ORTHODONTIC DIAGNOSIS

Orthodontic diagnosis involves recognition of a condition of malocclusion, its severity and a

background plan to normalise the condition of malocclusion in the context of the patient's age,
sex, chief concern, oral health and ethnic origin. The diagnosis and treatment planning are
often interlinked and can be influenced by a multitude of considerations such as social and
financial limitations of the individual and psychological profile to name a few.
Comprehensive diagnosis is fundamental to any plan of treatment and its successful
execution [1].
Orthodontic diagnosis deals with recognition of the various characteristics of the
malocclusion. It involves collection of pertinent data in a systemic manner to help in the
identifying the nature and cause of the problem.
Comprehensive orthodontic diagnosis is established by use of certain clinial implements
called diagnostic aids. Orthodontic diagnosis consists of 2 parts as direct and indirect
diagnosis.
The data we will obtain in direct diagnosis for orthodontic diagnosis are anamnesis, clinical
evulation and functional assessment.
The data we will obtain in indirect diagnosis for orthodontıc diagnosis are evaluation of the
patient's oral and extra-oral photos, radiological evaluation (Cephalometric radiography,
Panoramic radiography, Hand-wrist radiographs) and classified as orthodontic model analysis.
Anamnesis is ask to questions and gather information by talking to a patient in order to
diagnose or understand his condition. This process is called taking anamnesis. Anamnesis
consists of four basic parts such as determining the patient's main complaint, medical and
dental history, studying physical growth and development, social and rehavioral review
(Motivation, expectations and other).
What is the patient’s chief complaint?” This question is the basis of the anamnesis. At a
minimum, the treatment plan should aim to address this important fundamental compo- nent
of the patient’s initial screening. The clinician is responsible for accurately understanding and
addressing the chief complaint [2].

Medical and Dental History

First of all, questions about the family history and background of the patient are asked. The
family historys of orthodontic treatment and evaluation of parents, siblings for their facial
forms, occlusion and malocclusion may give clues on the child's facial form when he/she
grows inro adulthood. Hereditary anomalies related to the size and shape of the jaws such as
Prognathia inferior, Retrognatie inferior, Deep Bite are asked [1].

1.Exposure of the mother to radiographic examinations (x-rays) and viral diseases (scarlet
fever, measles, rubella) during pregnancy should be questioned [3]. Scarlet fever and measles
cause a delay in tooth eruption. Rubella causes tooth loss.
The stage of the first 3 months of pregnancy named as organogenesis phase. If the mother has
had a radiographic examination at the end of the organogenesis stage, there is a risk of cleft
lip and palate in the baby [4].

2.Trauma During birth causes many problems. Forceps delivery predispose to TMJ injuries
that can result mandibular growth retardation. Use of forceps and vacuum during labor causes
a bird face appearance. Altrought most children with a condylar fracture of the mandibla
recovar uneventfully, remember that a growth deficit related to an old injury is the most
probable causebof true facial asymettry [1].

3.Systemic and Metabolic Diseasis should be recorded before orthodontic treatment . Some
medical conditions such as Bleeding disorders (Hemophilia), Heart diseases (Endocarditis
risk), Illnesses as a child Medications used (immunosuppressives), Diabetes, Epilepsy,
Asthma, Allergies, HBV, HCV, HIV (Cross infection risk) can contraindicate the orthodontic
treatment [5]. It is important that all medical conditions be reviewed and further investigated
(e.g., with a phone call to the patient’s physician) if needed, as they may affect the treatment
directly or indirectly [2].

4. Nutritional status should be questioned. Inadequate nutrition(malnutritional) in protein,

calcium and vitamins can cause serious problems. Children exposed to prolonged malnutrition
show stunting of growth and slow maturation. Protein energy malnutrition leads to altered
skeletal and muscu- lar growth; vitamin D deficiency affects bone growth and maturation,
vitamin A and E deficienry alter the growth and development of the epithelium, while vitamin
B1 deficienry alters the development of the neurones leading to altered mental status [6].
Eating high-carbohydrate, sugary and soft foods has a higher risk of decay [7].

