A larger thanthis ratio will indicate increased lower facial height, smaller than this valuewillindicatedecreasedlowerfacialheight. 2.DentalRelationships: U1MxPl:Measuredattheintersectionofthelongaxisoftheuppercentralincisor withthemaxillaryplane(Fig.24). Itevaluatestheanteroposteriorinclinationof the most prominent maxillary central incisor. This angle averages 1096 (normal
inclinationofupperincisor). A larger than normal angle would indicate proclination of the upper central incisor and smaller than normal angle would indicate retroclinationofmaxillaryincisors. Figure.24
40|P a g e
L1 to MnPl: Measured at the intersection of the long axis of the lower central incisor with the mandibular plane (Fig. 25). It evaluates the antero posterior inclination of the most prominent incisor. A larger than normal angle would indicate proclination of lower incisors and a smaller than normal anglewouldindicateretroclinationofthemandibularincisors. Figure.25 mandibular central
L1toAPog:Thisisalineardistancemeasuredinmillimetersfromtheincisaledge of the lower incisor perpendicular to A Pog line (Fig. 26). This measurement averages +1 2 mm (normal position of lower incisors). A larger than normal distance would indicate protrusion of lower incisors and a smaller than normal value would indicate retrusion of the mandibularincisors. Figure.26
U1L1: The interincisal angle is measured at the junction of the long axis of upper central incisor withthelowercentralincisor(Fig.27)Itaverages 13510 (normal proclination of upper and lower incisors). The angle decreases with proclination of upper and lower incisors and increasewithretroclinationofincisors. Figure.27
41|P a g e
3.SoftTissueRelationship: NasolabialAngle:Measuredattheintersectionof alinedrawntangenttothebaseofthenoseanda linetangenttotheupperlip(Fig.28).Itaverages 100 degrees and its normal values range between 90 and 110 degrees. This angle is influenced both bytheinclinationofthecolumellaofthenoseand bythepositionoftheupperlip. Figure.28 Upper LipEL: This is a linear distance measured from the most anterior point on the upper lip perpendicular to the esthetic plane (tip of the nose to the soft tissue Pogonion) (Fig. 29). It averages 2 to 4 (normal position of upper lip whichisinsidetheline).Amorepositivedistance indicates the protrusion of the upper lip and a smaller measurement indicates the retrusion of theupperlip. LowerLipEL:Thisisalinearmeasurementfromthe most anterior point on the lower lip perpendicular totheestheticplane(Fig.30).Itaveragesfrom0to 2 inside the esthetic line (normal position of the lowerlip).Alargerdistanceindicatestheprotrusion of the lower lip and a smaller value indicates the retrusionofthelowerlip. Figure.29
CephalometricAnalysisForm
Measurement 1.SkeletalRelationship a.SagittalRelation MaxillatoCranium(SNA) MandibletoCranium(SNB) MandibletoMaxilla(ANB) b.VerticalRelation SNMxPl(SNtoANSPNS) MMPA(ANSPNStoGoMe) FacialProportion=
LowerFacialHeight(MeMxPl) TotalFacialHeight(NMe) X100=
Mean
Patient
Interpretation
813 783 32
83 274 55%2%
2.DentalRelationship UInctoMxPl LInctoMnPl LInctoAPog InterincisalAngle(UInctoLInc) 3.SoftTissueRelationship NasolabialAngle UpperlipEL LowerlipEL DiagnosticSummary: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 10010 1096 936 +12mm 13510
