The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.for more details please visit www.indiandentalacademy.com

1. Diagnosis & TreatmentDiagnosis & Treatment
PlanningPlanning
www.indiandentalacademy.com

2. www.indiandentalacademy.com

3. “The first step towards cure is to
know what the disease is......”

4. A century ago EDWARD. H.
ANGLE rightly said:
“In studying a case of malocclusion, give no
thought to the
– methods of treatment or appliances
until the case shall be classified with all
peculiarities and variations from the normal in
– type, occlusion and
– facial lines that have been thoroughly
comprehended.
Then the requirements and proper plan of
treatment become apparent”.

5.  Human head is the mostmost
complicatedcomplicated anatomical complex in
all creation.
 The interrelationships are infinite
and the causes and effects of these
relationships are almost
imponderable.

6.  A thorough understanding of the
normal variations in the
– Growth and development of
dentofacial structures,
– Their anatomical fit into each other
and
– Their reaction to intrinsic and extrinsic
factors /stimuli (genetic and
environmental) itself is
Orthodontic diagnosis.

7. Problem OrientedProblem Oriented
&&
Evidence Based DiagnosisEvidence Based Diagnosis
www.indiandentalacademy.com

8.  The goal of the diagnostic process is
to produce a complete description of
the patient’s problems and make a
problem list.
 To obtain the problem list, a
collection of relevant information is
required. This collection is called a
database.

9. Mechano-Mechano-
therapytherapy
Diagnosis & Treatment
Planning - Steps
Patient History
Clinical
Examination
Analysis of
Diagnostic Records
Classification Problem List
= Diagnosis
Treat pathology
(caries, gingivitis etc.)
Treat pathology
(caries, gingivitis etc.)
Problems
in
priority
order
A
B
C
D
Possible
solution to
individual
problems
OptimalOptimal
TreatmentTreatment
PlanPlan
Data
Base
A
B
C
D

10. Patient history, &Patient history, &
interview datainterview data
1. Family history
2. Motivation of patient for treatment
Internal
External
3. Reasons for taking treatment
Functional
Hygiene
Esthetics
Speech
4. Pubertal status
5. Prenatal History
1. Health of mother during pregnancy
Diseases : Bacterial / Viral
Medication
Radiation
Trauma
Patient history, &Patient history, &
interview datainterview data
1. Family history
2. Motivation of patient for treatment
Internal
External
3. Reasons for taking treatment
Functional
Hygiene
Esthetics
Speech
4. Pubertal status
5. Prenatal History
1. Health of mother during pregnancy
Diseases : Bacterial / Viral
Medication
Radiation
Trauma
Clinical Examination:Clinical Examination:
1. General examination
2. Extraoral
• Head shape
• Frontal symmetry
• Profile convexity
• Facial divergent
• Lip competency
• Incisor visibility,
3. Functional
• Mastication
• Deglutition
• Speech
• TMJ
4. Intraoral
• Hard tissues
• Soft tissues
Clinical Examination:Clinical Examination:
1. General examination
2. Extraoral
• Head shape
• Frontal symmetry
• Profile convexity
• Facial divergent
• Lip competency
• Incisor visibility,
3. Functional
• Mastication
• Deglutition
• Speech
• TMJ
4. Intraoral
• Hard tissues
• Soft tissues
Analysis ofAnalysis of
diagnostic records:diagnostic records:
1. Study Models
• Upper
• Lower
2. Radiographs
• Lateral Ceph.
• OPG
• A-P Ceph.
• IOPA
• Hand Wrist
• Occlusal
3. Photographs
• Extra-oral (3 + 2 smiling)
• Intra-oral (5)
Analysis ofAnalysis of
diagnostic records:diagnostic records:
1. Study Models
• Upper
• Lower
2. Radiographs
• Lateral Ceph.
• OPG
• A-P Ceph.
• IOPA
• Hand Wrist
• Occlusal
3. Photographs
• Extra-oral (3 + 2 smiling)
• Intra-oral (5)
Problem
List
Problem
List
Pathology:
1.
G
ingiva
(Attached
gingiva)
2.
Frenum
(Lab. / Ling.)
3.
Tonsils
/ Adenoids
4.
Tongue
5.
Dental Caries
Developm
ental Problem
s:
1.
Profile
and
Esthetics
•
Profile
(Convex, Straight, Concave)
•
Frontal ( Sym
m
etrical, Asym
m
etry)
•
Lips
2.
Alignm
ent
•
Upper (Crow
ding
/ Spacing)
•
Low
er (Crow
ding
/ Spacing)
3.
A-P
•
Skeleton
(Class
I, II, III)
•
Dental ( Class
I, II, III)
4.
Vertical
•
Skeleton
(VG
P
/Average
/ HG
P)
•
Dental (Deep
Bite
/ Norm
al / O
pen
Bite
5.
Transverse
•
Skeleton
(W
ide
/ Norm
al / Narrow
)
•
Dental (W
ide
/ Norm
al / Narrow
)
Problem
List
Problem
List
Pathology:
1.
G
ingiva
(Attached
gingiva)
2.
Frenum
(Lab. / Ling.)
3.
Tonsils
/ Adenoids
4.
Tongue
5.
Dental Caries
Developm
ental Problem
s:
1.
Profile
and
Esthetics
•
Profile
(Convex, Straight, Concave)
•
Frontal ( Sym
m
etrical, Asym
m
etry)
•
Lips
2.
Alignm
ent
•
Upper (Crow
ding
/ Spacing)
•
Low
er (Crow
ding
/ Spacing)
3.
A-P
•
Skeleton
(Class
I, II, III)
•
Dental ( Class
I, II, III)
4.
Vertical
•
Skeleton
(VG
P
/Average
/ HG
P)
•
Dental (Deep
Bite
/ Norm
al / O
pen
Bite
5.
Transverse
•
Skeleton
(W
ide
/ Norm
al / Narrow
)
•
Dental (W
ide
/ Norm
al / Narrow
)

