Category Archives: Basic Dentistry

Behavior management

Non pharmacological

1. Tell show do

  • Tell – Explain procedure with age appropriate language
  • Show – Demonstrate procedure
  • Do – Perform procedure

Communication should be gentle, addressing the child. Use euphemism (eg. call LA “sleeping juice”, rubber dam “umbrella”) and smile. Have positive reinforcement.

2. Behavior modelling – Show other children getting procedures and how they behave

3. Distraction – Music, videos, virtual reality

4. Relaxation therapy – Relaxation exercises to do at home

5. Systemic desensitization – Present the procedure in a graduated fashion to reduce anxiety

6. Hypnosis – Altered state of consciousness to produce desirable behavior

7. Aversive techniques: Must obtain parent consent, informed consent, document indication and duration. Should be legal in country of practice and be used with extreme caution.

  • Hand over mouth – and explain in child’s ear. Contraindicated in children below 3 and special health care needs
  • Protective stabilization – can cause physical and psychological harm. Active is by dental team, passive is by protective devices
  • Voice control – Changing volume, speed or tone of voice to get child’s attention


  • Nitrous oxide
  • Conscious sedation
  • General anesthesia

Prescribing Drugs

Factors when prescribing

  • Safety
  • Efficacy
  • Affordability
  • Availability
  • Route of admin
  • Frequency

How to prescribe

1. Formulation of drug: PO, IV, IM, PV, PR

2. Name of drug: Paracetamol, Amoxycillin

3. Dosage: mg, g, avoid decimals

4. Frequency: OD, BD, TDS, Nocte, PRN (state minimum dose interval in PRN)

5. Duration: 5/7, 2/52, 3/12

Eg. PO Augmentin 625mg BD x 5/7

  • 1-5 years: 1/4 of adult dose
  • 6-12 years: 1/2 of adult dose

Calculating Drug dosage

The Reference Manual of Pediatric Dentistry – Useful Medications For Oral Conditions

Use the app Dental Drugs (App storePlay store) to quickly refer for prescribing medications, calculating maximum anesthetic dosages or recalling common treatment/emergency protocols in practice

Radiology: X-Ray positions

Bilateral bite wing (BBW)

  • Patient head straight so occlusal plane is parallel to the floor
  • Bite should be normal
  • X-ray central beam:
    • Vertical angulation: +10°
    • Horizontal angulation:
      • Premolar BBW: 30° from mid-sagittal plane, aimed at inner canthus of the eye
      • Molar BBW: 60° from mid-sagittal plane, aimed at outer canthus of the eye

Watch video

Intraoral periapical (IOPA)

  • Identification dot on film always placed towards incisal/occlusal surface of teeth and towards midline
  • Vertical angulation at occlusal plane is zero, upward is negative and downwards is positive


  • Patient head slightly tilted down so occlusal plane is parallel to the floor
ToothVertical film angulationX-ray central beam aim
Incisors+45°Tip of the nose
Canine+45°Canine eminence – distal and inferior borders of ala of nose
Premolars+30°Perpendicular to pupil of the eye, film is horizontal
Molars+20°Perpendicular to outer canthus of the eye, film is horizontal
IOPA x-ray positions for maxillary teeth


  • Patient head slightly tilted up so occlusal plane is parallel to the floor
  • Film must touch floor of the mouth
ToothVertical film angulationX-ray central beam aim
Incisors-15°Tip of the chin
Canine-20°Perpendicular to ala of nose
Premolars-10°Perpendicular to pupil of the eye
Molars-5°Perpendicular to outer canthus of the eye
IOPA x-ray positions for mandibular teeth

Watch video

Orthopantomogram (OPG)

OPG landmarks

Other radiograph techniques

Intraoral radiographs

Extraoral radiographs:

Extraoral radiographs
Image from Pocket Dentistry

Chronology of tooth development and eruption

Primary teeth

  • Sequence of eruption: A-B-D-C-E
Notation of primary teeth
(Weeks in utero)
Crown completion
Root completion
Primary teeth development and eruption