2to4mm 0to2mm
43|P a g e
3.ModelAnalysis
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 threedifferentviews:lateral,frontalandhorizontal. LateralView:Wecanobservefromthisviewthefollowing: Angle'sclassification. Caninerelationship. Overjet(horizontalrelationship). Overbite(verticalrelationship),lateraloverbiteorsupraeruption. CurveofSpee. Inclinationofthefrontteeth,primaryevaluation(bestdoneoncephalometrics). FrontalView:Thefollowingcanbeseen: Themidlinesi.e.therelationshipbetweentheupperandlowermidlines. Deviating axial inclination i.e. mesial, distal, buccal or lingual tipping of the front teeth. Ant.orpost.crossbite,unilateralorbilateral,includingonetoothoragroupofteeth. Scissorsbite,alsounilateralorbilateral,individualoragroupofteeth. Diastemas,weshoulddeterminetheamountinmillimeters. OcclusalView:Determinesthefollowing: Eruptionstage,deciduous/mixed/permanent. Symmetryofthearch. Shapeofthedentalarche.g.square,parabolic,vshaped. Deviationintoothmorphology,e.g.pegshapelateral/fusion. Spacecondition(Archlengthanalysis,Boltonanalysis).
44|P a g e
One of the most important aspects when viewing the study models is to observe the amountofspacerequiredfortheeruptionofteeth,alsotermedthespacecondition,as mentioned above. In order to estimate if there is any arch discrepancy and space available,andwhetherweneedtoextract,thefollowinganalysisModelAnalysishas beendeveloped: PlasterModelAnalysis: The most common analyses used are: Mixed dentition analysis, Arch length analysis (NanceAnalysis),Toothsizeanalysis(BoltonsAnalysis).
1. MixedDentitionAnalysis: This analysis is based on measurement of the mandibular permanent incisor. A quantitativeassessmentofcrowdingmaybeobtainedbythismixeddentitionanalysis. Thespaceavailableineachdentalarchismeasuredonthestudymodelsandthesumof the mesiodistal dimension of the unerupted teeth is determined by measuring the mesiodistaldimensionsofthefoureruptedmandibularpermanentincisors(Fig.31,ad). Thus, predicting the combined sizes of the unerupted canine and premolars using an equation.Thefollowingdiagramsshowthemethodusedstepbystep:
a.Measuringmesiodistaltoothsize ofincisors b.Transferringsizestosheet
c.Calculatingsumofmandibularincisors
d.Predictionofuneruptedcanineandpremolars
Figure.31
45|P a g e
HowtoapplyMixedDentitionAnalysis: Determine the maximum mesiodistal width of each of the four mandibular permanentincisorsinthestudymodel.Calculatetheirsum. UsingthecombinedMDwidthofthemandibularincisorsdeterminethepredicted sizeoftheuneruptedupper3,4and5(cuspid,firstandsecondbicuspids)onone side.ThiscanbefoundusingtheTanakaandJohnstonpredictionformula:
(Tanaka MM, Johnston LE: J Am Dent Assoc 88:798, 1974)
Add the total mesiodistal width of the maxillary permanent incisors to the predicted values of the upper permanent canines and premolars and that will constitutethespacerequiredintheupperarch. Calculatethespaceavailablefromthemesialofthepermanentfirstmolarinone sidetothemesialofthepermanentfirstmolarontheoppositeside. Analyzethespaceusingthisequation: The space available space required = will give us the space adequacy or inadequacytoaccommodatetheteeth Redothesameprocedureforthelowerarch.

