Diagnosis and Treatment planning Of Malocclusion Orthodontic Department Of Xi'an Jiaotong University Medical College Dental Hospital Diagnosis Of Malocclusion Accurate diagnosis of Orthodontic problems comes from the detailed clinical examination, data analysis and comprehensive evaluation. The correct treatment program can be planed after an adequate diagnosis of malocclusion. Therefore, the correct diagnosis and treatment plan of Orthodontic problems play an important role in the whole treatment process. Interview Clinical Exam Analysis of Dx Records Classification Diagnosis (Problem list ) Database Pathology (caries, perio, etc.) Control before orthodontic treatment Interaction compromise cost/benefit other factors Orthodontic problems possible solution treatment plan concept Priority order, A, B, C, D, etc Patient parent Consult Treatment goals Treatment plan details 1. Clinical examination Patients with the general situation : Including the patient's name, sex, nationality, date of birth, birthplace and occupation information. Chief complaint and medical history Chief Complaint: Patient's chief complaint of all orthodontic treatment are the basic starting point, usually treatment plan begins to develop according to the chief complaints of patients. History: including past history, present history and genetic history Chief complaint and medical history 1. The Jaw’s traumatic may cause temporomandibular joint adhesions, so it could be difficult for jaw to move and develop. 2. Dental trauma may cause the teeth adhere to the alveolar bone, so it makes the tooth move difficult. 3. long-term Systemic chronic dyspepsia may affect the normal bone tissue reconstruction in the movement of the teeth, which may lead to the loosening of mobile teeth. Clinical examination Facial examination Facial profile from the Height of facial to points: a long face, short face, normal face. From the surface profile of the degree to sub-process: straight, convex , concave . Symmetry To the hypothetical median sagittal plane for the evaluation of the baseline, normal, nasal ridge, nasal tip, upper lip beads, submental vertex, arch basically located in the center line on this plane. Right and left eyes, ears, zygomatic process, nose, mouth, mandibular angle and a corresponding symmetrical teeth are symmetrical. facial Ratio Vertical ratio left and right ratio Evaluation of facial : photographs, body measurements, Xcephalometry Profile type The profile is divided into before and after the relative position according to the soft tissue glbella, the nose, pogonion of soft : straight type, concave type, convex type Dentition examination a, The development stage of occlusion: deciduous , dentition, permanent occlusion. The relationship between occlusion and age. Development of teeth and condition. Replacement of teeth, the tooth-loss situation. b, the basic situation of dentition: the number, shape, size, color, developmental status and caries status of the teeth. c, abnormal dentition parts: the part of crowded, misplaced, reversing, the open bite occlusion, lock bite occlusion and other malformations. Dentition examination d, molar relationship: Class I, II, III category of relations, also known as the neutroclusion, distoclusion and mesioclusion. the two latter can be divided into full and cusp-cusp relationship e, canine relationship: can also be divided into the neutroclusion, distoclusion and mesioclusion. f, anterior relationship: Overbite Over jet Class I Class II Class III Overbite normal：1/3 1/2>I度>1/3 2/3>II度>1/2 III度>2/3 1/3 Over jet Normal:3.0mm I度 3-5 mm II度 5-8 mm III度 > 8 mm 牙列的检查 g、 牙周情况 Slight periodontal loss: loss of attachment < 1/4 of the root length Moderate periodontal loss: loss of attachment 1/4 to 1/3 of the root length Severe periodontal loss: loss of attachment > 1/3 of the root length Severe complicated periodontal loss: loss of attachment > 1/3 of the root length combined with intra -osseous defect. h、Spee`s曲线 Spee`s曲线 Oral function and temporomandibular joint a, opening /closed type and the opening /closed degree b、CR-CO c, tongue function d, masticatory function e, swallowing function f, the pain and Snapping of temporomandibular joints Physical growth evaluation We should have a clear understanding for each patient's growth and development status, as the same abnormal performance, when the growth and development status is not the same, the treatment methods used may be different. Evaluation of growth and development mainly relies on the physiological characteristics of patients, such as the bone age, the dental age and the secondary sexual characteristics. A radiograph of the hand and wrist Far from the middle section of the middle finger epiphysis The medial sesamoid of thumb Radial epiphysis Body height Body height Psychological Situation In recent years, orthodontic patients at the psychological situation increase gradually. The patients which exist psychological situation usually exceed the normal requirements of the scope in the treatment, and he could be very sensitive about the existence of malocclusion, exaggerate in understanding the abnormal performance, be urgent for treatment and require a higher treatment sometimes exceeding the normal scope. Oral health assessment (dental caries, gingivitis, periodontal disease, etc.) Orthodontic appliance will reduce the function of selfcleaning, the existed dental caries, gingivitis, etc must be treated before the appliance fixed to the teeth, otherwise the development of the disease may be aggravated. Second, cast analysis the role of study cast at orthodontic treatment: 1. Record real teeth, alveolar bone, the palate and the base bone morphology and location. 2.Dentofacial deformity analysis conducted 3. Comparison in the course of treatment 4. Compared the efficacy before and after treatment 5.One of the essential legal basis The requirements for study cast 1. The cast should be extent possible, the extension of the maximum displacement of the soft tissue can reflect the situation in bone matrix. Generally it doesn’t carry out amendments to the soft tissue. The cast should include teeth, alveolar process, based bone, transitional fold, hard palate and lace cap, backwards be included maxillary tuberosity and molar pad nodule. 2.Cast must be accurate, clear and beautiful, and be able to reflect the patient's occlusion. Cast Analysis Cast analysis Arch Length analysis: arch length is divided into three sections, the previous length, the middle of the length and posterior segment length. Arch Perimeter dental space Analysis : Arch Required Arch Available Arch space= Arch Required - Arch Available · A B A the previous length,B the middle of the length and Cast Analysis Cast analysis Mixed dentition space analysis prediction of Arch Required estimation from radiographs estimation from Moyertables Tanaka-Johnston prediction method Arch Available measurement Estimation from radiographs The space between the demand for the four incisor according to their distance from mesial to distal . Uneruption of canine, premolar measurements x= y₁ Conventional space analysis does not include the location of lateral incisor and profile. Analysis only shows the lack of coordination, do not reveal the location of coordination. Moyer prediction table Use four mandibular incisor to estimate the distance of lower , the maxillary canine, premolar from mesial to distal .But this estimate has a tendency to over-estimate. Low incisor maxillary mandibular 19.5 20.0 20.5 21.0 21.5 22.0 20.6 20.9 21.2 21.3 21.8 22.0 20.1 20.4 20.7 21.0 21.3 21.6 Tanaka and Johnston预测法 Mandibular canine and premolars in one quadrant can be calculated by adding 10.5 mm to half of the measured mesiodistal width of the four mandibular incisors. 下颌：2112+10.5 = 345 Maxillary canine and premolars in one quadrant can be determined by adding 11.0 mm to half of the measured mesiodistal width of the four mandibular incisors. 上颌：2112+11.0 = 345 Tanaka and Johnston预测法 Mandibular canine and premolars in one quadrant can be calculated by adding 10.5 mm to half of the measured mesiodistal width of the four mandibular incisors. manibular：2112+10.5 = 345 Maxillary canine and premolars in one quadrant can be determined by adding 11.0 mm to half of the measured mesiodistal width of the four mandibular incisors. maxillary：2112+11.0 = 345 Cast Analysis Bolton Index Bolton index refers to the former upper and lower teeth crown width ratio of the sum of all relations and with the upper and lower dental arch crown width ratio of the sum. Bolton index used to diagnose patients with upper and lower teeth do not tune the width of the problem. Anterior than = 6 mandibular anterior teeth crown width / 6 maxillary anterior teeth crown width all teeth than = 12 mandibular tooth crown width / 12 maxillary teeth crown width × 100% The discrepancy of Bolton index may cause the malocclusion of anterior teeth, such as overcrowding, deep overbite ,deep over jet and so on. Bolton Analysis Model Analysis curves of Spee Measurement Methods: The ruler placed on the side of mandibular incisor teeth with the last mandibular molar on the cuspal, measure the distance between the lowest point and the ruler. Both sides of the measured value divided by the sum of two, plus 0.5mm is the correct curve of Spee `s required by the space. Spee`s曲线 Curve of Spee Flat Deep Model Analysis Analysis of dental arch symmetry Palate wrinkle method: In the first wrinkle on the palate and the last one to take the midpoint, make the connection between the two points and extended to measure both sides of the dental arch distance from this line to diagnose the dental arch symmetry. Coordinate Measuring : Coordinates the center line of plate aligned with the palate raphe, then measures both sides of the teeth before and after the location of buccolingual position. Model Analysis Width evaluation Arch width can be divided into three parts: The preceding width (inter-canine width) Middle arch width (first premolar width of the central inter-nest) Posterior segment arch width (the first permanent molars between the width of the central nest) the preceding width Middle arch width Posterior segment arch width Model Analysis Pont's index 1909 Pont made an ideal arch width of the prediction methods. with the sum of four maxillary incisors divided by first premolar and first permanent molars, in the multiplied by 100, to arrive at a fixed index. Pont's index is Obtained as follow （S）×100 /80 = Ideal interpremolar width （S）×100 /64 = Ideal intermolar width （S）=sum of the diameters of the four maxillary incisors Pont `s index 上和四个切 牙宽度之和 理想第一前 磨牙间宽度 理想磨牙 间宽度 上和四个切 牙宽度之和 理想第一前 磨牙间宽度 理想磨牙 间宽度 18 22.5 28.1 28.5 35.5 44.5 20 25 31.94 29 36 45.3 20.5 25.5 32 29.5 37 46 21 26.25 32.82 30 37.5 46.87 21.5 27 33.27 30.5 38 47.6 22 27.5 34 31 39 48.4 22.5 28 35 31.5 39.5 49.2 23 28.75 35.94 32 40 50 23.5 29.5 36.88 32.5 40.5 50.8 24 30 37 33 41 51.5 24.5 30.5 38 33.5 42 52.3 25 31 39 34 43 53 25.5 32 39.8 34.5 43.5 53.9 26 32.5 40.9 35 44 54.5 26.5 33 41.5 36 45 56.4 27 33.5 42.5 37 46.25 57.8 27.5 34 42.96 28 35 44 Model Analysis alveolar bone Analysis : Base bone: mandibular arch formed, namely, dental periapical alveolar arch. base bone is stable based alveolar bone, and won’t change due to the tooth’s movement or loss. Alveolar bone: It is the bone tissue which is on the top of the base bone surrounding the teeth. It is between the teeth crown and the base bone. Alveolar bone may change due to the tooth’s movement or loss. Model Analysis Diagnostic set -up Cutting down each tooth which will be on the malocclusion crowded model and arrange with an ideal location in order to diagnose if the adequacy of base bone length to accommodate existing teeth. And then decide whether or not to extract tooth and predict the location of tooth movement and direction, showing efficacy. Model Analysis The step of diagnostic set –up 1) Make an accurate record of occlusal relations, marking a centerline. 2) Marked all the teeth with pencil . 3) To saw along the contact point, not damage tooth crown width. 4) To saw all the teeth at the same level of the root side. 5) Rearrange the sawed teeth according to dental arch size and shape of the teeth as the treatment plan says, and fix with sticky wax. Three, X-cephalometry X-cephalometry is a study method by the United States of Broadbent and Germany in the 30's .The method used to study Hofrath Craniofacial Growth and malocclusion combined with bone disorders. The modern theory about growth and development comes from the majority study of x-cephalometry. X-线头影测量的发展 1920, Dr B.Holly Broadbent Sr interesting in the face change by Angle`s treatment. Dr T Wingate Todd had collected many skulls and had used Todd craniostat to measure human face. 1924, Broadbent transformed Todd craniostat into first craniometer by adding a metric scale. Todd emphasized investigation must be performed on health living children. During these years of skeletal study, lateral jaw and craniofacial radiographs were made by Todd, Hill and Thomas, while Broadbent used it in clinic. X-cephalometry applications. Craniofacial growth and development in the study, based on the method will soon be used to evaluate the craniofacial morphology, the proportion of the anatomical distinction between basic mistake occlusion. Through the x-cephalometry study, it is recognized that most of the mistake occlusion jaw position and the teeth are compensatory or the result of the interaction between adaptation. The location of possible jaw disorders through the teeth to achieve the normal compensatory . X-cephalometry applications. Normal bone was found on the teeth can also occur malocclusion. Moderate bone disorders with moderate dental disorders can become a serious malocclusion , therefore, in the tooth model on the same mistake appears malocclusion , probably completely different in the x-ray analysis, the patient may have a completely different facial type. X-cephalometry applications. X-cephalometry study are the clinical treatment course of teeth, jaw, face changes in the primary means of treatment before, during and after filming ,a series of xray film to overlap to study changes in the location of mandibular teeth. However, such changes include the both parts about growth ,development and treatment .At present , it is very difficult to determine which are part of the growth and development, which are treatment according to the current knowledge and technology. X-cephalometry applications. In addition to analyzing the relationship between different periods of time outside of the craniofacial, x-cephalometry also the prediction for the growth and development, it is estimated that the future growth of the facial trend-type. If the prediction and treatment of unforeseen changes in the framework will result in combined treatment plan, or blueprint known as the orthodontic treatment - VTO, become a specific therapeutic purposes. Thus promote the development of x-rays cephalometry analysis. X-cephalometry applications. In order to achieve X-cephalometry individuals comparing with similar groups, it is necessary to establish the same race, same sex, same age the average measured value. Downs suggest a xcephalometry analysis methods in 1948, and set up a normal average. X-cephalometry applications. X - cephalometry analysis can be divided into five functional parts: cranial, skull base, maxillary bony maxillary dentition, mandible and mandibular dentition. Analysis of the five parts of each other in the horizontal, vertical upward relations. Modern X-cephalometry is a method designed to describe the relationship between these functional units. It is generally believed that there are two ways to analyze a measurement and analysis. X-cephalometry applications. General There are three main types of view measurement method. ⑴ Linear measured : measured cephalometric tracing film or the distance between two points and compare the distance directly or in the proportion way. ⑵ angle measured: measured the angles between intersecting lines, the advantages of this measurement is it doesn't use the ratio to avoid the individual differences. ⑶ arc measurements: draw a series of arc to evaluate the location of anatomical structures. X-cephalometry applications. Another way is to use graphics to express the normal data, rather than a series of measurements. Directly to the patient's, edentulous patients with normal graphics through the template for comparison. The early x-cephalometry consider a normal graphics more easily recognizing the type of relationships. Dr. Moorrees `s Mesh are raised in the 60's with the performance of the grid to the patient's disorder. However, at that time because this method does not clearly establish normal relations, while not widely accepted. However, in recent years, with the development of the computer application, the normal template set up, such a direct comparison of the template has been adopted as an analytical method. X-线投影测量的基本知识 Lateral and frontal head radiographs 1 Head in a fixed position in a cephalometer 2 Head hold by ear rods. 3 X-ray direction is at right angle to sagittal plane of the head when profile film taken. 4 PA view, frontal plane of the head is perpendicular to the x-ray beam. 5 The film cassette is as close as possible to the face. the basic knowledge of X-cephalometry Lateral and frontal head radiographs A standard distance of 60 inch from source of radiation to midsagittal plane. Film to midsagittal plane according head size, they used vernier scales to correct enlargment. basic components of X-cephalometry system's : X-ray equipment, X-ray film devices, the head positioning device. The basic knowledge of X-cephalometry X-ray device (tube) Components: X-ray tube, transformers, filters, parallel-ray tube, cooling system. X-ray have the three basic conditions, cathode, anode and power Cathode composition: tungsten target, Copper Rods Cathode composition: tungsten wire, condenser Cup 变压器（高压） 铝盘 铅隔板 聚光杯 乌丝 乌靶 变压器（低压） 阴极 阳极 The basic knowledge of X-cephalometry Minimize error when serial films of same individual are taken at different times. to permit universal use of cephalometric data obtained from many different source. Possible errors: 1 a lack of perpendicularity of the X-beam to midsagittal plane and the film surface. 2 The film is not in closest place to head and face for minimizing enlargement. The basic knowledge of X-cephalometry Safety feature of the cephalometric technique - Use of the 90-kv peak to minimize softer xrays. - The beam is filtered to remove softer x-rays - The film is a double-emulsion film - A cassette with compatible intensifying screens. - Patient and operating personnel protection X-ray protection Utilization of high speed film and intensifying screen in order to reduce the dose of radiation and exposure time Filtration of secondary radiation Collimation by a diaphragm Proper exposure technique and processing The patient`s wearing a lead apron Landmarks and Tracing Three components of analysis are analysis of the skeletal features of the patient, the dental features and the profile of the patient. Tracing steps 1 Soft profile, external cranium, vertebra three crosses for registration. 2 cranial base, internal border of cranium, frontal sinus, and ear rods. 3 Maxilla and related structures. 4 Mandlbe Landmarks and Tracing Notes 1 Tracing as much anatomy as possible, especially in skull base area. 2 Know definition of the landmarks clearly 3 Know the variation of some landmarks location. 4 When left and right are two lines, trace the two lines and use the average with broken line. 5 repeat of the tracing as same for severe times. Landmarks and Tracing Sella (S) The geometric center of the pituitary fossa (sella turcica), determined by inspection constructed point in the midsagittal plane. (midsagittal) Landmarks and Tracing Nasion (N, Na) The intersection of the internasal and frontonasal sutures, in the midsagittal plane. (midsagittal) Landmarks and Tracing Porion (Po) The most superior point of the outline of the external auditory meatus ("anatomic porion"). When the anatomic porion cannot be located reliably, the superior-most point of the image of the ear rods ("machine porion") sometimes is used instead. (bilateral) Landmarks and Tracing Anterior nasal spine (ANS) The tip of the bony anterior nasal spine at the inferior margin of the piriform aperture, in the midsagittal plane. It corresponds to the anthropological point acanthion and often is used to define the anterior end of the palatal plane (nasal floor). (midsagittal) Landmarks and Tracing A-point (Point A, Subspinale, ) The deepest (most posterior) midline point on the curvature between the ANS and prosthion. Its vertical coordinate is unreliable and therefore this point is used mainly for anteroposterior measurements. The location of A-point may change somewhat with root movement of the maxillary incisor teeth. (midsagittal) Landmarks and Tracing B-point (Point B, Supramentale, sm) The deepest (most posterior) midline point on the bony curvature of the anterior mandible, between infradentale and pogonion. (midsagittal) Landmarks and Tracing Pogonion (Pog, P, Pg) The most anterior point on the contour of the bony chin, in the midsagittal plane. Pogonion can be located by drawing a perpendicular to mandibular plane, tangent to the chin. (midsagittal) Landmarks and Tracing Gnathion (Gn) The most anterior inferior point on the bony chin in the midsagittal plane. (midsagittal) Landmarks and Tracing Menton (Me) The most inferior point of the mandibular symphysis, in the midsagittal plane. (midsagittal) Landmarks and Tracing Gonion (Go) The most posterior inferior point on the outline of the angle of the mandible. It may be determined by inspection or it can be constructed by bisecting the angle formed by the intersection of the mandibular plane and the ramal plane and by extending the bisector through the mandibular