Orthodontics

Fifth Class College of dentistry

Dr Firas Lecture no 1

The diagnostic database

The diagnostic database is composed of multiple clinical, functional,
and record analyses that allow the clinician to formulate a comprehensive
diagnosis and begin to work toward a treatment plan that is most
beneficial to the patient.

Diagnostic records
Before writing a treatment plan for a certain case, we have to collect the
appropriate records. Orthodontic records may be required for a number of
possible purposes:
1-Diagnosis and treatment planning.
2-Monitoring growth.
3-Monitoring treatment.
4-Medico-legal record.
5-Patient communication and education.
6-Audit and research.

The orthodontic diagnostic records are:

1-Case sheet.
2-Study cast.
3-Photographs.
4-Radiographs.

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Case Sheet
A form is used to record the findings of a chair-side clinical
examination. Forms such as these can be digitized for paperless record
keeping. In addition to demographic information, the patient is asked to
describe his chief concern for seeking orthodontic treatment.
A medical history is taken, including an examination of nasal airway
competence. A dental history is taken. Habits involving the teeth are
recorded. Habits commonly seen are thumb sucking, tongue thrusting
during swallowing, and lip biting and sucking. The patient is asked if he
has had previous orthodontic treatment.

Study Casts
Study casts accurately represent the teeth, their supporting tissues, and
the relationship between upper and lower teeth in centric occlusion. They
contribute greatly to diagnosis and treatment planning and are valuable
instructional and illustrative aids during a consultation with patients.
Even if you are observing a young patient prior to the onset of
treatment, study casts are useful three-dimensional records for a growing
and changing patient. Study casts are among the most important records
taken prior to, during, and after orthodontic treatment. For treatment
planning, casts are indispensable. You must study the positions of the
maloccluded teeth, to plan how and where the teeth need to be moved
during treatment. After treatment, study casts will show the changes that
occurred during treatment. You need high-quality working casts for
appliance fabrication.
Impressions showing all
the erupted teeth, full depth of
the palate and good soft tissue
extension are needed.
Orthodontic models should be
trimmed with the occlusal
plane parallel to the bases, so
the teeth are in occlusion when
the models are placed on their
back.

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 Study models should show all the erupted teeth and be extended into
the buccal sulcus. They are poured in dental stone and typically produced
from alginate impressions. They should be mounted in occlusion, using a
wax or polysiloxane bite. They are produced using a technique known as
Angle trimming, which allows models to be placed on a flat surface and
viewed in the correct occlusion from varying angles.

Digital Casts
With advances in digital model technology, dentists will eventually no
longer take impressions and trim plaster diagnostic casts. Even the
laboratory fabrication of orthodontic appliances will be accomplished
through digital technology. Several companies are selling equipment
designed to capture digital images of individual teeth and arches for
restorative dentistry. This technology is reducing errors commonly made
in recording margins for crowns made in dental laboratories

Through CAD/CAM (computer-aided design/computer-aided

manufacturing) procedures, a three-dimensional cast can be created from
a digital model.
Digital versions of study models, which should not deteriorate with time
and do not take up physical space, are gradually replacing stone models.

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Photographs
Good clinical photographs form an essential
part and key colour record of the clinical
record. They provide a baseline record of the
presenting malocclusion, are important in
treatment planning especially in relation to
facial and dental aesthetics, allow monitoring
of treatment progress and are useful for
teaching. The usual views taken are:

Four extra-oral (in natural head position):

• Full facial frontal at rest
• Full facial frontal smiling
• Facial three-quarters view
• Facial profile
Five intra-oral:
• Frontal occlusion
• Buccal occlusion (left and right)
• Occlusal views of upper and lower arch

Some operators are beginning to take short video clips of the patient
talking and smiling, as this may provide additional useful information
about the dentition and smile in function.

The usefulness of photographs

1- Serve as a diagnostic records.
2- They are useful in assessment of facial symmetry, facial type and
profile.
3- Helps in assessing the treatment progress.

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Dental Cheek Retractors
The use of a cheek retraction system is a great way to help the patient
keep his or her mouth open while you’re working. Dental cheek retractors
lock in place to hold the patient’s mouth open throughout the time you
are working. They can be disposable or autoclavable, with many of the
disposable retractors made from clear materials to provide improved
visibility. Besides the clinical advantages, using a retractor can help you
obtain great photographs to document your work for reference or for
sharing with colleagues.

Radiographs
Any radiograph carries a low but identifiable risk, so each radiograph
must be clinically justified. A radiograph is only prescribed after a full
clinical examination to ensure that information cannot be gained by a less
invasive method. Radiographs are usually required prior to orthodontic
treatment to assess:

• Presence or absence of permanent teeth;

• Root morphology of permanent teeth;
• Stage of development of adult dentition;
• Presence and extent of dental disease;
• Presence of supernumerary teeth;
• Position of ectopic teeth; and
• Relationship of the dentition to the skeletal dental bases and their
relationship to the cranial base.

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Radiation protection
Currently in the UK, the medical use of ionizing radiation is covered by
two articles of legislation, which have been in force since 2000. The
ionizing Radiation Regulations (1999) are concerned primarily with the
safety of workers and members of the general public; whilst the ionizing
Radiation (Medical Exposure) Regulations (2000) relate to the safety and
protection of the patient. This legislation is based on the three basic
principles of the International Commission for Radiological Protection
(ICRP) that provide the foundation for all radiation protection measures:
• Justification;
• Optimization; and
• Limitation.

The dental practitioner is responsible for justifying the exposure of a

patient ionizing radiation and this should be based upon a defined clinical
need. Once an exposure is clinically justified it should be optimized,
keeping the dose as low as reasonably practicable (the ALARP principle)
and maximizing the risk-benefit ratio to the patient. The main elements of
this relate to the type of equipment and image receptor being used and to
the use of selection criteria—the number, type and frequency of
radiographs requested. The fundamental principle, however, is that
radiographs are only taken when clinically justified.

