Dr.

Tran Ngoc Quang Phi

Backgrounds
Angle classification
Six keys Andrew
Crown form
Arch form
Bolton analysis
Golden proportion
Angle Classification
Malposition  individual tooth
 Buccal or labial, lingual, mesial, distal, torso (rotation), infra
and supra.
 Impacted
Malocclusion  anteroposterior relationships of
permanent first molars and canines.
Canine relationship:
 The upper canine fits distal to the lower canine
Molar relationship
 Class I: normal relationships  mesial buccal cusp
UFMmesial sulcus LFM.
 Class II: distal buccal cusp UFMmesial sulcus LFM
 Class III: buccal cusp USPmesial sulcus LFM
Angle classification extension
Class II division 1:
 Narrowing of the upper arch, lengthen and protruding UC.
 Abnormal function of the lips, nasal obstruction, mouth
breathing.
Class II division 1 subdivision: class I on one side.
Class II division 2:
 Crownding, overlaping and lingual inclination UC
 Normal nasal and lip function
Class II division 2 subdivision: class I on one side.
Class III subdivision: class I on one side.
Mild class II: between class I and class II
Mild class III: between class I and class III
Class I Molar or Class I Canine?


Four items that you "must complete" for
successful orthodontic treatment
1. The teeth must be straight at the end of treatment.
2. There must not be any spaces between the front
teeth.
3. There must not be any overjet (the patient refers to
overjet as "overbite").
4. The teeth must (generally) bite together at the end
of treatment. It is OK to have a bicuspid out of
occlusion, but the teeth must not be open molar to
molar.
Six keys Andrew
1. Molar relationship :
 Class I Angle
 Cusp-embrasure relationship buccally
 Cusp-fossa relationship lingually
2. Crown angulation:
 All tooth crowns are angulated mesially (mesio-distal tip)
3. Crown inclination:
 Incisors are inclined labially
 Upper posterior teeth are inclined lingually, similarly from
the canine to the premolars; upper molars are inclined
slightly more than the canine and the premolars.
Angulation and inclination
 Lower posterior teeth are inclined lingually,
progressively from canine to molars
4. Rotations:
Rotations are not present

5. Spaces
Spaces are not present between teeth

6. Curve of Spee
The plane is either flat or slightly curve
Curve of Spee
Yes No
Anterior Crown form
Central incisor crown
form:
•Triangular-shaped
incisors: need to be
reshaped to avoid one-
point contact ( black
triangle and unstable)
•Rectangular-shaped
incisors: good esthetics
•Barrel-shaped incisors: do
not provide ideal esthetics
Canine crown form

Relatively flat facial contour Markedly curved facial contour

Narrow and pointed incisally Wide and flattened incisally

Arch form
Square Ovoid Tapered
The original arch form is considered the most stable
position since this is the "in balance" position of the
teeth and surrounding muscles: the neutral zone.
Any alteration of this position may result in
instability in retention.
 Relapse tendency after changing arch form (De La
Cruz-1995, Burke-1998): inter-canine width.
Expansion the lower arch form: 10%.
Tapered Ovoid Square
Japaneses 12% 42% 46%
Caucasians 44% 38% 18%
Systemized management of arch form
Determine the arch form at the start of treatment
Template 
Computerized cast analysis @
Arch wire stocked:
Round arch wire (NiTi and SS): ovoid only
.019/.025 (.018/.025 ) HANT: three shapes
 45% ovoid
 45% square

 10% tapered

.019/.025 (.018/.025 ) SS: ovoid only 


Bolton analysis
Anterior Bolton analysis
Max 6: 40.0 – 54.5 (+0.5)
Mand 6: 30.9 – 42.1 (+0.4)
Overall Bolton analysis
Max 12: 85 – 110 (+1)
Mand 12: 77.6 – 100.4 (+ 0.9)
Ideal ratio  canine class I
Determine distance between hooks or loop
Bolton discrepancy  proper solution
Anterior Bolton analysis Full archBolton analysis
Ideal ratio in Bolton analysis
Maxillary 6 Mandibular 6 Maxillary 12 Mandibular 12
40.0 30.9 85 77.6
40.5 31.3 86 78.5
41.0 31.7 88 80.3
41.5 32.0 89 81.3
90 82.1
48.0 37.1 91 83.1
48.5 37.4 96 87.6
97 88.6
51.5 39.8 103 94.0
52.0 40.1 104 95.0
106 96.8
54.5 42.1 107 97.8
Application?
•Chose the T –loop arch wire
•Adjust for the best fit occlusion
Golden proportion

ab a
 
a b
  1.618

DIAGNOSIS
Collect data
Orthodontic questionaire
Clinical examination
X-rays : POG and CEP
Models
Pictures
Cephalometric analysis
Model anlysis
→ Diagnosis: problem list
Orthodontic Questionaire
MEDICAL HISTORY
Under a physician's care at this time? Yes/No. Explain

Taking any medication at this time? Yes/No. Specify

Allergic to any medication? Yes/ No. Specify

Any other allergies? Yes/No. Specify

Need to be premedicated (antibiotics) for routine dental

procedures? _Yes _No. Specify and reason

Following diseases or conditions? (If yes, explain and
date):
AIDS__ Bleeding disorder __ Anemia__

Lung disease__ Cerebral palsy__ Heart condition__

Arthritis__ Hepatitis__ Kidney disease__Rheumatic

fever___ Asthma__ Diabetes__ Epilepsy__
Injury to face/head__

Tonsil/adenoid surgery__ Previous surgery__

Females: Is the patient pregnant? __ Yes __ No

DENTAL HISTORY
Date of last dental examination

Any injury to the face/teeth/gum? Explain and date.

Any previous orthodontic treatment/consultation?
Does the patient:
 Grind his/her teeth at night?
 Bite his/her fingernails?
 Suck thumb, finger, pacifier, etc.?
If yes, at what age was the habit discontinued? __years
Has another member of the family had orthodontic
treatment? Whom?
Medical conditions to be considered in
orthodontic treatment
Medical condition Implications Action
Asthma Root resorption Monitor every 6 mo for evidence
of EARR
Allergies Allergic reaction Determine materials causing
allergy
Coagulation disorders Bleeding risk Extraction?
Diabetes Periodontal disease Monitor adequate control of
diabetes
Epilepsy, High blood Gingival Plaque control, gingivectomy if
pressure hypertrophy necessary
Heart valve conditions Endocarditis Premedication when extraction,
fitting bands
Rheumatoid arthritis TMJ degeneration Monitor TMJ
Xerostomia Caries Fluoride supplement
PATIENT'S ATTITUDE AND MOTIVATION
Is the patient aware of the problem?

Consultation here prompted by _________________

Patient's interest in having treatment is:

__ Wants treatment ___ Willing if necessary __ Unwilling

If the patient’s teeth were to be changed, how would you

like them changed? _______________________________
If any features of the face could be changed, what would
you like to see? ___________________________________
GROWTH STATUS: (child patients only)
Height__________ cm Weight _________kg
Females: Has the patient started her menstruation?
__ Yes __ No. If yes, at what age? ________

Males: Voice changes? __ Yes __ No

Facial hair growth? __ Yes __ No
Has the patient had any recent rapid growth? ___________
If so, how much?_______________
Rational for Orthodontic questionaire
Chief complaints
Determine patient’s motivation, expectation
Medical and Dental history
Reveal the causes of problems
Relation between the patient’s conditions and
orthodontic treatment
Growth and development
Timing of orthodontic treatment
CLINICAL EXAMINATION
Esthetic analysis
Macro esthetics: facial proportion
Mini esthetics: tooth – lip relationships
Micro esthetics: dental appearance
Functional analysis
TMJ
Occlusion
Periodontal health
Bad habit
Macro esthetics: facial proportion
General view
Dolicofacial, brachyfacial, mesiofacial 
Frontal view
Vertical
 Proportion
 Chin height

 Lower face height

Horizontal
 Proportion: rule of fifth
Midline asymmetry
Vertical proportion
Horizontal proportion
The lower third @
A. Increase face height:
 Dolicofacial pattern
 Vertical maxillary excess (VME) 
 High lip line: anterior teeth display too much
 Gummy smile
 Lip length: normal
 ≠ Short lip 
 Excesssive chin height 
B. Decrease face height
 Brachyfacial pattern
 Vertical maxillary deficiency
 Mandibular defienciency 
 Short chin height 
Dolicofacial
•Long and thin faces. Weak
muscles of mastication that are
not strong enough to hold the
teeth together during
orthodontic treatment.
•Non extraction treatment of
these cases may result in bite
opening during the treatment.
•When extraction, space closes
quickly.
Be careful when treating a
protrusion case
Mesiofacial

•Mesiofacial is not long and

thin facial features, and not
short and square facial
features.
•In these cases you can extract
and the extraction spaces will
close "normally".
•You can treat these case types
non extraction and the teeth
will remain in occlusion
during treatment.
Brachyfacial
•Short, square faces with
very strong muscles of
mastication.
•Short clinical crowns with
some excess enamel wear on
the occlusal surface of the
teeth.
•In these cases, if you
extract, then the extraction
spaces will close slowly.


 Pre-orthodontic Post-
orthodontic@
@@
Short lip: @
Philtrum height < commisure height
Inverted lip
Asymmetry
Upper midline asymmetry
Orthodontist : < 2mm
Dentist : 2 – 4mm
Non-professional person: >4mm
Lower midline asymmetry
Cause
Upper : missing tooth, impacted tooth, crowding…
Lower: causes as upper arch, esp: TMJ
Always the tough cases
Profil view
 Proportion
 Convex, straight, concave
 Straight: anterior divergence, posterior divergence
 Mandibular plane angle
 Lower face
 Maxillary projection
 Mandibular projection
 Chin projection
 Lip
 Lip posture and incisor prominence
 Lip fullness
 Labiomental sulcus
 Throat form
 Chin – throat angle
 Throat length
 Submental contour
Profil view
Black pattern
Convex treatment?
Be careful not to set the patient's expectations too
high for reducing a convex profile: it takes 2-3mm of
tooth retraction to result in 1mm of lip retraction.
Move the chin forward to reduce feeling convex
Lefort I + BSSO for comprehensive treatment
Mini esthetics: Tooth – lip relationship
Philtrum height
Commisure height
Interlabial gap
Incisal display at rest
Smile analysis
 Emotional smile and social smile
 Incisal display on smile
 Gingival display
 Smile arc
 Buccal coridor width
 Arch form
 Transverse cant
Vertical measurements

A: Philtrum height A: Incisal display on smile

B: Commisure height B: Crown height and width
C: Interlabial gap C: Gingival display
D: Incisal display at rest D: Smile arc
Emotional smile and social smile

