Diagnosis &

Treatment Planning
“The first step toward cure is to
know what the disease is......”
The Goal of an Orthodontist..........
1. To obtain optimal occlusion with in a
framework of skeletal bases.
2. With the nerves, muscles surrounding in
harmony.
3. Normal function and stability.
4. And maintaining the health of the
surrounding tissues (PDL, gingiva, TMJ,
etc…).

3
Basic objectives of orthodontic
treatment

Jackson’s Triad
 Functional Efficiency
 Structural Balance
 Esthetic Harmony

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Jackson’s Triad:
 Functional stability
 Structural balance
 Esthetic harmony

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TO be spoken out by sir, No need of this
slide, thus delete it before presentation.
 Although this is definitive, it is obvious that it means different
things to different persons, so much so that large segments
of orthodontic profession, if presented with single case, would
start out in different directions toward different objectives by
different orthodontic means.
 The last should matter little except that orthodontists, being
committed to certain appliances with their inherent limitations,
are not free to be objective about their objectives.
 Concepts and standards have been devised which are
subservient to appliance limitations.
 These concepts and resultant orthodontic objectives are as
different as black and white.
A CRITICAL ANALYSIS OF ORTHODONTIC CONCEPTS AND OBJECTIVES
William L. Wilson –AJO-DO 1957

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 osisare
Some diagnosis
 Easy,
 Many are difficult and
 Few are impossible
yet all are important , for diagnosis is the
care.
trump factor in providing orthodontic care.
One century back EDWARD. H. ANGLE rightly said:

“In studying a case of malocclusion, give no thought to the

 methods of treatment or
 appliances
until the case shall have classified and all peculiarities and
variation from the normal in
 type,
 occlusion and
 facial lines have been thoroughly comprehended.
Then the requirements and proper plan of treatment
become apparent”.
The orthodontist must …
1. Know normal features of occlusion and
dentofacial complex.
2. Recognize the various characteristics of
the malocclusion & dentofacial deformity.
3. Understand the nature of the problem and
the etiology, if possible.
4. Design a treatment plan based on the
specific needs of the individual.

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Therefore, this presentation is
divided into following sections:
1. Know Normal features of occlusion and
dentofacial complex.
2. Recognize the Various characteristics of
the malocclusion & dentofacial deformity.
3. Understand the Nature of the problem and
the etiology, if possible.
4. Design a Treatment plan based on the
specific needs of the individual.

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 1.
Normal Features
of Occlusion & Dentofacial Complex
The Beginning …

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 2.
Diagnosis
or

Recognizing the various

characteristics of the malocclusion &
dentofacial deformity.
Diagnosis
 The goal of the diagnostic process is to
produce a complete description of the
patient’s problems and make a problem list.
 To obtain the problem list, a collection of
relevant information is required. This
collection is called a database.

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 Diagnosis & Treatment Planning -
Steps
Patient History
Clinical Data Classification Problem List
Examination Base = Diagnosis
Analysis of
Diagnostic Records

Treat pathology
(caries, gingivitis etc.)

Problems A Possible A
in B solution to B Optimal
Mechano-
priority C individual C Treatment
therapy
order D problems D Plan
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The Database
It is obtained from 3 sources.
1. Patient history, & interview data.
2. Clinical (extraoral, functional & intraoral)
examination.
3. Analysis of diagnostic records (models,
radiographs, cephalograms, photographs
etc.).

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The Database

DATA
BASE

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Patient History
 Name:
 Age:
 Sex:
 Address:
 Referred by:
 Presenting complaint:

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Family history
 Parents
 General & dental condition (malocclusion).
 Consanguinous / Non-consanguinous marriage
 Siblings
 General & dental condition (malocclusion).
 History of any orthodontic treatment.

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 Motivation of patient for treatment :
 Internal
 External
 Reasons for taking treatment :
 Esthetics
 Functional
 Hygiene
 Speech
 Pubertal status :
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Prenatal History
 Health of mother during pregnancy.
 Diseases : Bacterial / Viral
 Medication :
 Radiation :
 Trauma :
 Type of delivery :
 Normal
 Caeserian
 Forceps

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 TMJ ankylosis due to
prenatal trauma Change the picture
to Ali’s Patient with
(High forceps delivery) Sleep Apnea Syndrome

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Postnatal History
 Feeding :
 Breast feeding
 Bottle feeding
 Milestones of development :
 Standing
 Walking
 Running
 Speech

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Postnatal History
 Diseases :
 Past
 Present
 Medication :
 Past
 Present
 Nutritional status :

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Postnatal History
 Habits :
 Thumb sucking
 Mouth breathing
 Tongue thrusting
 Lip biting

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 Diagnosis & Treatment Planning -
Steps

Patient History
Clinical Data Classification Problem List
Examination Base = Diagnosis
Analysis of
Diagnostic Records