Permanent teeth

  • Sequence of eruption:
    • Maxilla: 6-1-2-4-5-3-7-8
    • Mandible: 6-1-2-3-4-5-7-8
Tooth numbering in maxilla and mandible
ToothArchTooth germ appearance (IU)Beginning of crown calcificationCrown calcification completeEruptionRoot completion
16At birth2.5-3 years6-7 years9-10 years
163-4 months3-4 years7-8 years
6-7 years
10 years
9 years
1610-12 months
3-4 months
4-5 years8-9 years
7-8 years
11 years
10 years
184-5 months6-7 years11-12 years
9-10 years
13-15 years
12-14 years
201.5-2 years5-6 years10-11 years12-13 years
22-242-3 years6-7 years10-12 years
11-12 years
12-14 year
1st year2.5-3 years7-8 years12-15 years
11-13 years
14-16 years
3rd year7-9 years
8-10 years
12-16 years17-24 years
17-21 years
18-25 years
Secondary teeth development and eruption

Common teeth notation systems:

  • FDI World Dental Federation notation
  • Universal Numbering System
  • Palmer notation
Common teeth notation systems
© 2021 DentaGama

Tooth extraction

Patient positioning when extracting teeth

  • Maxillary teeth: 3 inch below shoulder level of operator and 45 degree chair angulation
  • Mandibular teeth: At elbow level of operator and 90 degree chair angulation
  • 1st, 2nd and 3rd quadrant: Right front of patient
  • 4th quadrant anterior teeth: Right front of patient
  • 4th quadrant posterior teeth: Behind right side of patient/ just right side

Tooth extraction forceps and elevators

Click here

Tooth extraction techniques

Elevator techniques

Elevators works on principles of:

  1. Wedge
  2. Lever
  3. Wheel and axle
  4. Combination of the above

1. Wedge principle

Wedge principle

2. Lever principle

Lever principle

3. Wheel and axle

Wheel and axle

Post extraction steps

  • Ensure complete tooth and root removal and confirm by showing to patient
  • Inspect socket and remove sharp bony margins – if present smoothen with a file
  • Compress expanded socket with digital pressure
  • Apply pressure pack
  • Prescribe analgesics if needed

Post op instructions for patient

  • Bite on pressure pack for 30-60 minutes
  • Swallow saliva normally
  • Do not rinse or spit for 24 hours
  • Do not stick finger or tongue at extraction site
  • Drink water and fluids normally, do not use straw
  • Do not eat until the effects of anesthesia go away
  • Eat soft and cold diet
  • Apply cold compression/ice pack for swelling
  • After 24 hours use salt water rinse
  • Avoid smoking for 5 days


  1. Gross caries
  2. Tooth injury and tooth cannot be salvaged
  3. Tooth in jaw fracture line
  4. Impacted tooth
  5. Pre-prosthetic preparation
  6. Orthodontics
  7. Supernumerary teeth
  8. Associated pathology
  9. Severe periodontal disease
  10. Retained deciduous teeth
  11. Patient preference/economic constraints
  12. Preparation for radiotherapy



  1. History of irradiation in that area
  2. Lack of cooperation or consent from patient
  3. Lack of proper equipment
  4. Lack of adequate skill
  5. Severe infections – control infection first


  1. Severe metabolic disease – uncontrolled DM, renal disease
  2. Hepatic dysfunction – decreased coagulative factors
  3. Coagulopathies – hemophilia, platelet disorder
  4. History of CVD
  5. Leukemia
  6. Pregnancy
  7. Steroid therapy



a. Complication due to injection technique and anesthetic solution:

  • Needle brakage
  • Failure to work
  • Allergy
  • Syncope
  • Hematoma if in vessel

b. Complication pre-op

  • Lack of cooperation, anxiety
  • Poor access – trismus, decreased mouth opening, crowded/malaligned teeth

c. Complications during surgical procedure

  • Difficulty in luxation – root dilaceration, curvature, hypercementosis
  • Soft tissue injury
  • Damage to adjacent teeth
  • Fracture of mandible, alveolus or tuberosity
  • Fractured instrument – eg. needle
  • Tooth/root displacement into maxillary antrum – Caldwell Luc approach to remove
  • Loss of extracted tooth or root – stop everything and look for it, can do chest xray
  • Nerve injury:
    • Neuropraxia – temporary conduction loss
    • Axonotmesis – axon and myelin sheath damaged but epineurium, perineurium and endoneurium intact
    • Neurotmesis – nerve transection
    • Paresthesia – tingling/prickling sensation
    • Dysesthesia – abnormal sensation
    • Hyperesthesia
    • Hypoesthesia
    • Anesthesia
    • Formation of:
      • Phantom limb syndrome
      • Anesthesia dolorosa – sense of touch diminished but malfunctioning painful sensation left intact in trigeminal nerve

d. Complications after procedure

  • Hemorrhage
    • Primary – laceration of artery, surgery done in infected area with granulation tissue
    • Reactionary – occurs few hours after surgery , failure of coagulation
    • Secondary – 7-10 days after surgery, due to infection + partial division of blood vessel
  • Alveolar osteitis
  • Infection
  • Delayed healing
  • Pain