Major zygomaticus muscle Risorius muscle

Smile arc
The contour of the incisal edges of the maxillary anterior
teeth relative to the curvature of the lower lip during a
social smile
Transverse cant
Gummy smile
Crown lengthening
Orthodontic treatment
Lefort I Osteotomy
Plastic surgery
Micro esthetics:
gingival and dental appearance
Tooth proportion: crown height and width
Width relationship and golden proportion
Gingival height , shape and contour
Connectors and embrasures
Tooth shade and color
Crown height and width
The width of central
upper incisor should be
about 80% of it’s height.
The disproportion
should be done before
orthodontic treatment is
completed.
Width relationship and golden proportion
Gingival shape and contour
Gingival shape of upper
central incisors and canines
is more elliptical.
Gingival shape of upper
lateral incisors and
mandibular incisors is a
symmetric half-oval or half-
circular one.
The gingival zenith of
central and canine is located
distal to the longitudinal
axis.
The gingival zenith of lateral
incisors coincides with the
longitudinal axis.
Connectors and embrasures
Connector # contact point area:
Include the areas above and below
the contact point.
Greatest between the central incisors
and diminish from the centrals to the
posteriors.
Embrasures: triangular spaces incisal
and gingival to the connector.
Gingival embrasures are filled by
interdental papillae.
Short interdental papillae  black
triangle.
Tapered crown form  black triangle
Clinical considerations
Open bite
Tongue thrust
Functional shift
Missing tooth
Lower Anterior Tissue Thickness
Open bite
Principle: Teeth erupt until they hit something.
Open bite: the lower
incisor does not contact
the upper incisor. There
are obvious open bite
cases where the teeth are
separated in the anterior.
In some class II cases
where the amount of
overlap of the upper
incisor vs. the lower
incisor is normal (1/3
coverage), but the lower
incisor does not contact
the tooth nor the palate.
Tongue thrust
 A test for anterior tongue thrust is to:
 Take a small sip of water.
 Close the teeth together with the lips open.
 Swallow.
 A patient with an anterior tongue thrust will either:
 Not be able to keep his/her lips open.
 Will tilt his/her head back for gravity to keep the water from squirting
forward.
 Will squirt the water between the teeth forward onto their shirt (child
patient).
 A good exercise to give a patient with an anterior tongue thrust
(especially in the presence of open bite or excess anterior overjet) is:
 Take a small sip of water.
 Close the teeth together with the lips open.
 Swallow with the throat muscles. Tell the patient to hold their hand
on their throat as they learn this exercise to feel the muscle
contraction.
Functional Shift
Forward functional
shift
Lateral functional shift
Unilateral crossbite
Dental midlines not
centered.
The asymmetric face
from the frontal view.
Missing Tooth
This seems very obvious, but in many cases where a
tooth has been lost, the space has closed
spontaneously by dental drifting. It is very easy to not
notice a missing tooth in a dental arch when doing
your examination.
Be certain that you count 4 incisors, 2 canines, 4
bicuspids, etc. in each arch, before checking "none."
Lower Anterior Tissue Thickness
Principle: The lower arch is considered the limiting
arch in edgewise diagnosis.
To align crowded teeth, advancement (forward
movement) of the teeth will inevitably occur.
If the advancement of the lower incisors is significant,
then a periodontal defect (stripping of gingival tissue
is the most common) can occur.
Advancement of incisors with "thin tissue" has more
risk than advancement with "thick tissue" labial to the
lower incisors. As the teeth advance, the tissue will
become thinner.
Cephalometric analysis: lanmarks
Planes
Growth direction
SNB
Mandible is protrusive if > 83
Mandible is average if 76 – 82
Mandible is retrusive if <75
 Cephalometric analysis – Skeletal
Description Measurement Mean Range
Pal. plane to Md. Plane: Skeletal ANS-PNS to Md. plane 280 Closed 240 – 330 Open
Open/closed

Md. Plane angle: Skeletal Open/closed FH – MA: Child 260 Closed 200 – 300 Open
Adult 220 240 – 330

Y – Axis Vert/Hor Growth SGN - FH 590 Hor. 570 – 620 Vertical

Maxilla to Cranium NA +1mm Retruded -1 to +3 Protruded

Maxilla to Cranium SNA 820 Retruded 760 – 830 Protruded

Mandible to Cranium N  Po : Child -7mm Retruded -10 to -4 Protruded

Adult -1mm -4 to -1

Mandible to Cranium SNB 790 Retruded 750 – 830 Protruded

Maxilla to Mandible ANB 20 Class I : + 20 to +4.50

Class III tendency: +0.50 to +1.50
Wits A, B  Occlusal plane 0 mm Class I : -1 to +2
 Cephalometric analysis –
Dental
Description Measurement Mean Range
1
Interincisal Angle 1 to 1 1300 Best finish 125 0 – 1300