46|P a g e
SpaceAnalysisinMixedDentition
CombinedMesiodistalwidthoflowerincisors = Predictedsizeofupper3,4and5(oneside) Predictedsizeoflower3,4and5(oneside) UPPERARCH SpaceRequired: Mesiodistalwidthofincisors Predictedsizeofupper3s,4sand5s SpaceAvailable: ArchCircumference(66) SpaceAnalysis: SpaceAvailableSpaceRequired LOWERARCH SpaceRequired: Mesiodistalwidthofincisors Predictedsizeoflower3s,4sand5s SpaceAvailable: ArchCircumference(66) SpaceAnalysis: SpaceAvailableSpaceRequired = = = = = = + + + X2 = = = = = = = = + + + X2 = = = = + + + = = =
mm mm mm
/2+11.0 /2+10.5
mm mm
mm
mm
mm mm
mm
mm
47|P a g e
2.ArchLengthAnalysis,NanceMethod: Itisimportanttoquantifytheamountofcrowdingwithinthearches,becausetreatment variesdependingontheseverityofthecrowding.Spaceanalysis,usingthedentalcasts, isrequiredforthispurpose.Sincemalalignedandcrowdedteethusuallyresultfromlack ofspace,thisanalysisisprimarilyofspacewithinthearches.Spaceanalysisrequiresa comparisonbetweentheamountofspaceavailableforthealignmentoftheteethand theamountofspacerequiredtoalignthemproperly. The first step is calculation of space available. This is accomplished by measuring arch perimeter from the mesial of one first molar to the other, over the contact points of posteriorteethandincisaledgeofanteriors.Thiscanbeachievedbydividingthedental archintosegmentsthatcanbemeasuredasstraightlineapproximationsofthearch. Thesecondstepistocalculatetheamountofspacerequiredforalignmentoftheteeth. This is done by measuring the mesiodistal width of each erupted tooth from contact point to contact point, estimating the size of unerupted permanent teeth, and then summingthewidthsoftheindividualteeth.Ifthesumofthewidthsofthepermanent teeth is greater than the amount of space available, there is an arch perimeter space deficiencyandcrowdingwouldoccur.Ifavailablespaceislargerthanthespacerequired (excessspace),gapsbetweensometeethwouldbeexpected. Thespaceavailablespacerequired=willgiveusthespaceadequacyorinadequacyto accommodatetheteeth
48|P a g e
SpaceAnalysisinthePermanentDentition
UpperArch
A.SpaceAvailable(Archcircumferencefrom mesialoffirstmolartomesialoffirstmolar)
B.SpaceRequired(CombinedMDwidthofthe permanentteethfrom5to5)
Difference(AB)

LowerArch
A.SpaceAvailable(Archcircumferencefrom mesialoffirstmolartomesialoffirstmolar)
B.SpaceRequired(CombinedMDwidthofthe permanentteethfrom5to5)
Difference(AB)
49|P a g e
3.ToothSizeAnalysis,BoltonAnalysis: For good occlusion, the teeth must be proportional in size. If large upper teeth are combinedwithsmalllowerteeth,asinadenturesetupwithmismatchedsizes,thereis nowaytoachieveidealocclusion.Althoughthenaturalteethmatchverywellinmost individuals, approximately 5% of the population have some degree of disproportion amongthesizesofindividualteeth.Thisisdefinedastoothsizediscrepancy.Ananomaly in the size of the upper lateral incisors is the most common cause, but variation in premolarsorotherteethmaybepresent.Occasionally,alltheupperteethwillbetoo largeortoosmalltofitproperlywiththelowerteeth. Toothsizeanalysis,sometimescalledBoltonanalysisafteritsdeveloper,iscarriedoutby measuringthemesiodistalwidthofeachpermanenttooth.Astandardtableisthenused to compare the summed widths of the maxillary to the mandibular anterior teethand thetotalwidthofalluppertolowerteeth(excludingsecondandthirdmolars). Aquickcheckforanteriortoothsizediscrepancycanbedonebycomparingthesizeof upper and lower lateral incisors. Unless the upper laterals are wider, a discrepancy almostsurelyexists.Aquickcheckforposteriortoothsizediscrepancyistocomparethe size of upper and lower second premolars, which should be about equal size. A tooth sizediscrepancyoflessthan1.5mmisrarelysignificant,butlargerdiscrepanciescreate treatmentproblemsandmustbeincludedintheorthodonticproblemlist. TheBoltonprocedurecanbesummarizedasfollows: Thesumofthemesiodistaldiameterofthe12maxillaryteethandthesumofthe mesiodistal diameter of the 12 mandibular teeth including the first molars is calculated,thisiscalledtheOverallRatio: Sumof12mandibularteeth Sumof12maxillaryteeth
OverallRatio=
X100=91.3%
Wecanusethesameequationfortheanterior6teethonlyfromcaninetocanine. ThiscalledtheAnteriorRatio:
AnteriorRatio= 50|P a g e
Sumof6mandibularteeth Sumof6maxillaryteeth
X100=77.2%
HowtoapplytheBoltonsAnalysis: Iftheoverallratioofthe12mandibularand12maxillaryteethismorethan91.3%,then the size of the teeth should be checked against normal MD width of the permanent teeth.Ifthemaxillaryteetharelargerorthemandibularteetharesmallerthannormal thecorrectcombinedwidthofthearchatfaultshouldbedeterminedusingthetableat thebottomofthispage. Whendeterminingtheanteriorratio,thesameprocedureasaboveisused,calculations aredonewhentheratioismorethan77.2%orlessthan77.2%.
IdealRatio Maxillary Mandibular 12Teeth 12Teeth
IdealRatio Maxillary Mandibular 6Teeth 6Teeth
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
77.8 78.5 79.4 80.3 81.3 82.1 83.1 84.0 84.9 85.8 86.7 87.6 88.6 89.5 90.4 91.3 92.2 93.1 94.0 95.0 95.9 96.8 97.8 98.6 99.5 100.4
40.0 40.5 41.0 41.5 42.0 42.5 43.0 43.5 44.0 44.5 45.0 45.5 46.0 46.5 47.0 47.5 48.0 48.5 49.0 49.5 50.0 50.5 51.0 51.5 52.0 52.5 53.0 53.5 54.0 54.5 55.0
30.9 31.3 31.7 32.0 32.4 32.8 33.2 33.6 34.0 34.4 34.7 35.1 35.5 35.9 36.3 36.7 37.1 37.4 37.8 38.2 38.6 39.0 39.4 39.8 40.1 40.5 40.9 41.3 41.7 42.1 42.5
51|P a g e
IV References
1. Profitt,WR,Fields,HWandSarver,DM.ContemporaryOrthodontics.Fourth edition,Mosby,Inc.,St.Louis,2006. 2. Thilander, B and Ronning, O. Introduction to Orthodontics. Fifth edition, Minab/Gotab,Stockholm,1985. 3. Walther,DPandHouston,WJ.OrthodonticNotes.Fifthedition,Butterworth HeinemannLtd.,Oxford1994. 4. Wisth, P. Introduction to the Edgewise Technique: A Technical Manual. UniversityofBergen,Norway,1985. 5. American Board of Orthodontics. Specific Instructions for Candidates. AmericanBoardofOrthodontics,St.Louis,1990.
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KingSaudUniversity CollegeofDentistry DepartmentofPreventiveDentalSciences

PreClinicalOrthodontics andDentofacialOrthopedics 431PDSCourse

SitesofSkeletalMaturityIndicators Radiographicidentificationofskeletalmaturityindicators(Fig.11) 1.Epiphysisequalinwidthtodiaphysis. 2. Appearanceofadductorsesamoidofthethumb. 3. Cappingofephiphysis. 4. Fusionofepiphysis.

Theepiphysesanddiaphysesinthemiddle SMI3 MP5 phalynxofthefifthfingerareequallywide. 10.8 12

Ossificationoftheepiphysisinthedistal SMI8 DP3u phalynxonthethirdfinger. 13 15

Ossificationoftheepiphysisinthe SMI9 PP3u proximalphalynxonthethirdfinger. 13.9 15.5

Figure.12 ElevenSkeletalMaturityIndicators(SMIs) 29|P a g e

a.Measuringmesiodistaltoothsize ofincisors b.Transferringsizestosheet

(Tanaka MM, Johnston LE: J Am Dent Assoc 88:798, 1974)

IdealRatio Maxillary Mandibular 12Teeth 12Teeth

IdealRatio Maxillary Mandibular 6Teeth 6Teeth

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