border. (bilateral) Landmarks and Tracing Orbitale (Or) The lowest point on the inferior orbital margin. (bilateral) Soft tissue landmarks Landmarks and Tracing Soft tissue glabella (G) The most prominent point of the soft tissue drape of the forehead, in the midsagittal plane. Landmarks and Tracing Soft tissue nasion (N, Na) The deepest point of the concavity between the forehead and the soft tissue contour of the nose in the midsagittal plane. (midsagittal) Landmarks and Tracing Pronasale (Pn) The most prominent point of the tip of the nose, in the midsagittal plane. (midsagittal) Landmarks and Tracing Subnasale (Sn) The point in the midsagittal plane where the base of the columella of the nose meets the upper lip. (midsagittal) Landmarks and Tracing Superior labial sulcus (Sls) The point of greatest concavity on the contour of the upper lip between subnasale and labrale superius, in the midsagittal plane. (midsagittal) Landmarks and Tracing Stomion (St) The most anterior point of contact between the upper and lower lip in the midsagittal plane. When the lips are apart at rest, a superior and an inferior stomion point can be distinguished. (midsagittal) Landmarks and Tracing Labrale inferior (Li) The point denoting the vermilion border of the lower lip, in the midsagittal plane. (midsagittal) Landmarks and Tracing Labrale superior (Ls) The point denoting the vermilion border of the upper lip, in the midsagittal plane. (midsagittal) Landmarks and Tracing Inferior labial sulcus (Ils) The point of greatest concavity on the contour of the lower lip between labrale inferius and menton, in the midsagittal plane. (midsagittal) Landmarks and Tracing Soft tissue pogonion (Pg, Pog) The most prominent point on the soft tissue contour of the chin, in the midsagittal plane. (midsagittal) Reference line A line that is used as a basis for superimposition, or for comparison. Reference lines ideally should be stable with time and should not be affected by treatment. Intracranial reference lines Extracranial reference lines Intracranial reference lines Basion-Nasion line (Ba-N) A line considered by some to represent the cranial base more accurately than the SN line or the Bolton plane. Intracranial reference lines Frankfort horizontal plane (FH, Frankfort horizontal line, Auriculo-orbital plane, Eye-ear plane) The plane was adopted at the 13th General Congress of German Anthropologists in Frankfort, Germany in 1882. On a lateral cephalometric radiograph, the Frankfort horizontal plane is represented by a line connecting the cephalometric landmarks porion and orbitale. Intracranial reference lines Sella-Nasion line (SN, Nasion-Sella line, NSL) A frequently used cephalometric reference line representing the anterior cranial base. A line joining points S and Na. Intracranial reference lines Bolton plane A line connecting points Bolton and nasion; an alternate representation of the cranial base. Reference plane The above-mentioned reference plane are considered to be intracranial reference plane, or intracranial reference lines. Between them in the literature there is a lot of controversy, but it seems that less than to resolve. Each type of system, the existence of the advantages and disadvantages of a greater or lesser extent, a way there is another way than the good side, there are insufficient places. Because of the existence of large individual changes, there is no reference plane is absolutely stable, that is to say there is no analytical method is reliable. Reference plane How to eliminate this problem? There is only one way to select different reference plane set up on the analysis, expectations of the advantages of using a method to compensate for the shortcomings of another way to eliminate the different reference plane of the individual differences in change, as the average of the parameter error. Reference plane Completely solve the problem of reference plane, only the introduction of extracranial reference line, also known as the "true vertical line " Modern Xcephalometry should be in the natural head position under the shooting, which was really the horizon. Natural position have been suggested by some scholars that its level is also known as the "true level" line in the 60's and 70's at the end of the beginning. FH TO GOGN 22 ± 5 deg Y AXIS 59 ± 6 deg SKELETAL VERTICAL LFH 55% OF TFH S FH GO ME GN Reference plane At this location set up on the physiological status of the foundation, rather than on anatomical structure. Most patients with FH plane really close to the horizon. However, some patients also show significantly different. SN same plane with the horizontal angle of 7 degrees. Natural posture can place at 1-2 repetition range. Measurement plane Make measurements with the reference plane constitutes a point of view Commonly used measurement plane are: Mandibular plane, Go-Gn, mandibular tangent, Memandibular tangent plane, anatomical type planar, functional plane Flat facial Mandibular plane angle Measurement items and measurement methods Angle, line segment and the ratio of Normal range Evaluation of the impact of factors SNA 82 ± 2 deg NA TO FH 90 ± 3 deg SKELETAL HORIZONTAL - MAXILLA S N FH A SNB 80 ± 2 deg N-PG TO FH 88 ± 6 deg SKELETAL HORIZONTAL - MANDIBLE N S FH B Pg ANB 2 ± 2 deg SKELETAL HORIZONTAL - MAXILLA TO MANDIBLE N A B INTERINCISAL 130 ± 5 deg DENTAL - UPPER TO LOWER INCISOR U1 TO FH 110 ± 5 deg U1 TO NA 22deg U1 TO NA 4mm DENTAL - MAXILLARY INCISOR N FH A L1 TO NB 25deg L1 TO NB 4mm L1 TO GOGN 91 ± 