Lower Incisal Inclination 1 to MP 920 Retroclined 890 – 980 Proclined

Lower Incisal Protrusion 1 to NB +4mm Retruded +1 to +6 Protruded

Lower Incisal Protrusion 1 to APo +2mm Retruded 0 to +4 Protruded

Upper Incisal Inclination

1 to SN 1030 Retroclined 990 – 1060 Proclined

Upper Incisal Protrusion 1 to APo 5mm Retruded +2 to +7 Protruded

Upper Incisal Protrusion 1 to A vertical 4mm Retruded +2 to +6 Protruded

(to FH)
Cast analysis
Cast analysis by software
Advantages of computerized analysis
Accurate
Easy
More information:
Arch form
Loop distance (Bolton analysis)
Determine asymmetric Arch
Space analysis
Rotation
Prediction
DETERMINE THE PROBLEMS
Kind of problems:
Dental problems
Skeletal problems
Facial problems
Occlusal problems
TMJ problems
Periodontal problems
Causative factors
Degree of problems
Ackerman and Proffit diagram
Aligment (spacing and crowding)
Profile (convex, straight, concave)
Sagittal deviation (Angle class)
Vertical deviation (deep bite, open bite)
Transsagittal deviation (combine Angle class and cross
bite)
Sagittovertical deviation (combine Angle class and deep
bite or open bite)
Verticotransverse deviation (combine cross bite and deep
bite or open bite)
Transsagittovertical deviation (combine of problems in
three planes of space)
DENTAL PROBLEMS
Intra-arch problems
Inter-arch problems
Causative factors
Degree of the dental problems
Intra-arch problems
Position :
 Protrusion or retrusion of incisors
 Malposition
 Impaction
Rotation
Angulation
Inclination:
 Procline or recline
Spaces:
 Spacing or crowding
Curve of Spee
Inter-arch problems
Molar relationship
 Class I, II, III
Canine relationship
 Class I, II, III
Vertical relationship:
 Overbite, deep bite, open bite
Horizontal relationship:
 Overjet, end-to-end, anterior crossbite.
 Posterior crossbite
Upper and lower incisor angulation
Inter-arch discrepancy
Midline relationship:
 Midline asymmetry
Causative factors
Spacing
 Large jaw
 Small teeth
 Missing teeth
 Lateral over-expansion of arches or forward proclination of
anterior teeth.
Crowding
 Small or constricted arches
 Large teeth
 Retroclination
 Mesial drift of posterior teeth
Openbite
Bad habit: thumb sucking, finger sucking or pacifier
using, tongue thrush, lip habit.
High tongue posture
Airway obstruction: allergies, enlarged tonsils,
adenoids, septum problem…
Intracapsular TMJ problems
Skeletal growth abnormalities
Diagnosis of Impacted Teeth
Impacted Teeth : not erupted for 2 years following the
normal eruption age.
The eruption path is blocked, or if the eruption stops after
the tooth strays to a position labial or lingual to another
tooth.
The most common impaction: the upper canine.
DIAGNOSIS OF AN UPPER IMPACTED CANINE
Panoramic x-ray: Any overlap of the canine crown with
the lateral incisor roots  impaction?.
Palatal or labial?
 Palpate the labial tissue
 Occlusal x-ray
Crowding and impacted tooth
The "impacted tooth" may be BLOCKED OUT of the
arch because of crowding: in a good position but
cannot erupt due to a lack of space blocked out.
Evaluate the root formation to determine eruption
potential: incomplete root formation  eruption
potential.
Tx: space is made with open coils or extraction and a
deadline # 12 months is set to wait for its eruption.
Consideration in impacted tooth
Position: labial (good) or palatal
Angulation: the more vertical the more success
Space available: enough?
The path to the correct position?
The age: best under 25
The risk:
Ankylosis
Damage the adjacent teeth
Degree of problems:
Diagnostic Parameters
1. Canine and molar relationships: RM, RC, LM, LC
2. Angle classification
3. Overbite
4. Overjet
5. Stage of dental development
6. Presence of crossbite: with or without functional
shift
7. Space analysis
8. POG interpretation
9. CEP interpretation
1. Canine and molar relationships: RM, RC, LM, LC
a. Class I
b. Class II*
c. Class III*
d. Not fully erupted
2. Angle classification
a. Class I malocclusion
b. Class II malocclusion, division 1, 2 and subdivision*
c. Class III malocclusion, subdivision*
3. Overbite
a. Normal (5 % - 20%)
b. Moderate deep bite (20% - 50%)
c. Severe deep bite ( > 50%)*
d. Edge to edge
e. Anterior open bite
4. Overjet
a. Normal (1 – 3mm)
b. Excessive ( > 3mm)*
c. Edge to edge
d. Underjet (negative overjet)
5. Stage of dental development
a. Deciduous dentition
b. Early Mixed dentition
c. Late Mixed dentition
d. Permanent dentition
6. Presence of cross bite: with or without functional shift
a. None
b. Anterior
c. Posterior
d. Both
7. Space analysis
a. Adequate arch length ( +1 to -1mm)
b. Mild crowding (-2 to -3mm)
c. Moderate crowding (-4 to -6mm) or Severe (> -6mm)
d. Mild spacing (1 – 3mm)
e. Moderate spacing (4 to 6mm) or Severe (> 6mm)
8. POG interpretation
a. Normal
b. Abnormal: missing, supernumerary, ectopic, impacted
tooth)
9. CEP interpretation
a. Normal
b. Beyond the normal range: 1 SD
c. Beyond the normal range: 2 SD
d. Beyond the normal range: 3 SD