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Clinical Examination
Consists of
 General examination
 Extraoral examination
 Functional examination
 Intraoral examination
 Soft tissues
 Hard tissues

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General Examination
 Gait :
Build:
 Slight
 Posture :
 Moderate
 Body type :
 Well
Ectomorphic

 Height :
 Mesomorphic

 Weight :
 Endomorphic

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Body Types

Ectomorph Mesomorph Endomorph

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Diagnosis

Clinical Examination
Extraoral Examination

 Shape of head :
Dolichocephalic\Mesocephalic\
Brachycephalic
 Facial form :
Brachyfacial \Mesofacial\ Dolichofacial

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Diagnosis

Extraoral Examination
Facial form

Brachyfacial- Mesofacial- Dolichofacial-

Short & wide Average Long & narrow
Diagnosis

Extraoral Examination
 Facial Symmetry : Vertical\Horizontal
Diagnosis

Extraoral Examination
Horizontal Facial Symmetry

2
Diagnosis
Extraoral Examination

Symmetric Asymmetric
face face
2
Diagnosis

Extraoral Examination

Right composite Original Left composite

2
Diagnosis

Extraoral Examination

 Facial Profile : Straight

\Convex
N’
\Concave

Sn

Pg’
5
Diagnosis

Extraoral Examination
Facial Profile

Straight Convex Concave

3 Profile Profile Profile
Diagnosis

Extraoral Examination
Facial Profile

Straight profile Convex profile Concave profile

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Diagnosis

Extraoral Examination

 Facial divergence :
Straight\Posterior\
Anterior N’

FH Plane

Pg’

4
Diagnosis

Extraoral Examination
Facial divergence

Straight Posterior Anterior

6 Divergence Divergence Divergence
Diagnosis

Extraoral Examination
 Nose : Size
Nasolabial angle :
Normal (90-1000)\Obtuse\Acute

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Diagnosis

Extraoral Examination
 Lips :

Size :Normal\Short\Thin\Thick\Everted
Posture : Competent\Incompetent- Anatomic
Dental
Physiologic

Competent
lips
Diagnosis

Extraoral Examination
Lip Incompetency

Due to short upper lip Due to proclination Due to mouth breathing

(Anatomical) (Dental) (Physiological)
Diagnosis

Extraoral Examination
 Lips

Lip trap
Interlabial gap : ……….mm
Tonicity : Normotonic\Hypertonic
\Hypotonic

Lip trap 6
Diagnosis

Extraoral Examination
Lip tonicity

Normotonic lips Hypotonic upper &

hypertonic lower lips
Diagnosis

Extraoral Examination
 Mentolabial sulcus : Normal\Shallow\
Deep

Normal Shallow Deep

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Diagnosis

Extraoral Examination
 Chin : Adequate\ Recessive\ Excessive

Adequate Recessive Excessive

chin chin chin
Diagnosis

Extraoral Examination
 Face height : Upper anterior to lower
anterior face height ratio.
(Normal 45%:55%).

45%
55%

3
Diagnosis

Extraoral Examination
 Frankfort Mandibular plane angle :

Normal(250)\ High(>350)\ Low(<150)

FH Plane

Mand. Plane
Diagnosis

Functional Examination
 Respiration : Nasal\ Oral\ Oronasal

Mouth Breathing
2
Diagnosis

Functional Examination
 Mastication :
 Deglutition : Normal\ Abnormal (Tongue
thrust)

Infantile swallow Tongue thrust swallow

Diagnosis

Functional Examination
Tongue thrusting

Simple tongue thrust Complex tongue thrust

Diagnosis

Functional Examination
 Speech : Dysfluency\ Dysarticulation
 Path of closure :
Anteroposterior : Normal\Deviated
Lateral : Normal\Deviated

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Diagnosis

Functional Examination
Path of closure - Anteroposterior
Diagnosis

Functional Examination
Lateral deviated path of closure
Diagnosis

Functional Examination
 Perioral muscle activity :
Hyperactive mentalis\ Hypotonic upper lip
\ Cheek dysfunction

Hyperactive mentalis Cheek dysfunction 4

Diagnosis

Functional Examination
 TMJ : Pain\ tenderness
Clicking
Maximum protrusion of mandible
 Maximum opening (incisal edges) :
……..mm
 Freeway space : ………mm

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Diagnosis

Functional Examination
TMJ examination
Diagnosis

Functional Examination
Maximum opening
Diagnosis

Functional Examination
 Amount of gingival exposure :
During speech : ………mm
During smile : ………mm
Excessive
exposure
during
speech

Gummy
smile 5
Diagnosis

Functional Examination
 Visualised Treatment Objective (VTO) :

Positive VTO
4
Diagnosis

Intraoral Examination
Soft Tissues
 Frenal attachment : Normal\ Abnormal

Positive Blanch test 3

Diagnosis

Intraoral Examination
 Gingiva : Normal\ Edematous\ Fibrous
Attached gingiva :
Pockets :