6deg DENTAL - MANDIBULAR ANTERIOR N GO B GN Facial angle (FH-NPog) Facial axis angle of Ricketts (Ba-Pt-Gn) Facial height, Anterior; Posterior; and Total Gonial angle (Angle of the mandible, Condylar angle) Frankfort-mandibular incisor angle (FMIA) Frankfort-mandibular plane angle (FMA) Incisor-mandibular plane angle (IMPA) UI-to-AP distance Wits appraisal Angle of facial convexity (Gn-SnPg） H-angle (of Holdaway) Interlabial gap Lower face-throat angle (SnPg'-CMe') Lower lip length Upper lip length Nasolabial angle (NLA) Z-angle (of Merrifield) Measurement items and measurement methods Commonly used analytical methods – – – – – – – – – – – Downs Analysis Steiner Analysis Sassouni Analysis Harvold Analysis Wylie Analysis Wits Analysis Ricketts Analysis McNamara Analysis Template Analysis Mesh Analysis Computerized Cephalometric Analysis ？？ Steiner 分析 E s · N L · · · Go · · · B · · ·Po · Gn · A SNA SNB ANB SND 1-NA ∠1-NA 1-NB ∠1-NB Po-NB 1-1 OP-SN GoGn-SN SL SE Downs Analysis FH-NPo NA-PA AB-NPo FH-Me FH-Y FH-OcclP 1-1 1-MP 1-OcclP 1-AP 1/2 1/2 True Vertical 1/2 pretreatment 1/2 After treatment ※ Cited the extracranial reference line, perpendicular really. Mesh Analysis X-cephalometric analysis of soft tissue Profile type Through the glbella ,subnasale ,pogonion of soft tissue ,the point is divided into before and after the relative position: straight type, concave type, convex type. the line segment facial profile Richetts definited the aesthetic plane (E-Line): nose and chin over the tangent plane. Normal adult white: the lower lip after the plane is located at 2 ± 2mm, is located in the lower lip after lip slightly. Children: the lower lip is located in the plane, or slightly after the plane is located, because the development of chin and nose of some of the development of a more slow. African-American and Chinese: is located in the lower lip aesthetic plane before the 1-3mm. Steiner used "S" line to evaluated the lip’s position: the lower and upper lip is located after this line. through the nose shape of the midpoint to do mental tangent is S line H-line (Harmony line of Holdaway) A line tangent to the soft tissue chin and the upper lip, introduced by R. A. Holdaway for assessment of the soft tissue profile. H-angle (of Holdaway) The superior angle formed by the intersection of the H-line of Holdaway and the (bony) NB line. It provides a measurement of soft tissue protrusion or retrusion and is evaluated in conjunction with the ANB angle. The amount of deviation of the ANB angle from the average (1to3) is added or subtracted from the H-angle for appropriate assessment of the lip and chin projection. The Hangle takes the skeletal relationship into account, but does not consider nasal contour and projection. Merrifield's "Z" lines, through the most mental process tangent of the upper lip, lower lip should be in line or slightly after this point. Adult white horizontal line and the angle is 80 ± 5 º ,11-15-year-old the "Z" angle is 78 ± 5 º. Angle of facial convexity Describe the overall convexity (or concavity) of the soft tissue profile. The inferior angle formed by the intersection of lines GSn and SnPg is measured. The measurement does not take nasal projection into account. Norm 12 Legan 1980 Burstone : nose angle, male 114 º, female 118 º. Submental neck angle, male 114 º, female 106 º. Upper lip length A linear measurement (in mm) from subnasale to stomion superius, measured along the true vertical line. Lower lip length A linear measurement from soft tissue menton to stomion inferius, measured along the true vertical line. For optimal esthetics, it is considered desirable that approximately 2 to 4 mm of the maxillary central incisors be uncovered by the upper lip at rest. Similarly, in an esthetically pleasing smile, the upper lip is raised approximately to the level of the cementoenamel junction of the incisors, so that the full crowns of the maxillary incisors are shown. Posteroanterior Cephalometry Elements of the Posteroanterior diagnosis Soft tissue, through clinical examination and photographic examination Teeth and jaws, through the anterior and posterior cephalometric Dentition , through the tooth model, occlusion map and occlusion bite piece Technical Features Piece of equipment in line with the lateral The first fixed or natural head position Tip of the nose and forehead lightly with the film cartridge contacts Exposure than the larger number of lateral films Posteroanterior Posteroanterior 1 the lateral skull plate 2 mastoidectomy 3 occipital 4, nasal septum, crest, the end of nose 5 orbital 6 temporal fossa lateral sphenoid pterygoid constitute a large slash 7 petrous bone above 8 amount of zygomatic process of the lateral temporal Section 9 the zygomatic arch District 10 the nodules following temporal mandibular 11 mandible, body, sticks, coronoid process 12 teeth Posteroanterior 前后位 Grummons Analysis the limitations of X-cephalometry analysis confliction between X-ray measurement and clinical examination When the SNA had to besmaller after the reduction, but not clinical performance. So S points to be considered. Variability of the reference plane, S - N plane, FH plane . After the introduction of the real vertical extracranial correction. Natural head position in patients with the photos of the X-ray film corrective. X-ray film shooting would be good to have a benchmark mm to correct the magnification. Repetition, especially when the evaluation is even more important. S 点较低 · The existence of