Routine radiographs used in orthodontic assessment

A number of radiographic views are routinely used by the orthodontist:

Dental panoramic tomograph

Panoramic radiography or, more
specifically, the dental panoramic
tomograph (DPT) provides a useful
screen for the presence or absence,
position and general health of the
teeth and their supporting structures
with a relatively low-radiation dose.

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Because these radiographs are sectional in nature, they can be unclear in
some regions, particularly the labial segments where variations in the
depth of the anterior focal trough for different patients can influence
clarity of the incisors.

Occlusal radiographs
Occlusal radiographs are taken with the film placed on the occlusal plane
and can offer greater detail in the labial segments. They are particularly
useful in the maxillary arch, for assessing root form of the incisors, the
presence of midline supernumerary teeth and canine position, either alone
or in combination with additional views using parallax.

Periapical radiographs
Periapical radiographs are also useful for the assessment of local
pathology, root form and the presence or position of unerupted teeth.
They can also be used for parallax, particularly in identifying the position
of maxillary canine teeth. Either two periapicals are taken, incorporating
a horizontal tube shift between them; or a single periapical is taken in
conjunction with another radiographic view, such as an upper standard
occlusal or DPT and a vertical tube shift utilized.

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Cephalometric lateral skull radiograph
A cephalometric lateral skull radiograph is a specialized view of the
facial skeleton and cranial base from the lateral aspect, with the head
position at a specific distance from the film. The uses and analysis of
cephalometric radiographs are discussed in the next section.

Three-dimensional imaging
Plain film and cephalometric radiography are invaluable for accurate
diagnosis and treatment planning, but they only provide a two-
dimensional image of a three dimensional structure, with all the
associated errors of projection, landmark identification, measurement and
interpretation. A number of three-dimensional imaging techniques have
been developed over the past decade, which help to overcome some of
these shortcomings and give the orthodontist greater information for
diagnosis treatment planning and research.
Imaging of the hard tissues composing the
jaws and dentition using computed tomography
(CT) had remained impractical until relatively
recently, due to the high radiation dosage, lack
of vertical resolution and cost. However, with
the introduction of cone-beam computed
tomography (CBCT), doses have been reduced
and resolution increased, and although not yet
used for routine orthodontic diagnosis, this
technique is proving a very valuable tool in
certain circumstances, particularly the diagnosis
of impacted and ectopic teeth. It can also be very
useful in airway analysis, assessment of alveolar
bone height and volume (thickness) prior to
implant placement and imaging of
temporomandibular joint morphology.

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 Conventional computed tomography (CT) imaging involves the use of
rotating X-ray equipment, combined with a digital computer, to obtain
images of the body. Using CT imaging, cross-sectional images of body
organs and tissues can be produced. CBCT is a faster, more compact
version of traditional CT with a lower dose of radiation. Through the use
of a cone-shaped X-ray beam, the size of the scanner, radiation dosage
and time needed for scanning are all dramatically reduced. The three-
dimensional views produced may be useful in certain orthodontic cases:

• Accurate location of impacted teeth and a more accurate

assessment of any associated pathology, particularly resorption of
adjacent teeth
• Assessment of alveolar bone coverage
• Assessment of alveolar bone height and volume (which may be
relevant in potential implant cases)
• TMJ or airway analysis
Although the radiation dose is considerably smaller than conventional
CT scanning, the dose is still higher than for the conventional
radiographs. At the present time CBCT should therefore only be used
when conventional radiography has failed to give, or is very unlikely to
give, the necessary diagnostic information.

When to take radiographs

The need for radiographic investigation will vary according to the age of
the patient and their stage of dental development, in addition to the
clinical presentation. Comprehensive guidelines regarding the need for
orthodontic radiographic investigation are available:

Deciduous dentition
Radiographs are not routinely indicated in the preschool child. But there
is some indications include:
• Trauma to the upper labial segment for assessing potential risk to
the permanent successors; and
• Dental caries for assessing both the extent and prognosis.

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Mixed dentition
Radiographic investigation during the mixed dentition is indicated with
evidence of dental disease or abnormal dental development. Specific
orthodontic indications include:
• Asymmetric eruption pattern of the permanent dentition and
significant retention of deciduous teeth. Failure of eruption
associated with the maxillary incisors requires radiographic
examination, as this can be due to the presence of supernumerary
teeth. Similarly, maxillary canines should be palpable in the buccal
sulcus by 10 years of age. If not, radiographic examination for
detecting the presence of palatal impaction is indicated;
• Prior to any interceptive treatment, including extractions,
particularly optimal timing for loss of first permanent molars with
poor prognosis;
• Early treatment of class II malocclusion; and
• Early treatment of class III malocclusion.

Permanent dentition
Radiographic investigation is indicated prior to active orthodontic tooth
movement for assessing dental health and root form. This will usually
consist of a panoramic view supplemented with an anterior occlusal if the
incisor region is unclear, or bimolar views plus an anterior occlusal. A
cephalometric lateral skull radiograph is indicated as an aid to treatment
planning in the presence of a skeletal discrepancy, or when treatment is
being planned in both dental arches that involves extractions and bodily
movement of incisors.

Growth estimation by wrist x-ray

Separation between growing child and adults is challenging, depending
on stages of growth of the hand that divided into many stages. This stage
is characterized by beginning of calcification of ulnar sesamoid, increased
width of epiphysis of proximal phalanx of the second finger and increased
calcification of hook of hamate and pisiform. Signifies the onset of pubertal
growth spurt.

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 The End

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