Extraction forceps and elevators

Maxillary extraction forceps

Maxillary anterior forceps – Incisors and canines

Maxillary anterior forceps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary premolar forceps – Premolars

maxillary premolar forceps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary molar forceps – Molars

Maxillary molar forceps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary cow horn forceps – Molars with extensive loss of coronal structure

Maxillary cow horn forceps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary third molar forceps – Third molars

maxillary 3rd molar foreps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary bayonet forceps – Roots

Maxillary bayonet forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular extraction forceps

Mandibular anterior forceps – Incisors and canines

Mandibular anterior forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular premolar forceps – Premolars

Mandibular premolar forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular molar forceps – Molars

Mandibular molar forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular cow horn forceps – Molars with extensive loss of coronal structure

Mandibular cow horn forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular third molars forceps – Third molars

Mandibular third molars forceps
©Association of Oral and Maxillofacial Surgeons of India


Straight elevator – Luxation of maxillary and mandibular teeth

Straight elevator
©Association of Oral and Maxillofacial Surgeons of India

Coupland elevator – Split multi-rooted teeth and are inserted between the bone and tooth roots and rotated to elevate them out of the sockets

Coupland elevator
©Association of Oral and Maxillofacial Surgeons of India

Apexo elevator – Extraction of root pieces

Apexo elevator
©Association of Oral and Maxillofacial Surgeons of India

Cross bar elevator – Extraction of mandibular roots

Cross Bar elevator
©Association of Oral and Maxillofacial Surgeons of India

Cryer elevator – Extraction of roots, elevation of upper third molars

Cryer elevator
©Association of Oral and Maxillofacial Surgeons of India

Warwick James elevator – Extraction of retained roots, deciduous teeth, maxillary third molars, and teeth with less resistance

Warwick James elevator
©Association of Oral and Maxillofacial Surgeons of India

Root tip elevator – Removal of apical root tips/fragments of roots

Root tip elevator
©Association of Oral and Maxillofacial Surgeons of India

Local Anesthesia

Techniques of administrating LA

Nerve block in maxilla and mandible

1. Inferior alveolar nerve block: Mandibular posterior teeth


  • Between pterygomandibular raphe and coronoid notch (feel with thumb)
  • Insert from contralateral side, 1cm above occlusal plane
  • Contact bone, withdraw slightly and give LA

2. Mental nerve block: Mandibular anterior teeth


  • Between 1st and 2nd premolar

3. Anterior, middle, posterior superior alveolar nerve block: Maxillary teeth


  • At junction of mucobuccal fold

4. Greater palatine nerve block: Maxillary posterior teeth


  • In front of 1st molar at junction of vertical and horizontal hard palate
  • Withdraw after contacting bone

5. Nasopalatine block: Maxillary anterior teeth


  • Insert in incisive papilla

6. Infiltration: Picture

  • At mucogingival level

7. Buccal Infiltration: Picture

  • Parallel to occlusal plane
  • Distal to 2nd molar

8. Intrapapillary: Picture

9. Intraligamentary (supplemental): Picture

10. Intrapulpal (supplemental): Picture

11. Intraosseous (supplemental): Picture

12. Gow-Gates technique: Video

13. Vazirani-Akinosi technique: Video

Calculating LA dosage

Use the app Dental Drugs (App store, Play store) to quickly refer for prescribing medications, calculating maximum anesthetic dosages or recalling common treatment protocols in practice

Desirable properties of LA

  • Non irritant
  • Reversible effect
  • Long enough duration for procedure
  • Low toxicity
  • Fast onset of action
  • Potent

Mechanism of action of LA

LA = Tertiary amine base [B] + Water soluble hydrochloride [B.HCl]