5. Bad habits such as finger sucking, lip biting, nail biting are situations that we need to pay
attention to. As a result of finger sucking, jaw narrowness and push forward in upper incisors
occurs, lip biting can also create significant side effects. As a result lower lip biting, upper
incisor protrusion and diastema between incisors can occur. As a result of upper lip biting,
upper incisor retrusion, perplexity in tooth rows can occur. As a result of nail biting position
disorder in teeth and gingival recession can occur. As a result of unsuitable and / or prolonged
use of pacifiers and bottles, missing or malfunctioning affects the formation of normal
morphology can be seen [8].
6.Trauma is important infermation. Primary teeth traumas can cause enamel formation defect
(hypoplasia) or Ankylosis (Root-bone fusion) of the underlying permanent tooth.
Continuous dental trauma causes luxation, ankylosis. Jaw trauma causes pause in lower jaw
joint development [9].
7.The time to start Walking / Talking must be questionned. It can be Normal or Delayed.
8. Whether the patient has any allergies (antibiotic, latex, metal) should be questioned [10].
9. The patient may have upper respiratory tract diseases such as nasal septum deviation, nasal
polyp, enlarge tonsilla palatina and adenoid vegetation (tonsilla pharyngica hypertrophy). For
these reasons, the patient may only be breathing through the mouth and prolonged mounth
breathing causes upper jaw narrowness [4].

Physical Growth Evaluation

According to Björk, it is possible to examine growth and development in four stages.
In order to eliminate skeletal anomalies, the period of growth and development of the
individual should be determined very well.
For normal youths who are approaching puberty, several questions usually provide the
necessary information about where the child is on the growth curve: How rapidly has the child
grown recently? Have clothes sizes changed recently? Are there signs of sexual maturation?
When did sexual maturation occur in older siblings? Valuable information can also be
obtained from observing the stage of secondary sexual characteristics [5]. When the pubertal
period (growth spurt) begins or is about to begin, skeletal anomalies should be treated.
Skeletal development period can be determined from hand- wrist radiographs and cervical
vertebrae [5].
Hand Wrist Radiographs
The hand and wrist radiograph help in estimating the skeletal age of bone for determining the
physical maturation status of the child. The bone age is of great help to the orthodontist in
coordinating the orthodontic therapy with the growth process. The idea of using hand and
wrist radiograph for determining the skeletal age is that; the skeleton in hand and wrist region
is made of several small bones; 27 small bones, distal ends of long bones radius and ulna. The
development of these bones from the appearance of calcification centers to epiphyseal plate's
closure occurs throughout the entire postnatal growth period and therefore provides a useful
means of assessing skeletal maturity [11].
Standard cephalometric cassettes are used for hand-wrist radiographs and the cassettes are
placed upright position. Left hand and wrist should be positioned passive, fingers almost
closed and parallel to each other [12].
Common used atlas of hand wrist radioghraphs:
 Greuchlich-Pyle
 Tanner-Whitehouse
Social and Behavioral Evaluation
Social and behavioral evaluation; the patient's motivation for treatment, patient’s expects at
the end of the treatment, and how cooperative the patient is.
Motivation of the patient for treatment can be classified as external motivation and internal
motivation [5].
External motivation is supplied by pressure from another individual, as with a reluctant child
who is being brought for orthodontic treatment by a determined mother.
Internal motivation, comes from within the individual and is based on his or her own
assessment of the situation and desire for treatment [5].
CLINICAL EVALUATION
There are two goals of the orthodontic clinical examination:
1- a. Evaluate oral health,
b. Jaw function, facial proportions, and smile characteristics
2- Decide which diagnostic records are required for the patient individually [5]
Evaluation Of Oral Health
Before starting orthodontic treatment of patients, any systemic disease or pathological
condition should be taken under control.
In addition, the health of hard and soft tissues; Dental caries, pulp pathologies and
susceptibility to periodontal diseases should be evaluated [5].
Evaluation Of Jaw and Occlusal Function
Chewing, speech and temporomandibular joint problems are evaluated. Patients with
malocclusion have difficulty chewing normally. Palpation of masticatory muscles and TMJ; It
should be a routine part of every dental examination and any TMJ problems such as joint
pain, voice or limitation in patency should be noted.
Sleeping disorders; may be associated with severe mandibular insufficiency, and this
functional problem often causes orthodontic consultation [5].
Evaluation Of Speech
Certain malocclusions may cause defects in speech due to interference with the movement of
tongue and lips. This should be observed while talking with the patient. Especially patients
with cleft lip and palate have difficulty in making many sounds, patients having tongue trust
habit tend to lips. Orthodontists and speech therapists work multidisciplinary in these patients
[5].
Evaluation Of Function
Detecting lateral or anterior shift of the lower jaw during mouth opening and closing is
important in determining whether the anomaly is functional or morphological. Many patients
with a Class II malocclusion and an underlying skeletal Class II jaw relationship will position
the mandible forward making the occlusion look better than it really is. It is called 'Sunday
Bite' [5].
During function;
*Swallowing pattern (can be normal / atypical),
*Lips (can be Hypo/Hypertonic),
*The amount of sliding in the lower jaw in the sagittal / transversal direction while the teeth
pass into centric occlusion is evaluated [5].
Assessment of Developmental Age
The growth and development of the individual have an important role in orthodontic
treatment. When examining the growth of an individual, it is important to calculate how much
an individual has grown and the amount of remaining growth. Some methods for determining
age and the degree of dental and skeletal development chronological age, sexual age, dental
and skeletal age. In clinical examination, it is evaluated whether the secondary sex
characteristics have developed or not, and the harmony between tooth age and chronological
age is evaluated [5].
Extraoral Evaluation
Facial Esthetics /Facial Proportions
Head shape types are;
Mesocephalic: Avarege shape of the head. They have normal dental arches.
Dolicocephalic: Long and narrow head. They have narrow dental arches.
Brachycephalic: Broad and short head. They have broad dental arches.
Three face forms are;
Mesoprosopic: Average or normal face form
Euryprosopic: broad and short face form
Leptoprosopic: Long and narrow face form [13]
Assesment Of The Face
Frontal
The first step during assesment of face is to examine the face in frontal view. In frontal view,
bilateral symmetry and the coincidence of the midline of the face and the midline of
upper/lower jaws is evaluated [5].
Profile
Profile is examined by viewing the patient from the side. Facial profile helips in diagnosing
the gross deviation of maxillo-mandibular relationship [5].
Evaluation of Facial Symmetry
The patient’s facial symmetry is examined to determine disproportions of the face in
transverse and veticel planes. Facial asymmetry can ocur as a result of:
-Congenital defects (facial microsomia)
-Condyle fracture due to jaw trauma in childhood
-Muscle dysfunction (torticollis, cerebral palsy)
-Hemi-facial atrophy/hyperthropy
-Unilateral condylar ankylosis and hyperplasia [5]

