DIAGNOSIS AND

TREATMENT
PLANNING
SUBMITTED SUBMITTED BY :-
TO :- DR. VISHAL DHEEMAN
CHIRAG
CONTENTS
■ Introduction
■ Classification of diagnostic aids
■ Essential diagnostic aids-
■ Case history-
■ Clinical examination-
■ Radiographs-
1. IOPA, Bitewing, Occlusal-
2. OPG, cephalometric radiographs, Hand-wrist radiographs-
■ Photographs
■ -Conclusion
INTRODUCTION
■ Diagnosis is defined as 'The act/ process of identifying or determining
the nature and cause of a disease or injury through evaluation of patient
history, examination and review of laboratory data’→
■ Orthodontic diagnosis deals with the recognition of the various
characteristics of the malocclusion.
■ It involves collection of pertinent data in a systemic manner to help in
identifying the nature and cause of the problem
■ Orthodontic diagnosis should be based on the sound scientific
knowledge combined at times with clinical experience and common
sense
■ Comprehensive orthodontic diagnosis is established by use of certain
clinical implements called diagnostic aids.
CLASSIFICATION OF DIAGNOSTIC
AIDS
■ Orthodontic
diagnostic aids are
of two types:
■ 1. Essential
diagnostic aids
■ 2.Non - essential
diagnostic aids
/Supplemental
diagnostic aids
CASE HISTORY
■ Case history is the information
gathered from the patient or the
parent that aids in overall
diagnosis of the case.
■ Personal Details
▸ Name
▸ Age
▸ Sex
▸ Address
▸ Occupation
■ CHIEF COMPLAINT
(major reason for seeking consultation and
treatment).
There are three major reasons for patient
concern about the alignment and occlusion
of the teeth:
1. Impaired dento-facial esthetics that can
lead to psychosocial problems
2. 2. Impaired function
3. 3. Desire to enhance dento-facial
esthetics and thereby the quality of life
■ MEDICAL
HISTORY
Before orthodontic treatment is
undertaken, a full medical history
is recorded. Very few medical
conditions contraindicate the use
of orthodontic appliances Medical
History
■ Most of these conditions may
require certain precautionary
measures to be taken prior to or
during orthodontic therapy.
Some systemic conditions and
their orthodontic considerations:

1.Diabetes mellitus
■ Ortho Rx should be avoided in
poorly controlled insulin
dependent diabetes mellitus-
■ Morning appointments are
advisable.
2.Endocarditis
■ Invasive procedures such as
extraction, placement of
bands, removal of bands and
flap procedures should be
performed under antibiotic
prophylaxis Bonded
instruments are preferred over
banded ones so as to clear of
the gingival bleeding
3.Hemophilia A
■ These patients pose a risk
of increased bleeding
following extraction.
Extraction as a part of
orthodontic treatment isn't a
contraindication
■ Care should be taken
during insertion and
removal of arch wires in
order to avoid any injury to
oral soft tissue
4.Asthma
– Anxiety is a known trigger, therefore the appointment is made as stress
free as possible and the patient instructed to have their medication
before the appointment Methyl methacrylate is also a trigger factor,
fixed appliances are preferred over removable appliances

5.Chronic renal failure

6.Epilepsy
■ Removable appliances are contraindicated in patients with poorly controlled epilepsy
due to airway obstruction during seizuresPhenytoin - gingival hyperplasia
DENTAL
HISTORY-
■ Should include information on
the age of eruption of the
deciduous and permanent
teeth, H/o extraction, decay,
restorations and trauma to the
dentition.
■ -Gives information about the
attitude of the patient towards
dental treatment
PRENATAL HISTORY-
■ condition of the mother during
pregnancy-type of delivery- forceps
delivery-TMJ Injuries- mandibular
growth retardation

POSTNATAL
HISTORY
■ -type of feeding, presence of habits and
h/o trauma
FAMILY HISTORY▸
■ Many malocclusions are inherited such as skeletal class II
and class III, congenital conditions such as clefts of lip and
palate
GENERAL EXAMINATION
■ Height And Weight-Provide a clue to the physical growth and
maturation of the patient
■ Gait- It is the way a person walks. Abnormalities of gait are usually
associated with neuromuscular disorders that may have a dental
correlation
■ Posture-refers to the way the a person
stands.-abnormal postures can
predispose to malocclusion due to
alteration in maxillo-mandibular
relationship
■ Body build (Physique)
1. Aesthetic: thin physique and usually
posses narrow dental arches
2. Plethoric: obese persons, they generally
have large, square dental arches
3. Athletic: normally built, being neither
thin nor obese, they have normal sized
dental arches
■ Sheldon classification of general body build
■ 1.Ectomorphic- tall and thin physique
■ 2.Mesomorphic-Average physique
■ 3.Endomorphic- short and obese physique
EXTRA ORAL EXAMINATION
■ Shape of head
1.Mesocephalic- average shape of
the head, they posses normal
dental arches.
2.Dolicocephalic-long and narrow
head, they have normal dental
arches
3.Brachycephalic-broad and short
head, they have broad dental
arches
■ Facial form :- Round,Oval & Square
1.Mesoprosopic- average or normal face form
2.Euryproscopic - broad and short
3.Leptoproscopic - long and narrow face form
■ Assessment of facial symmetry
■ Asymmetries that are gross and are detected
easily should be recorded.
■ Congenital defects
■ Hemifacial atrophy/hypertrophy
■ Unilateral condylar ankylosis and
hyperplasia
Facial profile
■ It examined by viewing patient
from side.
■ The profile is assessed by
joining the following two
reference lines
■ 1.A line joining the forehead
and the soft tissue point A
■ 2.A line joining the point A and
soft tissue
■ Based on the relationships
between these two lines, three
types of profiles exist
■ 1.Straight profile - two lines form a nearly straight line
■ 2.Convex profile -two lines form an angle with the concavity facing the
tissue -Prognathic maxilla, retrognathic mandible -Seen in class II
division I malocclusion
■ 3.Concave profile- the two reference lines form an angle of convexity
towards the tissue Prognathic mandible & retrognathic maxilla Seen in
class III malocclusion
Facial divergence
■ It is defined as an anterior or posterior
inclination of the lower face relative to the
forehead.
1. Anterior divergent - A line drawn between the
forehead and the chin is inclined anteriorly
towards chin
2.Posterior divergent - A line drawn between the
forehead and chin slants posteriorly towards the
chin
3.Straight or orthognathic- The line between the
forehead and the chin is straight or perpendicular
to the floor
■ Examination of lips
1.Competant lips: The lips are in slight contact when the
musculature is relaxed
2.Incompetant lips: They are morphologically short lips that do
not form a seal
3. Potentially incompetent lips: They are normal lips that fail to
form a lip seal due to proclined upper incisors
4.Everted lips: they are hypertrophied lips with weak musculature
■ Examination of nose
1. Nose size: Normally the nose is one third of total facial height
2. Nose contour: Straight, convex or crooked as a result of nasal injuries
3. Nostrils: Oval and bilaterally symmetrical
■ Examination of chin