  • Injected into tissues
  • Base liberated in alkaline pH of tissues

B.HCl + HCO3 = B + H2CO3 + Cl

  • Base diffuses through nerve sheath into axoplasm and partially ionizes

B + H+ = BH+

  • Ionized form of BH+ enters sodium channel from interior of nerve and combines with a specific receptor in the channel to block sodium influx into the nerve and therefore prevent action potential initiation

BH+ + Receptor = Block sodium influx

Mechanism of action of local anesthesia

Structure of LA

Aromatic group – Intermediate bond (amide/esters)- Tertiary amine

Structure of local anesthesia


  • Lignocaine
  • Prilocaine – metabolism in liver and lungs. Primary product of metabolism is ortho-Toluidine – associated with methemoglobinemia
  • Mepivacaine
  • Bupivacaine


  • Cocaine – Only cocaine causes vasoconstriction
  • Procaine – used in case of drug induced arteriospasm. Procaine broken down to PABA – associated with allergic reaction.
  • Amethocaine
  • Chloroprocaine

Factors affecting LA action

1. pKa (physiologic pH): ↓ pKa leads to faster onset of action as ↑ molecules diffuse through the nerve sheath

2. Lipid solubility: ↑ lipid solubility leads to ↑ potency and therefore block conductions at low concentration

3. Protein binding: ↑ protein binding leads to ↑ duration of action as it firmly attaches to proteins at receptor sites

4. Non nervous tissue diffusibility: ↑ diffusibility leads to slower time of onset

5. Vasodilator activity: ↑ vasodilator activity leads to ↑ blood flow to region and therefore ↑ removal of anesthetic molecules and so ↓ potency and duration

6. Tachyphylaxis: ↑ tolerance when injected repeatedly. Mop up of HCO3, alkaline pH of tissues not sustained

7. Infection: Acidic pH therefore prevent ready formation of free base

Contents of LA

Local anesthetic agentLignocaine HCLBlock nerve conduction
VasoconstrictorEpinephrine– Increase duration by decreasing absorption of LA
– Control bleeding
– Prevent systemic toxicity
Reducing agentSodium metabisulphiteAntioxidant
PreservativeMethylparabenBacteriostatic and antioxidant
Isotonic solutionSodium chloride or Ringer’s solution
Diluting AgentDistilled water
To adjust pHSodium hydroxide
Nitrogen bubble1-2mm in diameterTo prevent oxygen from being trapped in the cartridge and potentially destroying the Vasopressor or vasoconstrictor
Contents and their function in LA

Pharmacokinetics of LA

1. Uptake:

  • LA causes vasodilation and increased uptake into circulation
  • Esters cause more vasodilation
  • Procaine used in case of drug induced arteriospasm
  • Only cocaine causes vasoconstriction

2. IV of LA:

  • May cause increased toxicity/adverse effect
  • Used to treat ventricular dysrhythmias
  • Local and systemic toxicity effects:
Local and systemic complications of LA
LA systemic toxicity

3. Toxicity: Balance between absorption into circulation and rate of elimination from circulation

4. LA crosses blood brain barrier (BBB) and placental barrier

5. Esters metabolized by pseudocholinesterase

  • Atypical pseudocholinesterase – cannot metabolize esters – increase toxicity
  • Pseudocholinesterase also metabolize succinylcholine – therefore atypical pseudocholinesterase associated with difficult general anesthesia (sleep apnea). Succinylcholine used to cause short term paralysis as part of GA
  • Procaine broken down to PABA – associated with allergic reaction

6. Amides metabolized in liver

  • Liver perfusion and function important to determine rate of amide elimination
  • Liver cirrhosis, hypotension and congestive heart failure – reduce rate of elimination and therefore increase toxicity
  • Prilocaine metabolism in liver and lungs. Primary product of metabolism is ortho-Toluidine – associated with methemoglobinemia

Contraindications of LA

AbsoluteLA allergyEg. to estersGive amide
AbsoluteSulfur allergyAvoid articaineGive non sulfur containing LA
AbsoluteBisulfite allergyAvoid LA with vasoconstrictorGive LA with no vasoconstrictor
RelativeAtypical pseudocholinesteraseAvoid estersGive amide
RelativeMethemoglobinemia Avoid articaine and prilocaineGive other LA
ASA (III-IV)Significant liver dysfunctionAvoid amidesGive esters judicially
ASA (III-IV)Significant renal damageAvoid amides and estersGive LA judicially
ASA (III-IV)Significant CVDAvoid high concentration of vasoconstrictorGive LA with epinephrine concentration 1:100,000 or 1:200,000
ASA (III-IV)Clinical hyperthyroidismAvoid high concentration of vasoconstrictorGive LA with epinephrine concentration 1:100,000 or 1:200,000
Contraindications of LA

History, clinical examination and treatment planning



  1. Date
  2. File number
  3. Full name
  4. Age/date of birth
  5. Gender
  6. Contact
  7. Physical address
  8. Occupation
  9. Name of guardian/parent – for children
  10. Source of referral (if referred)

Presenting complaint

In patients own words, what is the problem

History of presenting complaint

  • S – Site
  • O – Onset
  • C – Character (throbbing, continuous, dull, acute, sharp)
  • R – Radiation (to head)
  • A – Associated symptoms (fever, discharge)
  • T – Timing (day or night, after eating)
  • E – Exacerbating factors (hot/cold food), Alleviating factors (Pain medications)
  • S – Scale (scale of 1-10, rate the pain)

Previous treatments concerning the presenting complaint

Past dental history

  • Index visit or
  • Previous dental treatments done
    • What they were
    • When
    • Where
    • If extraction done – any complications
    • Tolerance to LA

Dental habits

  • How many times do they brush their teeth
  • How do they brush
  • Which toothpaste
  • How often they change their brush
  • Any interdental cleaning methods used – floss, toothpicks
  • Abnormal habits eg. mouth breathing, lip sucking

Past medical history

  • History of chronic illness:
    • CHD/CVS, infective endocarditis
    • Respiratory – asthma, bronchitis
    • GIT – peptic ulcers, diarrhea, vomiting, jaundice, hepatitis, gastritis
    • Diabetes
    • CNS disorders
    • Bleeding disorders – hemophilia, anticoagulant therapy
    • Infectious diseases – TB, HIV, Herpes
    • On any medications – NSAID, corticosteroids, anticoagulants, anticonvulsants
  • Previous hospital admission – When, where, why, treatment provided
  • Food or drug allergy

Obs and gyn history for females

  • Last menstruation date and regularity
  • Pregnancy status
  • Type of contraceptives used

Family social history

  • Alcohol – amount and frequency
  • Smoking – amount and frequency
  • Drugs
  • Family status – parents, siblings, chronic illness in family
  • Martial status and children
  • Water source – borehole or city council

For pediatric and orthopedic patients

Birth history:


  • Health and nutritional status of mother during pregnancy
  • Complications during pregnancy:
    • Infections – rubella, TB, syphilis, UTI
    • Pre-eclampsia
    • Hypertension
    • Diabetes
    • Antepartum bleeding
  • Drugs
  • X-ray
  • Rh incompatibility may result in erythroblastosis fetalis – leading to green blue discoloration of dentition. Picture


  • Full term or premature
  • Mode of delivery – Normal/C-section and why?
  • Did the baby cry on birth
  • Birth weight
  • Breast fed or formula milk given


  • Vaccinated
  • Developmental history
  • Nocturnal feedings/sweetened milk – predisposes to early childhood caries (read more)
  • Brushing habits – frequency, by who, supervised?


  • Finger sucking/thumb sucking
  • tongue thrusting
  • Mouth breathing
  • Nail biting – check nails

Diet chart

  • 24 hour diet chart
  • 7 day diet chart (as investigation)

Family social history

  • Name of school
  • Class
  • Performance in school
  • Social or antisocial
  • Occupation of parents
  • Family history
  • Water source

Clinical examination

General examination

  • Anxious or calm
  • Build, nourishment – well, poor
  • Posture

Vital signs:

  • Temperature
  • Pulse rate
  • Respiratory rate
  • Blood pressure

NB: Also measure weight and height for children – to calculate BMI and dosage of LA and drugs

Extra oral examination

  • Palpate submental, submandibular and neck lymph nodes
  • Facial symmetry – any swellings or asymmetry
  • Facial profile
  • Scars
  • Eyes – jaundice (look down), pallor (look up)
  • TMJ movements – clicking or popping sounds, pain, path of closure
  • Lips competency
  • Hands – examine nails, finger clubbing, cyanosis