Composite photographs are the best way to illsutrate normal facial asymmetry. Fort his boy,
whose mild asymmetry rarely would be notices and is not a problem, the true photograph is in
the center (B). On the patient’s right (A) is a composite of the two right sides, while on the
left (C) is a composite of two left sides. This technique dramatically illustrates the difference
in the two sides of a normal face, in which mild asymmetry is the rule rather than the
exception. Usually, the right side of the face is alittle larger than the left, rather than the
reverse as in this individual [5].
Evaluation Of Horizontal Facial Proportions (fifths of the face)
Facial proportions and symmetry in the frontal plane. An ideally proportional face can be
divided into central, medial, and lateral equal fifths. The separation of the eyes and the width
of the eyes, which should be equal, determine the central and medial fifths. The nose and chin
should be centered within the central fifth, with the width of the nose the same as or slightly
wider than the central fifth. The interpupillary distance (dashed line) should equal the width
of the mouth [5].

Evaluation of Vertical Facial Proportions

Vertical facial proportions in the frontal (A) and lateral (B) views are best evaluated in the
context of the facial thirds, which the Renaissance artists noted were equal in height in well-
proportioned faces. In modern Caucasians, the lower facial third often is slightly longer than
the central third. The lower third also includes thirds: The mouth should be one-third of the
way between the base of the nose and the chin [5].

Profile Evaluation
Profile convexity or concavity results from a disproportion in the size of the jaws but does not
by itself indicate which jaw is at fault. (A) A convex facial profile indicates a Class II jaw
relationship, which can result from either a maxilla that projects too far forward or a mandible
too far back. (B) A straight or slightly convex profile is normal and usually reflects a normal
jaw relationship. (C) A concave profile indicates a Class III jaw relationship, which can result
from either a maxilla that is too far back or a mandible that protrudes forward [5].
Evaluation Of Lip Posture
Normally the upper lips covers the entire labial surface of upper anterior teeth except the
incisal 2-3 mm. The lower lip covers the entire labial surface of the lower anterior and 2-3
mm of the incisal edge of the upper anteriors [14].
Classification:
*Competent Lips: Lips in contact at rest and function with minimal contraction of circumoral
muscles.
*Incompetent Lips: Anatomically short lips, which do not contact when musculature is
relaxed. Lip seal achieved only by active contraction of the orbicularis oris and mentalis
muscles.
*Potentially İncompetent Lips: Lip seal is prevented due to the protruding maxillary incisors
despite normally developed lips [15].
* Everted Lips: These are hypertrophied lips with reduntant tissue but weak muscular tonicity.
On the profile, the nose dominates the middle part of the face and therefore it is important to
examine it [14]. Nose size-normally the nose is one third of the total facial height. Nose
contour; the shape of the nose can be straight, convex or crooked as a result of nasal injuries.
Nostrils; they are oval and should be bilaterally symmetrical. The narrow nostrils can be
associated with mouth breathing habit. A child may have a deviated nasal septum, and one
side of the nose may be blocked. History of allergic rhinitis and recurrent throat infection calls
for evaluation by an ENT expert [1].
The nasolabial angle The nasolabial angle measures the inclination of the columella in
relation to the upper lip. The angle should be in the range of 90 to 120degrees. The
morphology of the nasolabial angle is a function of several anatomic features. Procumbency
of the maxilla tends to produce an acute nasolabial angle, and maxillary retrusion tends to
produce an obtuse nasolabial angle, but the angle is very much affected by nasal form itself.
Mentolabial sulcus is defined simply as the fold of soft tissue between the lower lip and the
chin; it may vary greatly in form and depth. The sulcus is affected by facial height, overjet,
and chin projection [14].
Mental Muscle Activity; Hyperactive mentalis activity is seen in some malocclusion cases. It
causes puckering of the chin.
Checklist of Facial Dimensions to Evaluate During Clinical Examination
This checklist is just that: a list of things that should be noted systematically during the
clinical examination. Precise measurements are not necessary, but deviations from the normal
should be considered when the problem list is developed.

Classification Of Appearance and Esthetics

Profile, vertical facial proportions, lip fullness, chin shape, nose shape, size of ears are
evaluated for macroaesthetic. Examples of problems that would be noted in this first step
would be asymmetry, excessive or deficient face height, mandibular or maxillary deficiency
or excess, and so on. The first step in evaluating facial proportions is to take a good look at
the patient, examining him or her for developmental characteristics and a general impression.
It is a mistake for any dentist to focus on just the teeth after a cursory look at the face. It is a
disastrous mistake for an orthodontist not to evaluate the face carefully.
Miniesthetics includes the display of the teeth at rest, during speech, and on smiling. It
includes such assessments as excessive gingival display, inadequate anterior tooth display,
inappropriate gingival heights, and the extent of the buccal corridors (the dark spaces in the
corners of the mouth beyond the teeth) and crowding, vermilion border, smile arch.
Evaluation of tooth–lip relationships begins with an examination of symmetry, in which it is
particularly important to note the relationship of the dental midline of each arch to the skeletal
midline of that jaw (i.e., the lower incisor midline relative to the midline of the mandible, and
the upper incisor midline relative to the midline of the maxilla).
A second aspect of dental–soft tissue relationships is the vertical relationship of the teeth to
the lips at rest and on smile. During the clinical examination, it is important to note the
amount of incisor display. For patients with excessive incisor display, the usual cause is a
long lower third of the face, but that is not the only possibility; a short upper lip could produce
the same thing.
A third important relationship to note is whether an up–down transverse rotation of the
dentition is revealed when the patient smiles or the lips are separated at rest. This often is
called a transverse cant of the occlusal plane but is better described as a transverse roll of the
esthetic line of the dentition. Neither dental casts nor a photograph with lip retractors will
reveal this. Dentists detect a transverse roll at 1 mm from side to side, whereas laypersons are
more forgiving and see it at 2 to 3 mm—but at that point, it is a problem.
Microesthetics: The elements that make a tooth’s anatomy as similar as possible to that of a
natural tooth are considered microesthetics. This includes assessment of tooth proportions in
height and width, gingival shape and contour, connectors and embrasures, black triangular
holes, and tooth shade [5].

ORTHODONTIC DIAGNOSTIC RECORDS

Good treatment is based on good diagnosis and treatment planning, which in turn depend on
accurate records. Orthodontic diagnostic records should include models, photographs and
radiographic imaging.
Facial Photographs
Facial photographs offer a lot of information on the soft tissue morphology and facial
expression A series of facial photographs has been a standard part of orthodontic diagnostic
records for many years [5]. Useful in assessment of facial symmetry, facial type and profile,
serve as a diagnostic records, Help in assessing the progress of the treatment radiographs.

Extraoral photographs
The minimum set is three photographs, frontal at rest, frontal smile, and profile at rest, but it
can be valuable to have a record of tooth–lip relationships in other views. In addition, frontal
oblique, submental, close-up smile photos should also be taken when necessary [5].
Intraoral photographs
The major purpose of the intraoral photographs is to enable the orthodontist to review the hard
and soft tissue findings from the clinical examination during analysis of all the diagnostic
data. What is surprising is how often one discovers something on the photographs that was
overlooked at the time of oral examination. Another purpose of the intraoral photograph is to
record hard and soft tissue conditions as they exist before treatment. Photographs that show
white-spot lesions of the enamel, hyperplastic areas, and gingival clefts are essential to
document that such preexisting conditions are not caused by any subsequent orthodontic
treatment [14]. Five standard intraoral photographs are suggested: right, center, and left views
with the teeth in occlusion, and maxillary and mandibular occlusal views. The occlusal
photograph should be taken using a front surface mirror to permit a 90-degree view of the
occlusal surface.
Radiographs allow viewing of teeth and their supporting structures.
Extraoral Radiographs
Panoramic Radiographs
It enables viewing of both maxillary and mandibular arches with their supporting structures.
Panoramic radiographs are used to visualize deciduous root resorption and root growth of
permanent teeth, ankylosed and impacted teeth, and to diagnose the presence and extent of
jaw fractures and pathology. The panoramic radiograph should be supplemented with
periapical or occlusal radiographs only when greater detail is required [5].
Cephalometric Radiographs
Lateral cephalometric radiographs are the standard for comprehensive orthodontic treatment.
They allow analysis of the pretreatment form (positions and relationships) for diagnosis and
treatment planning. They provide for evaluation of progress and the posttreatment result when
follow-up cephalograms are taken. In addition, bone age can be evaluated from the cervical
vertebrae with cephalometry [5].

