History:

• Biodata
• Presenting complain
• HPC
• PDH
• Dental habits
• PMH
• FSH
• Birth history
• Abnormal habits

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Clinical examination:

General examination

Extraoral examination:

• JACCLOWD
• TMJ movements – clicking or popping sounds, pain, path of closure
• Facial profile
• Facial symmetry
• Lip competency
• Incisor showing on smiling – Normally 2-4mm
• Nasolabial angle and lip protrusion:
  • Between upper lip and base of nose
  • Normal 90° – 110°
  • Convex – Class II, retrusive mandible
  • Concave – Class III, protrusive mandible
  • Becomes retrusive and obtuse angle with age

• Vertical facial relationship – Angle of lower border of mandible to cranium
  • Use occipital region to draw imaginary line
  • Average
  • Reduced – Short face syndrome: Deep bite, overlapped lips
  • Increased – Long face syndrome: Anterior open bite, incompetent lips

Intraoral examination:

• Oral hygiene status
• Type of dentition: primary, mixed, permanent
• Soft tissue and hard tissue examination

• Dental arches:
  • Crowding: mild, moderate, severe
  • Spacing
  • Tooth rotations: mesioversion, distoversion lingoversion, buccoversion, labioversion)
  • Tooth displacement
  • Ugly duckling stage

Orthodontic examination:

• Anterior – posterior plane: Molar, canine, incisor relationship – Class I, II, III
  • Molar malocclusions: Maxillary 6 MB cusp and mandibular 6 buccal groove.
    • Angles class I: 7 types:
      • 1. Maxillary teeth crowded
      • 2. Anterior teeth proclined
      • 3. Anterior crossbite
      • 4. Posterior crossbite
      • 5. Permanent molars drifted mesially
      • 6. Diastema
      • 7. Deep overbite
    • Angles class II:
      • Division I: Incisors proclined
      • Division II: Incisors retroclined
      • Subdivision: if right or left unilateral Angles class II
    • Angles class III:
      • Type 1: Edge to edge bite
      • Type 2: Normal overbite
      • Type 3: Anterior cross bite
      • Pseudo class III malocclusion: Mandible moves forward
• Vertical plane:
  • Overbite: Normal 20-40%. <20% = reduced overbite, >40% = deep bite
  • Open bite
  • Anterior crossbite/ reverse overjet
• Transverse plane:
  • Midline
  • Crossbite
  • Scissor bite

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Investigation

• OPG, study model, photograph, lateral cephalogram, CT scan

OPG:

• Name and age of patient
• Date when the x-ray was taken
• Quality
• Teeth present
• Dental age, development of crown and roots, root completion 2-3 years after eruption
• Radiolucent/radiopaque lesions

Study model analysis: Note date of impression, patient name, D.O.B, file number

a) Interarch analysis:

• A-P, transverse, vertical plane
• Use dividers to measure

b) Intra arch analysis: Maxillary and mandibular

• Shape (U, V)
• Arch symmetry (position of teeth, missing teeth)
• Palate vault
• Number of teeth present, or eupting
• Individual tooth malformation, malposition, or rotation

c) Space analysis:

• Arch parameter (X) = Measure arch from 5 to 5, distal surface
• Tooth material (Y)= Width of each tooth. Angles lines of occlusion:
  • Maxillary – use central fossa and cingulum (in anterior teeth)
  • Mandible – use buccal cusp tips and incisal edges
• Difference between arch parameter and tooth material:
  • X – Y = Positive (spacing), Negative (crowding)
  • ≤ 4mm = Mild crowding
  • 5-8 mm = Moderate crowding
  • > 9mm = Severe crowding

d) Bolton’s analysis: Maxillary and mandibular relationship for overbite/overjet

• Sum of mesiodistal width of 12 teeth: CI, LI, C, PM, PM, M1 on both sides

Sum of mandibular 12/Sum of maxillary 12 X 100 = 91.3% ± 1.91 (ie. range: 89.39-93.21)