■ 1.Mentolabial sulcus-Deep mentolabial sulcus: Class 2 division 1
malocclusion-Shallow mentolabial sulcus: Bimaxillary protrusion
■ 2.Mentalis activity-Hyperactive mentalis activity -Class 2 division 1
malocclusion
■ Chin position and
prominence
1.Prominent chin - Class 3
malocclusion
2.Recessive chin - Class 2
malocclusion
■ Nasolabial angle:
Normally its 110 degree
1.Increased - In patients with
retrognathic maxilla
2. Decreased - In patients with
prognathic maxilla
INTRA ORAL EXAMINATION
Examination of tongue:
The lingual frenum should be
examined for tongue tie
Examination of palate
1. Variation in palatal depth
2. Presence of swelling in the
palate
3. Mucosal ulceration and
indentation
4. Presence of clefts in the palate
■ Examination of gingiva
■ -Inflammation, recession,
pockets-
■ Anterior marginal gingivitis-in
mouth breathers-
■ Traumatic occlusion- localized
gingival recession
■ -Gingival hyperplasia- certain
drugs
Examination Of Frenal Attachment-
■ Maxillary labial frenum :Thick fibrous
and attached relatively low - midline
diastema-
■ Abnormal frenal attachment-Blanch test:
Upper lip is stretched upwards and
outwards for a period of time .The
presence of blanching in the interdental
papilla is diagnostic of an abnormal
frenum.
■ -Lingual frenum : Tongue tie or
ankyloglossia – Unrestrained buccinator
activity -narrowing of maxillary arch
Examination Of Tonsils And Adenoids-
■ Abnormal inflamed tonsils cause alteration
in tongue and jaw posture there by upsetting
the orofacial balance leading to malocclusion
Assessment Of Dentition
■ 1.Teeth present inside oral cavity
■ 2.Teeth unerupted
■ 3. Teeth missing
■ 4.Status of dentition
■ 5.Presence of caries, restorations,
malformations ,wear and discolouration
■ 6.Molar relation -Angles class
1,2,3
■ 7.Overjet,overbite, deep bite,
open bite and cross bite should
be examined
■ 8.Look for shift in midline
■ 9.Individual tooth irregularities -
rotations displacements intrusion
and extrusion are noted
■ 10.See for arch form -
Normal,narrow,square
FUNCTIONAL EXAMINATION
1.Assessment of postural rest position
and interocclusal space
■ The postural rest position with the position of mandible at which
the muscles that close the jaws and open them are, in a state of
minimum contraction to maintain the posture of mandible
■ At the postural rest position space exist between upper and lower
jaws .This interocclusal clearance is called freeway space
■ .Normally the freeway space is 3mm in canine region
■ There are various methods of assessing the postural rest position.
During examination the patient should be seated upright, with the back
unsupported and ask to look straight ahead
■ The following are some of the methods used to record postural rest
position
■ 1.Phonetic method
■ 2.Command method
■ 3.Non command method
■ 4.Direct intra oral procedure
■ 5.Direct extra oral procedure
■ 6.Indirect extraoral procedure
2.Evaluation Of Path Of Closure
■ The path of closure is the movement of mandible from rest position
to a habitual occlusion. Abnormalities of path of closure are seen in
some form of malocclusions
■ 1.Forward path of closure :-mild skeletal prenormally or edge to
edge.
■ 2.Backward path of closure- class 2 division 2 malocclusion
■ 3. Lateral path of closure seen in occlusal prematurities and a
narrow maxillary arch
 3.Assessment of Respiration
■ Three types of breathing nasal, oral and oro- nasal
■ a. Mirror test
■ b. Cotton test
■ c. Water test
■ d. Observation