magnification Cephalometric analysis of computer systems ⑴ save time, rather time-consuming manual measurement. ⑵ computer cephalometric points used in the logo is established, eliminating manual measurement error. The signs point is still rely on manual identification completly. ⑶ easyly storage, extract the measurement. ⑷ integrate with the management systems Office for easy queries. ⑸ integrate with the document of photographs and model to establish a patient database. ⑹ forecasting and simulation of orthodontic treatment, orthognathic surgery treatment results. ⑺ model and predicte the growth and development. ⑻ facilitate exchanges between doctors and patients. Other X-ray film applications 1, surface fault-chip 2, periapical film 3, occlusal film 4, temporomandibular joint films V. The standard of malocclusion diagnostic Individual Normal Occlusion Ideal Normal Occlusion six elements of normal Occlusion Molar relationship Anterior inclination Inclination of posterior teeth Contact points Reverse toothless Normal Spee `s curve Occlusion and malocclusion The main three objectives of orthodontic treatment ① good function ② acceptable form of facial ③ stability after treatment All of these are closely related to occlusion Only understanding the expression of normal occlusion, the diagnosis of malocclusion, design, and formulate appropriate treatment plan can be obtained Six elements of normal occlusion Elements one: the relationship between dental arch 1. Maxillary first molar buccal tip bite on the maxillary first permanent molars in the buccal groove of the past. 2. Maxillary first molar distal marginal ridge of teeth in the mandibular the first permanent molars near the ridge on the edge. 3. Maxillary first molar teeth of the tongue bite on the mandibular first permanent molars in the central fossa. Six elements of normal occlusion 4. Between maxillary premolar cheek tip and mandibular premolar , there have relations with a sharp concave. 5. Maxillary premolar of the tongue and lower jaw between the premolars relations have pointed Waterloo. 6. Maxillary canine and mandibular canine teeth and lower jaw together before grinding between teeth, canine in a bit more recent. 7. Maxillary incisor and mandibular canine cover contacts, from top to bottom arch center line in line. Six elements of normal occlusion Elements two: crown axis All the crown has a positive angle, but the clinical crown to clear the long axis of the lip surface of the tooth with the real axis there are still some differences in the crown of each tooth with the anatomical point of view on the long axis of tooth point of view has not been entirely uniform. In his research found maxillary 123,456, respectively, the angle is 5 ° 9 ° 11 ° 2 ° 2 ° 5 ° 5 °, the angle of the mandibular teeth were 2 ° 2 ° 5 ° 2 ° 2 ° 2 ° 2 °. Six elements of normal occlusion Three elements: crown inclination 1. The vast majority of maxillary incisor crown with a positive inclination, the mandibular incisor crown inclination slightly negative. , 2. Maxillary central incisor crown inclination of the crown slightly larger than the lateral incisor, canine and premolar is similar to a slight negative angle. 3. Mandibular incisor teeth from molar to the second negative angle, and gradually increase Six elements of normal occlusion Four elements: reverse of the teeth generally,there is no reverse teeth in normal occlusion, the arch circumference would be shorter if there has reverse anterior teeth, the reverse posterior teeth in the dental arch will occupy more space, which will affect the existence of normal occlusion. Six elements of normal occlusion Five elements: the relationship between tooth contacts all the teeth have a good point of contact, and more closely, without space in the existence of dental arch Six elements of normal occlusion Six elements: Spee `s curves The spee `s curves should have more flat, or slightly deeper Six elements of normal occlusion The six elements of the above-mentioned in the normal occlusion of the system is the six elements of interdependence, which formed the basis of evaluation of occlusion,the more important reason is that these six elements can be used as treatment goals in most patients. However, any establishment of a normal occlusion also depends on two factors: ⑴ dental arch in the mouth of the balance of power in all directions; ⑵ jaw and alveolar bone development and normal position. Individual Normal Occlusion Ideal Normal Occlusion Usually there is slightly but does not affect the normal physiological functions of the individual referred to as the normal occlusion. Generally crowded into a small arch, slightly larger than the normal and not entirely consistent with the facial morphology of dental arch deformity that is acceptable, that is, allow individual normal occlusion performance of the deformity. our clinical goal is individual normal occlusion Comprehensive space analysis ⑴ the solution of crowded - model analysis ⑵ Anterior adductor - X-cephalometry ⑶ molar relationship adjustment - model + X + Clinical ⑷ Spee's curve corrected - model analysis + Clinical ⑸ Arch width coordination - model analysis ⑹ Bolton ratio - model analysis ⑺ midline correction - clinical examination the diagnosis basis of malocclusion Clinical examination Model Analysis X-cephalometry analysis The diagnosis basis of malocclusion Chief complaint Clinical examination Data analysis classification of malocclusion diagnosis Problem List The diagnosis basis of malocclusion 1 Angle Classification 2 Problem List Profile –Facial type (Sagittal Plane, Transverse Plane, Vertical Plane) The diagnosis basis of malocclusion Abnormal dentition (the order according to the seriousness) Crowding、Spacing、Rotation、Overjet Overbite、Curve of Spee、Arch Form Midlines、Ectopic eruptions, intraeruptions Cross-bite,( anterior ,posterior , single, multrup) Other (mandibular movement, TMJ, periodontal) Treatment goals The problem of pathological priorities: 1, chronic diseases, such as: rheumatoid arthritis, chronic diarrhea. 