Hand-wrist Radiographs
Traditionally, hand-wrist radiographs have been used to evaluate skeletal maturity. The stage
of ossification of the wrist and phalanges in the hand correlates to skeletal maturity The hand
and wrist region have number of small bones whose appearance and progress of ossification
occur in a predictable sequence. This enables skeletal age of a person the yare useful in
assessing growth for planning growth modification procedures and surgical procedures.
However, efforts to correlate skeletal maturation to the cervical vertebrae have diminished the
need for a hand-wrist radiograph. It has been shown that the peak of pubertal growth can be
estimated adequately from a lateral cephalometric film [2].
Postero-anterior Radiographs
They are used in the frontal examination of malocclusions. The major indication for a frontal
cephalometric radiograph was facial asymmetry. And also upper jaw crowding, cross bite,
orthognathic surgery patients, jaw fractures, nasal septum deviation, nasal polyp, frontal-
ethmoidal-maxillary sinus are evaluated with posterior anterior radiographs [5].
Intraoral Radiographs
Periapical Radiographs that are used to view the teeth and their supporting structures.
Periapical radiographs are used to confirm root resorption, presence of periapical lesions,
periodontium, root and alveolar bone, eruption direction and time, impacted supernumerary
and missing teeth, examination of interproximal caries, measurement of the width of
unerupted teeth.
Bite-wing Radiographs
It records the coronal part of upper and lower dentition along with their supporting structure.
Bitewing geometry is based on the paralleling technique, where the image receptor is placed
parallel to the teeth and the x-ray beam is aimed perpendicular to the receptor. It is used to
detect proximal caries, height and contour of inter alveolar bone, periodontal changes,
secondary caries below restorations, determine interproximal calculus [16].
Occlusal Radiographs
This image shows the maxillary incisor region and may taken when there is a clinical
indication of potential underlying diseases or developmental anomaly in this era. An occlusal
images is helpful in assessing the position of misplaced and unerupted canines. It is also used
to control the opening of the suture in the expanded upper jaw, to diagnose the presence and
extent of supernumerary teeth, fractures [17].
3D Dental Volumetric Tomographs
Dental volumetric tomography is an imaging method that takes a cross-sectional view of the
area to be examined. With this method, the details that cannot be seen on the normal film can
be seen from every angle The ability to view structures from all three planes of space without
any superimposition and geometric distortions is the key advantage of CBCT over
conventional images. It is used for Impacted and transposed teeth, cleft lip and palate,
orthognathic surgery patients, airway analysis, TME analysis, face analysis, biomodel
acquisition, virtual mini screw positioning [5].
Orthodontic Model
Matthaeus Gottfried Purmann (1692) was the first to report taking wax impressions. In 1756,
Phillip Pfaff used plaster of Paris impressions. Friedrich Christoph Kneisel was the first to use
plaster models to record malocclusion [18].
DR. PAUL W. SIMON (1928)
Gnathostatic models are orthodontic study models where the base of the maxillary cast is
trimmed to correspond to the Frankfort horizontal plane. The Frankfort horizontal plane,
which passes through the eye points and the ear points. He also used the orbital plane, where
the eye points intersect and perpendicular to the ear-eye plane, and the raphe-median plane,
which cuts the two occipital points of the raphe-palatine, perpendicular to the ear-eye plane
[19].
Study models provide a three-dimensional record of the dentition and are essential for many
reasons. Although CBCT radiographic imaging and occlusal scanning and other imaging
technologies may eventually allow us to replace this record, models are used for the
following: 1. To calculate total space analysis 2. To assess and document the dental anatomy
3. To assess and document the intercuspation 4. To assess and document arch form 5. To
assess and document the curve of occlusion (occlusal curve analysis) 6. To evaluate
functional occlusion, potentially with the aid of articulators 7. As a basis from which to
measure progress during treatment 8. To detect abnormalities (e.g., localized enlargements
and distortion of arch form) 9. These records and their pretreatment and posttreatment
evaluation allow for long-term improvement in treatment planning [20].
Intermaxillary examination
Intermaxillary examination performed in the sagittal, vertical, transversal plane. In Sagittal
Plane Relationships between canine and molar teeth, determination of Angle classification,
relationships between incisors in the anterior region, the amount of overjet is being examined
can be done. In Transversal plane posterior crossbite, buccal nonocclusion, midline shift
cases can be examined. In Vertical plane Open bite, deepbite, supraversion / infraversion
cases can be examined.
Intramaxillary examination alveolar and dental arch form, symmetry, spee curve, erupted
teeth, shape anomaly, number anomaly, position anomaly can be determined by individually.
Study model analysis has been the gold standard for diagnostic procedures and dental
treatment for many years. Various methods have been used for measuring and analyzing
plaster models as study models, including calipers, rulers and other measuring tools. The data
from the measurement was subsequently calculated to relevant formulas to produce the results
of the analysis [21].
The most common model analyses on orthodontic models are Bolton analysis and Hays
Nance analysis.
Bolton Model Analysis: Compares the lower and upper arch tooth sizes with each other. The
relationship of the total mesiodistal width of the maxillary teeth to that of the mandibular teeth
was calculated by Bolton in 1958. This relationship is crucial in the creation of an occlusion
without diastemas, rotations or crowding; with proper overjet and overbite; and a class one
molar relationship in the finishing stage of orthodontic treatment. Therefore, it is crucial to
accurately measure the mesiodistal width of the teeth to have an ideal occlusion at the end of
treatment [22].
Hays-Nance Model Analysis: Hays Nance analysis reveals the relationship between tooth size
and dental arch length for proper alignment of the teeth in the absence of irregularities or
diastemas. It compares the tooth sizes with the dimensions of the alveolar arch. This is a basic
mathematical equation comparing the required and available space. The amount of crowding
or excess space is determined [23].
Before going into detail about these two analyzes, it is helpful to provide some information on
a few terms.
Tooth Size: Traditionally, measurements on dental casts are performed with the aid of either
Vernier calipers or needle pointed dividers.
Arch Perimeter: Arch perimeter is also measured by either Vernier calipers or needle
pointed dividers [24].
The Actual Arch Length Measurement with Brass Wire: Measure the arch perimeter using
brass wire. From mesiobuccal line angle of maxillary right first molar, pass the wire along the
buccal cusp and incisal edges in the anterior region, ‘pass the wire on the left quadrant like a
mirror image till the mesiobuccal line angle of the left maxillary first molar. In case of
proclined incisors, pass the brass wire in the cingulum region, and if the anterior teeth are
retroclined, pass the wire labial to them like a smooth curve [25].
Measurement of Spee Curve: The depth of curve of Spee was measured as the perpendicular
distance between the deepest cusp tip and a flat plane that was laid on the top of the
mandibular dental cast, touching the incisal edges of the central incisors and the distal cusp
tips of the most posterior teeth in the lower arch [25].
1. BOLTON MODEL ANALYSIS: It is used to examine whether the mesio-distal
dimensions of the teeth in the lower and upper jaw arch are compatible with each other. An
Overall Analysis measures the sum of mesio-distal width of all 12 (first molar to first molar)
mandibular teeth and compares them to the 12 maxillary teeth. The overall ratio known to be
91.3%.The anterior analysis measures the sum of Mesio-distal width of front 6 mandibular
teeth and compares them to maxillary teeth. The anterior ratio is known to be 77.2%. An
overall ratio of more than 91.3% means that the mandibular teeth are bigger when compared
to normal. A ratio smaller than 91.3% would mean the mandibular teeth are smaller than
normal. Anterior analysis follows the same principle. Having a different ratio than normal is
referred to as Bolton Discrepancy. A standard deviation of more than 2 yields a significant
discrepancy[22].

OVERALL RATIO

Sum of mandibular12(M-D)
X 100 = 91,3
Sum of maxillary12(M-
D)

ANTERIOR RATIO

Sum of mandibular 6
X 100 = 77,2
Sum of maxillary 6

2. HAYS NANCE MODEL ANALYSIS: It is used to compare the mesio-distal widths of

teeth with the lengths of the alveolar arch. Nance in 1947 did an analysis to estimate the space
required for permanent canines and premolars using erupted permanent incisors. He measured
the maximum mesiodistal width of each permanent incisor (maxillary and mandibular incisors
on the cast), using a brass wire (0.010 inch) measured the arch perimeter. Measure maximum
mesiodistal width of unerupted permanent canine, first and second premolar from radiograph.
In 1993 Nanda revised Hays Nance procedure, he changed, added few points. Nanda advised
to perform Huckabas analysis to the radiographic value of measured unerupted premolars to
minimize the error. He also has asked to perform cephalomertic analysis (tweeds analysis) as
it allows for correction of protrusion of mandibular incisors. [26]

Hays Nance model analysis can be used for both permanent and mixed dentition.

A-) Hays Nance Analysis for permanent dentition

B-) Hays Nance Analysis in the mixed dentition

A-) Hays Nance Analysis For Permanent Dentition:

The Actual Arch Length: With the soft brass wire, the arch is bent in accordance with the
sagittal and transversal dimensions of the dental arch. This arch must be perfectly straight and
symmetrical

Ideal Arch Length: The mesio-distal widths of incisors, lateral incisors, canines, 1st and 2nd
molars are measured one by one by means of a caliper. The sum of these measurements gives
the ideal arch length.

Arch Length Discrepancy: The Actual Arch Length – İdeal Arch Length gives us the arch
length discrepancy

If the value obtained is (+) , that means there is an excess of space.

If the value obtained is (-) , that means there is a space deficiency. [23]

B-) Hays Nance Analysis In The Mixed Dentition:

The Actual Arch Length: With the soft messing wire, the arch is bent in accordance with the
sagittal and transversal dimensions of the dental arch. This arc must be perfectly straight and
symmetrical

Lee way space is included in this measurement during the mixed dentition period.

Upper jaw: 1,8 mm (0,9mm right – 0,9 mm left)

Lower jaw 3,4 mm (1,7 mm right – 1,7mm left)

*** If there are 2nd primer molars, the lee way length should be subtracted from this
measurement after the actual arch length is measured. ***

*** If the 2nd primer molars are lost, it means that the lee way space have been used,
therefore the lee way length is not deduced after the actual arch length is measured. ***

İdeal Arch Length: The mesio-distal widths of the incisors are measured individually. The
mesio-distal widths of the canine and premolars are measured. However, since these teeth
have not yet erupted during this period, this calculation can be made with 2 different methods.

X-Ray Method

Calculation according to the lower incisors amount

X-Ray Method: A long X-ray tube should be used. It is recommended to take 2 separate X-
rays. One from the small molar area, and another one from the canine area. Magnification
amount is about 0.2mm

Calculation According To The Amount of Mandibular Incisors: From the Moyers table,
according to the lower incisor amount, the sum of the mesio-distal width measurements of the
canine, 1st and 2nd premolars are found.

Lower incisors amount + (2 x Value found from Moyers table)= Required tooth arch length
[23].

Tanaka and Johnston, by using the width of mandibular incisors, developed a different way
of predicting unerupted canine and premolar size. Tanaka and Johnston conducted a study on
506 orthodontic patients in the Orthodontic Department of Case Western University school of
dentistry at Cleveland.

They gave regressive equations of the form Y = A+B(X)

Where Y = sum of the mesio distal widths of the unerupted canines and premolars

X = sum of the mesio distal widths of the lower incisors A & B are constants.

For the maxillary arch, Y = 11 + 0.5 ( X )

For the mandibular arch, Y = 10.5 + 0.5 ( X )

Advantages:

• Technique involves simple, easily repeated procedure with minimum material requirement.

• Prediction chart and radiograph is not required

Limitations:

• Error in predicted size if patients are not from North western European descent [27].

DIGITAL MODELS AND SPECIAL COMPUTER SOFTWARE MODELS

Digital models have recently been introduced in clinical orthodontics, having potential to both
classify malocclusion and formulate treatment plans. Digital models and tridimensional
technology minimize many of the problems, while providing the orthodontist with standard
routine data, such as tooth size, overbite, overjet, Bolton and cast discrepancy, symmetry and
shape of arches, intensity of the curves of Spee and Wilson, among others. The motivation for
using digital models arose from the disadvantages of using dental casts, including the
following: need for proper storage places, resulting in greater need for space in the office; risk
of breaking which would cause permanent destruction of patient's records; duplication of casts
in order to communicate with other dentists and specialists; increased hours of laboratory
work and associated costs.

Fleming et al 1 concluded in their systematic review in 2011 that orthodontic measurements

on digital models were comparable with those derived from plaster models [28].
[1] ] Kharbanda O.P., Orthodontics: Diagnosis and Management of Malocclusion and
Dentofacial Deformities, 3rd Edition, 2020, Chapter 12.

[2] Nanda R., Esthetics and Biomechanics in Orthodontics 2nd Edition, 2014, Chapter 1.

[3] Graber L.W, Orthodontics Current Principles and Techniques, 5th Edition, 2021, Chapter
1.

[4] Ülgen, M., Principles of Orthodontic Treatment, 7th Edition,2005, Chapter 7

[5] Proffit, W. R., Fields, H. W., & Sarver, D. M. ,Contemporary orthodontics. St. Louis, Mo:
Elsevier/Mosby, 2013, Chapter 6.

[6] Kharbanda O.P., Orthodontics: Diagnosis and Management of Malocclusion and

Dentofacial Deformities, 3rd Edition, 2020, Chapter 9

[7] Krishnan V, Davidovitch Z, Integrated Clinical Orthodontics ,1st edition,2012, Chapter 5

[8] Kharbanda O.P., Orthodontics: Diagnosis and Management of Malocclusion and

Dentofacial Deformities, 3rd Edition, 2020, Chapter 11

[9] Kharbanda O.P., Orthodontics: Diagnosis and Management of Malocclusion and

Dentofacial Deformities, 3rd Edition, 2020, Chapter 2

[10] Krishnan V, Davidovitch Z, Integrated Clinical Orthodontics ,1st edition,2012, Chapter

3

[11] Hashim HA, Mansoor H, Mohamed MHH. Assessment of Skeletal Age Using Hand-
Wrist Radiographs following Bjork System. J Int Soc Prev Community Dent. 2018;8(6):482-
487.

[12] Ülgen, M., Principles of Orthodontic Treatment, 7th Edition,2005, Chapter 10

[13] Ardani I G, Heswari DW, Alida A. The correlation between Class I, II, III dental and
skeletal malocclusion in ethnic Javanese: A cross sectional study. J Int Oral Health
2020;12:248-52
[14] Graber, T.M., Vanarsdall, R.L.Jr. Orthodontics: Current Principles And Techniques. 6th
ed. St. Louis: Mosby Year Book Inc, 2016, Chapter 9.

[15] Alam, Mohammad. (2011). A to Z Orthodontics. Volume 5: Soft tissue morphology.

[16] Dean A. McDonald and Avery's Dentistry for the Child and Adolescent. Elsevier/Mosby.
2020. Chapter 2

[17] Isaacson K. G., Thom A.R. Guidelines for the Use of Radiographs in Clinical
Orthodontics 4th Edition, 2015

[18] Phulari B. S. History of Orthodontics 2013.

[19] Simon P. The Necessity of Gnathostatic Diagnoses in Orthodontic Practice, The Journal
of the American Dental Association (1922),15. 22-26.

[20] Graber, T.M., Vanarsdall, R.L.Jr. Orthodontics: Current Principles And Techniques. 6th
ed. St. Louis: Mosby Year Book Inc, 2016, Chapter 34.

[21] Lippold C, Kirschneck C, Schreiber K, Abukiress S, Tahvildari A, Moiseenko T, Danesh

G. Methodological accuracy of digital and manual model analysis in orthodontics - a
retrospective clinical study. Comput Biol Med. 2015; 62: 103–9.
[22] Nalcaci R. Topcuoglu T. Ozturk F. Comparison of Bolton analysis and tooth size
measurements obtained using conventional and three-dimensional orthodontic models Eur J
Dent (2013) 66-70

[23] Ayşe Gülşen , Belma Işık Aslan , Fatma Deniz Uzuner, Gülce Tosun, Neslihan Üçüncü
Discrepancy in the lower arch perimeter in patients with a unilateral cleft lip and palate:
orthodontic model analysis. Odontol Turc 2019;36(1):16-20

[24] Tomassetti, J & Taloumis, L & Denny, J & Fischer, J. (2001). A Comparison of 3
Computerized Bolton Tooth-Size Analyses with a Commonly Used Method. The Angle
orthodontist. October 2001 The Angle Orthodontist 71(5):351-7

[25] Correia, Gabriele & Habib, Fernando & Vogel, Carlos. (2014). Tooth-Size discrepancy:
A comparison between manual and digital methods. Dental press journal of orthodontics. July
2014 Dental Press Journal of Orthodontics 9(4):107-13
[26] Keerthika A.1 , Jeevarathan J.2 , Ponnudurai Arangannal3 , Vijayakumar M.4 , Amudha
S.4 , Aarthi J. Mixed Dentition Analysis Procedure: A Review Indian Journal of Public Health
Research & Development 12/2019
[27] M M Tanaka, L E Johnston The prediction of the size of unerupted canines and
premolars in a contemporary orthodontic population J Am Dent Assoc.1974 Apr 1;88(4):798-
801.
[28] Peluso, Matthew & Josell, Stuart & Levine, Sam & Lorei, Brian. (2004). Digital models:
An introduction. Seminars in Orthodontics September 200410(3):226-238