4.Examination of TMJ-
■ Auscultation and palpation of TMJ
■ Look for clicking, crepitus pain of the masticatory muscles, limitation of
jaw movement, hypermobility and morphological abnormalities.
■ Normal inter-incisal distance is 40-45 mm
5. Evaluation Of Swallowing
■ Persistence of infantile swallow can be a cause for malocclusion. It is
indicated by the following features
■ a. Protrusion of tip of the tounge
■ b. Contraction of perioral muscles during swallowing
■ c. No contact at the molar region during swallowing
 6. Speech
■ Certain malocclusions may cause defects in speech due to interference
with movement of the tongue and lips.
■ The patient can be asked to read out from a book or asked to count
from 1-20 while observing the speech.
■ Patients with cleft palate may have a nasal tone.
ORTHODONTIC STUDY MODELS
■ These are the accurate plaster reproductions of teeth and their surrounding
tissues.
■ They are an essential diagnostic aid that makes it possible to study the
arrangement of teeth and the occlusion from all directions.
■ Uses of study models
■ 1. They enable the study of the occlusion from all the aspects
■ 2. They enable accurate measurements to be made in dental arch
■ 3. They help in assessment of treatment progress by dentist as well as
the patient
■ 4. They help in assessing the nature and severity of malocclusion
■ 5. It makes possible to simulate treatment procedures on the cast such as
model surgery
■ 6. Study models are useful to transfer records in case the patient is to be
treated by another clinician
■ 7. They are helpful in motivation of the patient.
 PLASTER STUDY MODELS
Disadvantages
1.Plaster study models break
2.Continued use for measurements and display can wear away plaster,
decreasing accuracy and increasing likelihood of fracture.
3. Storage in another area presenting both time and space problems
4. They may undergo physical changes during handling5. Portability
problem
6. Communication is difficult when only one set of models exist
■ DIGITAL STUDY MODELS
■ These are obtained by laser scanning of impressions or the
plaster study models.
■ Once the scanning is done the digital models are obtained by
using computer aided design and manufacturing ( CAD/CAM)
where it is transferred into a digital,
■ 3-D image of the dentition.
■ Software's enable the digital models to be viewed from all
aspects and manipulated.
ADVANTAGES OF DIGITAL STUDY
MODELS:
■ 1. Reduction in space needed to store the models
■ 2. Easy retrieval and transmission of the image to other computers
■ 3. Measurement of dental cast can be carried out without the use of
caliper.
■ 4. The digitized models can be viewed from any angle and also
opened to allow upper and lower models to be viewed seperately
■ 5. Possibility of viewing digital models at multiple locations
allowing patients to be treated at multiple sites.
GNATHOSTATIC SET UP
■ They are the
orthodontic study
models where the
base of maxillary cast
is trimmed to
correspond the
Frankfort horizontal
plane.
RADIOGRAPHS
1.Intra oral radiographs:- The techniques used in intra oral periapical
radiography area.
■ Paralleling technique
■ Bisecting angle technique
USES OF IOPAS
1.To confirm the presence or absence of teeth
2.To study the extent of periapical pathology
3.To study the alveolar bone and pdl4
.To study the height of alveolar bone crest
5.To assess the axial inclination of roots
6.To detect retained root fragments and root stumps
7.To determine the size and shape of unerupted teeth.
DISADVANTAGES of IOPAS
1. Assessment of the entire dentition requires too many radiographs
2. Children may not allow placement of intra oral films
3. They cannot be used in patients with high gag reflex and trismus.

■ Advantages of IOPAs
1.Low radiation dose
2.Possible to obtain the localised areas of interest
3.They offer excellent clarity of teeth and their supporting structures.
■ .Bitewing radiographs
■ 1. To detect proximal caries
■ 2. To study the height and contour of
interdental bone
■ 3. To study secondary caries
■ 4. To detect overhanging proximal
restorations
■ 5. To detect interproximal calculus
■ Occlusal radiographs
■ Uses of occlusal radiographs
■ a. To locate impacted and unerupted teeth
■ b. To locate supernumerary teeth
■ C. To locate foreign bodies in salivary
ducts
■ d. To study bucco-lingual expansion of
cortical plates due to pathology of jaw
■ e. To study the arch expansion procedures
EXTRA ORAL RADIOGRAPHS
■ These are useful whenever large areas of face and skull are to
be visualized Panoramic Radiographs
■ Uses
1. They are useful in assessing dental development by studying
deciduous root resorption and root development of permanent
teeth
2. Used to view ankylosed and impacted teeth
3. To study the path of eruption of teeth
4. To diagnose the extent of fractures
5. To diagnose the presence of supernumerary teeth

■Advantages
1. A broad anatomic area can be visualized
2. The patient radiation exposure is low
3. Can be used in patients with trismus
DISADVANTAGE
1. Distortion, magnifications and overlapping of structures occur
2. inclination of anterior teeth cannot be visualized
3.Requires equipment that is expensive
■ Other radiographs
1. Cephalometric Radiographs
2. Hand-wrist Radiographs
3. TMJ views- Transcranial view, Transorbital view,
Transpharyngeal view
 FACIAL PHOTOGRAPH AS A
DIAGNOSTIC AIDS
Facial photographs offer a lot of information on the soft tissue
morphology and facial expression Three extraoral views are
routinely taken
1. Frontal view
2. 2. Profile view
3. 3. Oblique facial view
■ Photographs are taken in such a manner that FH plane is
parallel to the floor
 ■ Intra oral photograph include
■ 1 Left and right lateral view
■ 2. Frontal view
■ 3. Maxillary and mandibular view

USES
1.They are useful in assessment of facial symmetry, facial type
and profile
2.They serve as diagnostic records
3.They help in assessing the progress of the treatment.
Recent Advances In Diagnostic Aids
■ Xeroradiography
■ Digi graph
■ MRI
■ Tomography
■ Occlusograms
■ Laser Holography
■ Digital Subtraction Radiography
■ Photocephalometry
■ cineradiography
CONE – BEAM COMPUTED
TOMOGRAPHY
■ CBCT scanner was used in mayo clinic USA 1982.
■ This imaging technique later become much more popular with in dental
community
■ 1st CBCT scanner for dentomaxillofacial applications was patented in
1995 by Attilio tacconi and pieromozzo
The Principle Of CBCT
■ Conventional CT scans use a fan shaped beam of X-ray and images are
required Sequential slice while the patient is advanced through the
gantry
■ These slices are then stacked together to create final CT image .
■ In contrast , CBCT uses a cone shaped beam capturing the full volume
of interest in single rotation, which can be up to 3600.
■ X ray source and detector rotate simultaneously while patient remains
stationary
Types Of Dental CBCT Scanners
■ Classified according to the
1. Method of positioning the patient for imaging , sitting, standing or
supine.
2. Field of view of the scanner which is maximum volume that can be
scanned. The CBCT scans can be either large that capture whole
maxillofacial region ,medium capturing, dentoalveolar region.
TREATMENT PLANNING

■ Defination:-
Treatment plan is an outline of all the measure that can
be best instituted for a
Patient as so to offer maximum, long term benefit.
TIMING OF ORTHODONTIC
TREATMENT
1. Reduces risk of trauma associated with proclined anteriors.
2. Possible to utilize growth.
3. May reduce need for extraction in the future by expansion producers and growth
modification.
4. They can also have a psychological benefits by the self esteem of the child.
5. Early treatment often reduce the need for long term future treatment.
DISADVANTAGE OF EARLY
TREATMENT
1. Treatment duration May prolonged as most children often need a second phase of
treatment in the permanent dentition phase.
2. By prolonging the duration of treatment the patient compliance is often a problem.
3. They often prolonged retention.
ENVELOPE OF DISCREPANCY
SEETING UP GOALS

■ From a patient views of, the basic need for orthodontics treatment is improvement in
esthetic and function.
■ The orthodontist has an added goals in the form of treatment stability.
■ The orthodontist should aim at providing quality treatment that will remain relatively
intact for many years to come after the therapy is completed.
■ Most patients are satisfied once the anterior teeth are straigtened.
■ It is responsibility of orthodontist to educate the patient on the importance of moving
teeth to position that stand for stability.
ENLISTING THE TREATMENT
OBJECTIVE
■ The orthodontist should enlist the Problem that have to be attended to in a decreasing
order of priority.
■ The problem list help in setting up objective and possible solution to the problem.
■ Most patients seek treatment to improve asthetic or function.
■ The orthodontist must be realistic in setting up objectives
■ They should reflect the patien’s needs, the doctor’s level of competence, patient co-
operation, etc .,..
ASSIGNMENT OF GROWTH
POTENTIAL
■ The growth status of an individual is an important factor that should be considered
while planing treatment.
■ A patient who is still growing presents the orthodontist with numerous options that
exploits the individual growth potential.
■ In an adult treatment options are limited to moving teeth and surgical correction
■ The growth status of individual should thus be determined prior to treatment planning
so as to carry out appropriate treatment procedures.
ASSESSMENT OF ETIOLOGICAL FACTORS