Remember it as: J A C C L O W D (Jaundice, anemia, clubbing, cyanosis, lymphadenopathy, oedema, wasting, dehydration)

Intraoral examination

  • Oral hygiene status
  • Type of dentition: primary, mixed, permanent

Soft tissue examination:

  • Gingiva – shape, size, color, bleeding, ulceration, growths, pockets, recession
    • Plaque and gingival score
  • Buccal mucosa – color, texture, ulcer, growth, sinus
  • Floor of mouth – swellings, ulcer
  • Tongue – size, movements, plaque
  • Palate – normal, high vault, clefts
  • Tonsils – normal, swollen
  • Frenal attachments – normal, higher

Hard tissue examination:

  • According to quadrants
  • Teeth present
  • Teeth missing
  • DMF
  • Palpate, percuss
  • Check interproximal caries with floss
  • Wear (attrition, abrasion, erosion)
  • Discoloration
  • Malformation
  • Mobility – Millers classification 1950
    • 0 = No detectable mobility
    • 1 = Distinguishable mobility
    • 2 = Horizontal movement > 1mm
    • 3 = Horizontal and vertical movement > 1mm
  • Orthodontic assessment
  • Fluorosis – TF score for every tooth
TF score for fluorosis

Tooth fracture classification

Periodontal assessment


  • Color: Pink, physiologic pigmentation, red, cyanotic
  • Size: Mild, moderate, severe inflammed
  • Shape: Scalloped, rounded, col – if space between 2 teeth
  • Consistency: Firm, flabby
  • Texture: Stippling on attached gingiva

Oral hygiene:

  • Calculus – presence of supra or subgingival calculus
  • Plaque seen with naked eye

Gingival index by Loe and Silness 1963:

  • Facial and lingual surface of index teeth: 16, 11, 24 and 36, 31, 44
  • Rate:
    • 0 = Normal
    • 1 = minimal inflammation, erythema, no bleeding
    • 2 = Bleed on probing
    • 3 = Spontaneous bleeding
  • Find mean score
  • GI score:
    • 0-1 = Mild
    • 1-2 = Moderate
    • 2-3 = Severe

Periodontal index by Turesky et al modified Quigley Hein 1970:

Index teeth and disclosing tablet

  • 0 = No plaque
  • 1 = Flecks at cervical margin
  • 2 = Thin continuous band at cervical margin
  • 3 = Band wider than 1mm, < 1/3 of crown
  • 4 = Plaque < 2/3 of crown
  • 5 = Plaque > 2/3 of crown

Furcation involvement – Glickman classification 1953

  • Grade 1 – Incipient, pocket formation into furcation fluting, interradicular bone intact
  • Grade 2 – Moderate loss of interradicular bone but not through and through
  • Grade 3 – Probe goes through and through, orifice occluded by gingival tissue
  • Grade 4 – Exposed furcation

Periodontal charting:

  • Draw continuous line of free gingival margin – facial and lingual
  • Draw interrupted line indicating bone level on facial side
  • Record 6 point pocket depth
  • Record tooth mobility
  • Record missing teeth (X), open contacts(//) and how many mm, overhang restorations (V)
  • Calculate clinical attachment loss (CAL): Gingival recession + pocket depth
    • 1-2mm = Mild
    • 3-4mm = Moderate
    • > 5mm = Severe
    • Localized: < 30% of sites
    • Generalized: > 30% of sites

Orthodontic assessment

  • A-P: Molar, canine, incisor relationship – Class I, II, III
  • Vertical: Open bite, overbite – deep or open
  • Transverse:
    • Crossbite anterior or posterior
    • Midlines
    • Crowding or spacing
    • Rotation or displacement
    • Proclination
  • Upper and lower arch form – Normal, V shape, square shape


  • Radiological – describing a x-ray:
    • Name and age of patient
    • Date when the x-ray was taken
    • Quality
    • Teeth present
    • Dental age and why
    • Radiolucent/radiopaque lesions
  • Microbiological
  • Histopathological
  • Study model
  • Diet chart
  • Plaque score
  • BMI