• < 91.3% = Maxillary teeth in excess
• >91.3% = Mandibular teeth in excess

e) Anterior ratio: Maxillary and mandibular relationship for overbite/overjet

• Sum of mesiodistal width of 6 teeth: CI, LI, C on both sides

Sum of mandibular 6/Sum of maxillary 6 X 100 = 77.2% ± 1.65 (ie. range: 75.55-78.85)

• < 77.2% = Anterior maxillary teeth in excess
• >77.2% = Anterior mandibular teeth in excess

NB: Bolton’s analysis and anterior ratio cannot work if required teeth are missing

Photographs: Smile and profile analysis, record keeping

Lateral cephalogram analysis

Mixed dentition analysis using study models:

a) Radiograph/Huckaba analysis:

True width of 1st molar/Apparent width of 1st molar = True width of unerupted PM/Apparent width of unerupted PM

b) Moyer’s prediction table:

• Use sum of mandibular 4 incisors to predict mesiodistal width of permanent canine and premolars
• 75 percentile usually used

c) Tanaka and Johnston:

• Estimated mesiodistal width of canine and premolar of one quadrant = 1/2 of the mesiodistal width of mandibular 4 incisors + 10.5mm (for mandible) or 11mm (for maxilla)

d) Nance – Arch perimeter analysis:

• Mesiodistal width of erupted permanent teeth and from IOPA of unerupted teeth

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Diagnosis

• List name, age and gender
• Write problem list in priority
• Eg. Angles class I malocclusion with an anterior open bite extending from 15/45 to 25/35, with an overjet of 6mm and tongue thrusting habit

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Treatment plan

• List treatment objectives according to PC and priority
• List treatment plan

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Cephalometric analysis

• S – Sella turcica – center of pituitary fossa
• N – Most anterior point of frontal and nasal bone junction
• A – Inner most point between ANS and incisor
• B – Inner most point between mandible and incisor
• Pog – Anterior most point of mandible
• Gn – Most anterior inferior point of bony chin
• Go – Point where posterior border of ramus and lower border of mandible bisect
• Porion – External auditory meatus upper contour midpoint
• Orbitale – Inferior margin of orbit – lowest point
• Frankfort plane (FH) – Porion to orbitale
• Occlusal plane – Use molars and premolars
• Mandibular plane – Gn to Go

Steiner’s analysis

Skeletal analysis:

1. SNA angle: 82° ± 2

• Ant-post position of maxilla with cranial base
• Increased angle = Prognathic maxilla

2. SNB angle: 80° ± 2

• Ant-post position of mandible with cranial base

3. Angle ANB: 3 ± 1

• Difference between SNA and SNB – magnitude of skeletal jaw discrepancy
• Factors affecting:
  • Vertical height of face
  • Abnormal position of nasion
• Increased angle = Class II
• Decreased angle = Class III

4. Mandibular plane angle: 32° ± 4

• Steepness of mandibular plane to cranial base
• Increased angle = Vertical growth
• Decreased angle = Horizontal growth

5. Occlusal plane angle: 17° ± 4

• Determine relationship of teeth in occlusion with cranial base
• Increased angle = Skeletal open bite
• Decreased angle = Skeletal deep bite

Dental analysis:

1. U_I – NA angle and distance: 22°, 4mm

• > 4mm or increased angle = Protrusion eg. class II division 1
• < 4mm or decreased angle = Retrusion eg. class II division 2

2. L_I – NB angle and distance: 25°, 4mm

• > 4mm or increased angle = Protrusion eg. class II division 1
• < 4mm or decreased angle = Retrusion eg. class II division 2/ class III

3. Interincisal angle: 130°-131°

• Increased angle = Class II division 2
• Decreased angle = Class II division 1

4. Lower incisor to chin (Holdaway ratio)

Soft tissue analysis: