Tournée de l’Ordre 2012

• Dr Jean-Marc Retrouvey• Dr Donald Taylor

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Note: For the sa

ke of

privacy, re

al patients’

faces have been re

placed

by royalte

e free pictures

Objectives of the Day

• Discuss the different modalities necessary to obtain an adequate diagnosis

• Revisit the basic principles of interceptive orthodontics and understand the importance of early intervention

• Determine the importance of the use of orthodontics to optimize the dental health of adults

• Discuss Invisalign

OrthodonticDiagnosis

Dr Donald TaylorDr Jean-Marc Retrouvey

1. Review the fundamental principles of diagnosis

2. How to prepare proper orthodontic record3. The importance of differential diagnosis4. The selection of cases that can be treated in

your office

Objectives

1. Review of fundamental principles

• Screenings of malocclusions (children and adults)

• Orthodontic evaluation1. Observation-Reevaluation2. Intervention3. Treatment4. When to refer to the

orthodontist

Brief History of Diagnosis in Orthodontics

Angle’s Classification 1920’s. Based on molar

relationship

Akerman Profitt 1970-1980: more information

based on skeletal and dento-alveolar relationships

New approach “Outside in ”:

Importance of facial harmony

Diagnosis-Differential Diagnosis

• Important to differentiate the severity of the malocclusion

• It is imperative to create an orthodontic record for each patient!

Orthodontic Record

The orthodontic record is composed of two sections

1. Collection of Information 1. Medical and Dental History2. Extraoral Examination3. Functional examination

(TMJ, orofacial muscles, tongue position, respiration, habits)

4. Intraoral Examination and Study Models 5. Radiographs

• panoramic • cephalometric

2.Extraoral Examination

Orthodontic Record: 2nd Section

2. Interpretation of the findings The collection of the findings is not sufficient.

You must Interpret these findings to allow you to arrive at a precise diagnosis.

This interpretation must be written in the chart and must be in a logical order that can be understood by others.

1. Collection of Information 1. Medical and Dental History2. Extraoral Examination3. Functional examination

(TMJ, orofacial muscles, tongue position, respiration, habits)

4. Intraoral Examination and Study Models 5. Radiographs

• panoramic • cephalometric

1. Patient’s History

History

• Chief complaint:– It is really important to write the reason for the

visit in the terms described by the patient• Ex: I have an overbite….• Ex: My teeth are crooked..

• Medical, Dental and Familial History– This allows you to detect problems which are

environmental and or genetic

1. Collection of Information 1. Medical and Dental History2. Extraoral Examination3. Functional examination

(TMJ, orofacial muscles, tongue position, respiration, habits)

4. Intra-oral Examination and Study Models

5. Radiographs• panoramic • cephalometric

2.Extra-oral Examination

WHY PERFORM AN EXTRAORAL EXAMINATION ?

• Determine the harmony of facial structures• Judge facial symmetry• Analyze the smile• Evaluate the position of the teeth in relation

to the soft tissue of the face

Has an important influence on the prognosis of the result of

orthodontic treatment

Facial Type

Normocephalic

• The length and width of the face are in ideal proportions

• The growth pattern is most probably favorable

Brachycephalic Dolychocephalic

Facial Types deviate from

ideal and the growth pattern is not favorable

Brachycephalic Dolichocephalic

Tendency for a deep bite Tendency for an open bite

Analysis of the Profile

The angle Glabella, Subnasale et Pogonion gives a good idea of the relationship of the skeletal bases in relationship to the soft tissues of the face

Facial profile and soft tissuesA pleasant profile is not measurable: It is an esthetic judgment

1. Collection of Information 1. Medical and Dental History2. Extraoral Examination3. Functional examination

(TMJ, orofacial muscles, tongue position, respiration, habits)

4. Intraoral Examination and Study Models 5. Radiographs

• panoramic • cephalometric

3. Functional Examination

1. Verify the medical and dental history

2. Palpate the TM Joints and Perioral musculature

3. Record mandibular movements and excursions

Functional Examination

A malocclusion whose origin is skeletal with joint degeneration.

It can be seen that the condyle on the left is actively resorbing

1. Collection of Information 1. Medical and Dental History2. Extraoral Examination3. Functional examination

(TMJ, orofacial muscles, tongue position, respiration, habits)

4. Intraoral Examination and Study Models

5. Radiographspanoramic cephalometric

4. Intra oral examination and study models

Intra-oral Photographs (obligatory and of diagnostic quality)

Study modelsStudy models must be of good quality to allow proper study

When to mount a case in CR

• Angle determined that this relationship was essential in order to have a functional occlusion and optimal esthetics…….with a full compliment of teeth

• One of the goals of orthodontic treatment is to achieve a class I molar relationship. There are exceptions

1. Molar Classification

Is there a problem with this classification?

Even though Class I is very important , it does not take into account the denture position in relation to facial structures

It is not guaranteed that a Class I molar relationship is the only mark of success of orthodontic treatment

It is vertical problems which cause us miseries

Two malocclusions which present with a Class I malocclusion (or almost)

Are the problems skeletal or dento alveolar?

The Angle classification has nothing to do with the complexity of the cases

2. Overbite1. Etiology of exaggerated deep

bite– Over eruption of the incisors– Under eruption of the molars– Skeletal dysplasia– Deep Curve of Spee

The chief complaint of the patient was: « I have a crooked

tooth »

The etiology greatly helps to determine the modalities of treatment

• Supra erupted incisors• Under erupted molars• Deep Curve of Spee

• Hypoplastic Mandible

• Intrusion with fixed braces

• Level Curve of Spee

• Orthognathic surgery

2.Open Bite• Possible etiologies of open bite

– Anterior position of the tongue( habits)– Genetic factors– Sleep apnea

3.Overjet

• The etiology was multifactorial

• Dentoalveolar• Skeletal• A combination of the

above

Overjet

The incisors seem to be very protrusive

Equally, the mandible is very retrusive

4. Midlines

• Skeletal• Dental

Midlines

• We use the reference line to determine the different midlines- maxillary and mandibular

Reference line

1. Midline reference line2. Maxillary midline3. Mandibular midline

If there is a facial deviation, how is it corrected?

If a dental deviation is it skeletal or functional?

Midlines

6. Tooth size/Arch size

Small lateral incisors Large teeth

Width of the teeth Bolton analysis – Normal: 77%

Tooth Upper right Upper left Ideal

Central incisor 8.85

Lateral incisor 6.9

Canine 7.88

Tooth Lower right Lower left Ideal

Central incisor 5.5

Lateral incisor 6

Canine 6.95

• UA (Σ 13-23) = mm• LA (Σ 33-43) = mm

• ( 35.3 / 43.3 ) x 100 = %

The Boley Gauge ofDr. Retrouvey

He as developed a computer program to calculate Bolton Discrepancy

7.Number of teeth and sequence of dental eruption

• What is normal?• Can we take advantage of the sequence of

eruption? Yes (E space)• Is the timing early or late?

Patient age 16 years: slow eruption and multiple impacted teeth

Curve of spee

• Flat (normal) • Deep. Probably a skeletal malocclusion

8.Curve of SpeeVery important to evaluate

• Flat or moderate: good prognosis• Accentuated curve: Prognosis les positive

– Do we level?– How much space is necessary?– We need to analyze the cephalogram. Helps with

differential diagnosis

9. Amount of Crowding

• There are different factors to consider

• Difference between the mixed dentition and the permanent dentition (Leeway Space)

• Inclination of the lower incisors (Curve of Spee)

• Non-apparent available space ( non anatomic restorations)

Is this crowding a concern?

Mixed dentition

The control and utilization of the Leeway space is really important

The Boley Gauge ofDr. Retrouvey

He has developed a computer program to calculate E space

If leeway space is not adequate

• Normally, extractions will be required

• Sometimes we can expand the arches

• Depends on the amount of attached gingiva at labial of the lower incisors and facial features

1. Collection of Information 1. Medical and Dental History2. Extraoral Examination3. Functional examination

(TMJ, orofacial muscles, tongue position, respiration, habits)

4. Intraoral Examination and Study Models 5. Radiographs

• panoramic • cephalometric

5.Radiographs

Analysis of Pantographic radiograph

Analysis and interpretation of the cepalogramMandatory when contemplating all orthodontic treatment!

Analysis:– Skeletal (values as normal as possible)– Dentoalveolar – Pearl: The cases where the mandibular plane angle is

normal typically gives the best prognosis

Cephalometric analysisAngles Ceph.

ValuesNormal

Skeletal Measurements

SNA 79.5 81 ± 3

SNB 75.0 78 ± 3

ANB 4.5 3 ± 2

Witts -4.0 2 mm ± 2mm

Facial ∠ 86.0 88 ± 4

MPAST 38.0 32 ± 3

Y axis 60.0 60 ± 4

Dental Measurements

(UI,NA) 16.0 23 ±6

(LI,NB) 23.0 27.5 ±5

(UI,LI) 135.0 130 ± 7

(LI,MP) 91.0 91.4 ± 4

Pre-Treatment

The skeletal measurements give us the relationship of the osseous bases relative to the cranial base

Diagnosis of the malocclusion

• Write the most significant elements

• Example– Class II division I

malocclusion– Severe retrusion of the

mandible– Increased overbite – Moderate crowding of the

upper arch– Upper right canine

palatally impacted

Problem listProblem Resolution Comments

Class II molar Maintain Correct Improve

There are potential skeletal problems

Mandibular retrusion Correct Reevaluate in 6 months

Overjet Maintain Correct Improve

Impacted canine Consultation with surgeon su Wait 6 months

May need to be Surgically exposed

Crowding Rapid palatal expansion Extraction Arch development

x

x

x

x

ConclusionsIdentify the malocclusion presented and arrive to a proper

diagnosis is the most important aspect in orthodontic treatment.

Then the formulation of the objectives and establishment of a feasible treatment plan are indispensable in establishing the path to follow in treatment

Observe, wait, treat or refer, but above all be sure that you inform the patient and parent of the diagnosis and options of treatment so that THEY make an informed decision to chose the best course for the to follow.