4
Diagnosis

Intraoral Examination
 Tongue : Size :
Posture :
Habits :

5
Diagnosis

Intraoral Examination
Soft Tissues
 Oral Mucosa :
 Palate : Normal\ High\ Low
 Oral hygiene :

5 High palate
Diagnosis

Intraoral Examination
Hard Tissues
 Number of teeth present :

 Teeth absent :

 Supernumerary\ Missing teeth :

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Diagnosis

Intraoral Examination
Hard Tissues
 Impacted teeth :
 Shape, size and form of teeth :

Normal\ Abnormal
 Enamel texture : Normal\ Hypoplastic

White spots
Enamel cracks

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Diagnosis

Intraoral Examination
Enamel hypoplasia and white spots
Diagnosis

Intraoral Examination
Hard Tissues
 Caries\ Restorations :
 Endodontically treated teeth :
 Occlusal facets wear :

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Diagnosis

Intraoral Examination
Maxillary arch
 Shape : Average\ Vshaped\ U shaped \
Square
 Symmetry :
 Alignment : Crowding\ Spacing\ Rotations

4
Diagnosis

Intraoral Examination

Normal arch U shaped arch

V shaped arch 3
Diagnosis

Intraoral Examination
Mandibular arch
 Shape : Average\ Vshaped\ U shaped \
Square
 Symmetry :
 Alignment : Crowding\ Spacing\ Rotations

4
Diagnosis

Intraoral Examination
Severe crowding
Diagnosis

Intraoral Examination
Arches in Occlusion
 Molar relation : Cl I\ Cl II\ Cl III
 Canine relation : Cl I\ Cl II\ Cl III
 Incisor relation :
 Overjet : Normal\ Increased\ Reverse ……..mm
 Overbite : Normal\ Deepbite\ Openbite……mm

M O 6
Diagnosis

Intraoral Examination
Arches in Occlusion
 Transverse relationship : Crossbite\
Scissorbite
 Curve of spee : Normal\ Flat\ Deep .……
mm
 Midline :

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Diagnosis

Intraoral Examination
Normal (Cl I) occlusion

2
Diagnosis

Intraoral Examination
 Class II molar & canine relation.

3
Diagnosis

Intraoral Examination
 Class III molar relation.

3
Diagnosis

Intraoral Examination
Overjet

Reverse overjet
Increased overjet 2
Diagnosis

Intraoral Examination
Over bite

Deep bite Open bite

2
Diagnosis

Intraoral Examination

Cross bite

Scissor
bite
2
 Diagnosis & Treatment Planning - Steps

Patient History
Clinical Data Classification Problem List =
Examination Base Diagnosis
Analysis of
Diagnostic Records

1
Diagnosis

Analysis of Diagnostic Records

Diagnostic records include.
 Models.
 Radiographs - IOPA, OPG, Handwrist
radiograph.
 Photographs.
 Cephalograms.

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Diagnosis

Analysis of Diagnostic Records

Radiographic examination
 Number of teeth present :

 Teeth absent :

 Root formation : Permanent teeth

Decidous teeth

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Diagnosis

Analysis of Diagnostic Records

Radiographic examination
 Eruption levels :
 Supernumerary :
 Impacted teeth :
 Third molars :

5
Diagnosis

Analysis of Diagnostic Records

Radiographic examination
 Lamina dura and height of interdental
crest :
 Character of restoration :
 Pathological conditions :

4
Diagnosis

Analysis of Diagnostic Records

Handwrist radiograph :
 The stage of ossification of bones in the
radiograph is examined.
 The bones assessed include 1) the ulnar
sessamoid 2) the pisiform 3) hook of
hamete and 4) the metacarpels.
 This assessment is also known as the
Carpel Index

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Diagnosis

Analysis of Diagnostic Records

Ulnar
Sesamoid

Hook of
hamete

Pisiform
Diagnosis

Analysis of Diagnostic Records

Photographic analysis
 Three extraoral views and five intraoral
views are taken.
 Extraoral views - frontal, lateral and 3/4th
smiling views.
 Intraoral views - frontal, right lateral, left
lateral, upper occlusal and lower occlusal.

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Diagnosis

Analysis of Diagnostic Records

Model analysis
 Bolton’s analysis
 Carey’s analysis

Cephalometric analysis
 Steiner’s analysis
 Tweed’s analysis

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 Diagnosis & Treatment Planning - Steps

Patient History
Clinical Data Classification Problem List =
Examination Base Diagnosis
Analysis of
Diagnostic Records

2
For want of a good seperation, a molar band was not
seated;
For want of a proper fit, a band became loose;
For want of a fixed band, the archwire became distorted;
For want of comfort on holiday, the father cut the
archwire;
For want of an intact archwire, there was anchorage
loss;
For want of proper anchorage, the case failed.