2, the impact of the local oral health diseases, such as: periodontal disease, such as dental caries. 3, the psychological barrier, especially for the treatment have failed to meet practical ideas. Treatment goals According to the chief complaint of patients with the problems and consider the possibility of treatment. For all listed issues, not have to carry out treatment, thus the possibility of the existence of which the question of deformity correction. Therefore, in the formulation of treatment plans in accordance with the problem of patients and the patients are listed in the specific circumstances to identify the goal of treatment should be carried out. Treatment goals 1, normal facial morphology, the need for correction 2, the presence of bony deformity, bony deformities must be corrected 3, the need to correct the molar relationship, review spee’s cover whether or not to correct 4, anterior process of the correct degree 5, other issues considered at the same time to correct Treatment Plan Treatment plan rely on the treatment goals , as much as possible set out detailed methods and steps. First of all, clear the scope of treatment Modification of Growth Orthodontic treatment Orthodontic-Surgery Treatment Plan Based on treatment goals and then to be considered for correction of deformity using the specific methods and steps to carry out the order in which they plan. At the same time, to be expected after the end of treatment to improve facial form and maintain the level of what kind of relationship between upper and lower jaw, it is necessary to consider the correction after the end of the molar relationship between the canine relationship, review occlusion, covering the relationship between dental arch axis and the inclination of the coordination. Treatment Plan In addition, we must also consider the stability of correction after treatment and the possibility of recurrence. In the choice of treatment should be considered when there is: ① the role of each other (the relationship between open occlusion and the surface high) ② the scope of concessions ③ Analysis of the pros and cons ④ special reasons Treatment Plan The issue treatment plan should consider Oral Health Mandibular dentition Maxillary dentition The relationship between the posterior teeth Appliance choice Treatment Plan Oral Health Of the patient's oral health education, such as brushing, diet, use of fluoride toothpaste. Caries and periodontal disease treatment Mandibular dentition Mandibular dentition should first carry out the plan, the size of the mandibular dentition and the form should not be changed in general, over-expansion of the cheek or to the forward incisors in most cases are due to the role of soft-tissue recurrence. Extraction depends on the analysis of whether the demand for space. Any dumping of deep overbite with appear abnormal, tooth extraction must be carefully decided. Treatment Plan Maxillary dentition Maxillary generally in accordance with the plan to carry out the plan of mandibular, mandibular maxillary tooth extraction should be under normal circumstances the extraction of symmetry. If the non-extraction of mandibular, maxillary gap was far from the teeth to move or the first premolar extraction to obtain. The relationship between the posterior teeth Molar relationship is the treatment of the issue must be taken into account, is not it needs to be remedied? How to correct? Class I canine relationship is the one of the goals of treatment. Class I molar or completely far-China relations (II-type) is acceptable Of maxillary first premolar extraction. Treatment Plan Appliance choice Appliance activities Get rid of bad habits Tilted teeth Mobile Gap to maintain Retainer Fixed appliance Conventional treatment, three-dimensional control of tooth movement Functional appliance To stimulate or limit the maxillary, mandibular growth and development chief complaint and case history Clinical examination Diagnostic data analysis Categories Database Diagnosis (list of questions ) Orthodontic treatment before the disease control (such as: caries, periodontal disease, etc.) Choose the ideal and the sacrifice plan According to the priority order of questions, A, B, C, D, etc Questions for each possible solution Choice of treatment plan Can be modified with special consideration Treatment goals Healing techniques Thinking Questions How to assess the facial soft tissue? What is the dental arch length? What is the dental arch circumference? How to calculate the degree of dental arch crowding? Mixed dentition how far the forecast of nearly 345 gap between the two? X-cephalometry of the basic principles of what? X-cephalometry what the main purpose? What is the reference plane? Intracranial reference plane of the shortcomings of what? In the gap analysis of what issues should be considered? Dental abnormalities, including what the diagnosis? What is the treatment goal? What is the treatment plan?