■ The etiological factors responsible for the malocclusion should be determined and
adequate steps should be planned for their elimination.
■ The continuous presence of etiological factors can constitute a server limitations to the
corrective procedure to be undertaken and may also predispose to relapse of a treated
malocclusion.
PLANNING THE FINAL
INTERINCISAL
RELATIONSHIP
■ Establishment of an ideal inrer- incisal realationship is one of the prime objective that
should be planned.
1. Class 1 incisor realationship.
2. Class 2, division 1 relationship
3. Class 2 division 2 incisor realationship.
4. Class 3 incisor realationship
PLANNING SPACE REQUIREMENTS

Correction of crowding:- correction of crowded teeth requires space. The rule of thumb is
that for every mm of crowding , a mm of arch length( space) is required.
Rotation:- rotated anterior teeth occupy lesser arch length. Hence space is required for
derotating these teeth, which is calculated by subtracting the distance between the proximal
surface of adjacent teeth from the total mesio- distal width of rotated teeth.
Leveling the curve of spee:- one of the common features associated with skeletal
malocclusion is an increased curve of spee.
A flat arch occupies more space than one with an excessive curve of spee.
Correction of proclination:- retraction of proinclined teeth requires space.In case of space
dentition, the existing space can be made use of to correct the proinclination.
If the dentition is not spaced, then alternate ways of gaining space should be planned.
For every one mm of reduction in proinclination two mm of space is required.
Molar correction:- presence of an unstable molar relation at the end of treatment is cause of
instability.
The molar should be moved to achiev good intercuspation.
Space for anchorage loss:- most tooth movement are accomplished by appliances that
anchor on to certain other teeth in the dental arch.
Some methods of gaining spade include :
1. Use of existing spacing.
2. Expansion
3. Extraction.
4. distalization
5. Derotation of posterior teeth..
PLANNING EXTRACTION
PLANNING ANCHORAGE

Number of teeth being moved:- the greater the number of teeth being moved, the greatest
would be the demand on anchorage .
Type of teeth:- tooth movement involving multi rooted posteriors offer greater strain on
anchorage than tooth movement involving smaller teeth
Type of tooth movement:- tipping tooth movement are less demanding on anchorage than
bodily tooth movement.
Duration of treatment:- complicated orthodontic treatment of prolonged duration strains the
Anchor teeth, resulting in greater anchorage loss
In case of maximum anchorage demand, adequate reinforcement of the anchorage should be
planned.
SELECTION OF APPLIANCE

■ Growth potential:- growing patients who exhibit skeletal malocclusion should be treated
with appliances that modulate the growth so that the existing skeletal problem is solved
or at least not worsened.
■ Type of tooth movement:- removable appliance can be used in patients requiring simple
tipping movement.whenever, bodily tooth movement required, fixed orthodontic
appliances should be used.
■ Cost: Removable appliances are by far less expensive than fixed appliances as they take
less chair side time and use limited material to fabricate.
■ Oral Hygienie: Maintenance of good oral hygiene is an essential part of orthodontic
treatment.
PLANINIG RETENTION
■ Stretched periodontal ligament: The stretched gingival fibres are a frequent cause of relapse
in case of rotated teeth, since these fibres take a long time to reorganize around their new
positions. Thus adequate retention for an appropriate period should be planned depending on
the type of malocclusion.
■ Unstable occlusion: Teeth placed in unstable position at the end of orthodontic therapy tend
to relapse.
■ Continuation of growth pattern: Continuation of the growth pattern that has caused a skeletal
malocclusion after orthodontic therapy results in resurfacing of the malocclusion after
treatment.ad keeping in