  • Summarize findings: eg. A 5 year old African male with early childhood caries, dentoalveolar abscess secondary to extensive decay on 55, irreversible pulpitis 85 and 75, and occlusal caries on 54, 64, 84, 74
  • For periodontal diagnosis: Severity – extent – diagnosis, eg:
    • Mild – localized – chronic periodontitis
    • Moderate – generalized – plaque induced gingivitis secondary to orthodontic treatment and mouth breathing

Prognosis for periodontology

1. Excellent prognosis:

  • No bone loss
  • Excellent gingival condition
  • Good patient co-operation
  • No systemic/environmental factors

2. Good prognosis:

  • Adequate remaining bone support
  • Adequate control of etiologic factors and maintainable dentition
  • Adequate patient co-operation
  • No systemic/environmental factors or well controlled

3. Fair prognosis:

  • Less than adequate bone support
  • Some tooth mobility
  • Grade 1 furcation
  • Adequate maintenance possible
  • Acceptable patient co-operation
  • Presence of limited systemic/environmental factors

4. Poor prognosis:

  • Moderate-advanced bone loss
  • Tooth mobility
  • Grade 1 or 2 furcation involvement
  • Doubtful patient co-operation
  • Presence of systemic/environmental factors

5. Questionable prognosis:

  • Advanced bone loss
  • Tooth mobility
  • Grade 2 or 3 furcation involvement
  • Inaccessible areas
  • Systemic/environmental factors

6. Hopeless prognosis:

  • Advanced bone loss
  • Extraction indicated
  • Non maintainable areas
  • Uncontrolled systemic/environmental factors

NB: Factors affecting prognosis:

  • Diagnosis: Disease severity, plaque and calculus
  • Systemic factors: DM, puberty, genetic
  • Occlusal factors
  • Prosthetic and restorative factors: Caries, teeth vitality, abutment selection, subgingival restorations, fixed or removable prosthesis
  • Patient factors: Compliance, co-operation, attitude
  • Environmental factors: Smoking, alcohol. bruxism

Treatment objectives

  1. To control infection and relieve pain and discomfort
  2. To modify attitude to dental care, and behavior to dental treatment
  3. To improve oral hygiene
  4. To restore integrity and function of the dentition
  5. To achieve cariostasis
  6. To improve esthetics and correct malocclusion
  7. To maintain a healthy oral cavity
  8. Diet planning

Treatment planning

  1. Oral hygiene instruction (OHI)
  2. Emergency phase: Systemic diseases, infections
  3. Etiological phase: Plaque and calculus
  4. Restorative phase: Filling, RCT, Prosthetic replacement
  5. Maintenance phase: Recall and review

Periodontal treatment planning

  1. Preliminary phase: Systemic disease, infections, OHI
  2. Etiological phase: FMS, root planing, fluoride treatment, cavity prep and filling
  3. Surgical phase: Disimpaction, gingivectomy, implants, open flap debridement, GTR, furcationplasty
  4. Restorative phase: Crown, bridge, crown for implant
  5. Supportive periodontal therapy/maintenance phase: Review after 2 weeks
    • High risk – recall every 3 months
    • Moderate risk – recall every 6 months
    • Low risk – recall every year

Pediatric treatment planning

  1. Systemic phase – Stabilize chronic illness before dental treatment
  2. Emergency phase – Antimicrobials
  3. Preventive phase – OHI, behavior management, fluoride application, diet counselling, pit and fissure sealants
  4. Preparatory phase – Oral prophylaxis, caries control if multiple lesions, preventive orthodontic consultation
  5. Corrective phase – Restorations, prosthetic replacement, extractions, Interceptive orthodontic consultation
  6. Maintenance phase – Recall and review, 3-6 months
  • Significance of oral prophylaxis:
    • Introduction to dental environment/behavior management
    • Oral hygiene education
    • Uncover carious lesion covered in plaque
    • Healthy gingiva

Orthodontic History, Examination, Investigation, Treatment Planning and Cephalometric Analysis


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

Clinical examination:

General examination

Extraoral examination:

  • 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
Nasolabial angle
  • 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
Vertical facial relationship

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


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


  • 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

Bolton's analysis and anterior ratio

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
Moyer's prediction table

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


  • 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

Treatment plan

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

Cephalometric analysis

Cephalometric landmarks

  • 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
Cephalometric planes

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. UI – 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. LI – 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:

Soft tissue analysis
Steiner's analysis
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