11. Timing of Orthodontic
Treatment:
 Pubertal growth spurts
 Peak Height Velocity (PHV)
 The importance of the body type

12.  If all the structures of the craniofacial
complex like the skeletal units , the
dentition and the soft tissue
components grow in harmony , then
the result would be a good occlusion
with a well balanced face.
 But the human face like most of our
other specialized anatomic parts,
certainly has its share of variations.

13.  The more our knowledge increases
the more our ignorance enfoldsmore our ignorance enfolds.
 The vast stretches of the
unanswered and the unfinished will
outstrip our collective
comprehension.

14. ? @ ? * kK ? & ? #
? A ? L ? I ?
W ? ? ? Q ? F ?
% ? ?

15. Class II Malocclusion

16.  A class II malocclusion is one such
relationship of the components of the
human head which has remained
enigmatic despite staggering
advances in our level of knowledge
and comprehension.
 Our lore on this subject abounds with
clinical dogma, with sacred tradition,
and even with myth.

17.  Since Class II malocclusion is
recognized easily by health
professionals as well as by patients
and their families, especially in cases
of excessive over jet, the correction
of class II problems may constitute
more than half of the treatmenthalf of the treatment
protocolprotocol in a typical orthodontic
practice.

18.  It is interesting to note that the
process of evolution in orthodontic
diagnosis and treatment planningdiagnosis and treatment planning
has been gradual.
 Now, let us trace through historylet us trace through history, the
changing perceptions on the etiology
of class II malocclusion.

19.  For decades together class II was
erroneously considered a purely sagittalsagittal
problem.problem.
 Pioneered by Dr. Angle’s classificationDr. Angle’s classification of
malocclusion based on anteroposterior
relationship of first molarfirst molar, probably
thousands of class II of all hues and
varities were treated as basically sagittal
discrepancies, often with disastrousdisastrous
results.

20.  It was not the orthodontists alone
who were guilty of nescience, but
even the surgeons jumped onto the
bandwagon and restricted
themselves to sagittal correction of
what was actually a problem
involving more than one plane.

21.  The Angle system of classification
still remains at the core of
orthodontic diagnosis a century after
its development, even though this
classification scheme is not sensitive
to imbalances in the vertical and
transverse dimensions.

22.  First, let us see, how malocclusions
such as Class II develop as sagittal
discrepancy.

23. SAGITTAL PLANE
Prognathic Maxilla
Retrognathic Mandible
Combination of the two
A N IMA TIO NA N IMA TIO N

24. 2
Normal Mandible,
Prognathic Maxilla

25. 2
Prognathic Maxillary
Dentition

26. Normal Maxilla,
Retrognathic Mandible.

27. 2
Prognathic maxilla,
Retrognathic mandible.

28.  Can also be
because of
decreased cranial
flexure, the
posterior positioning
of glenoid fossa
which neutralizes
the horizontal
growth of mandible
ending up in Class
II.

51. VERTICAL
DISCREPANCY
 With the passage of time, inevitably there
was gain of knowledge and wisdom and
the focus now began to shift towards other
etiologic possibilities of class II
malocclusion
 It was schudy in 1964, who brought into
focus the vertical dysplasia causing and
affecting the class II malocclusion.
 Until then, investigators had never
explored the vertical dimension of the
posterior aspect of the face. But here were
the secrets to be found.

52. 2
Vertical Discrepancies
 Discrepancies in the vertical dimension occur in
the form of a long facelong face or a short faceshort face
syndrome.

53. Rotations of Mandible
 The rotationrotation of the mandible due to
vertical growth discrepancies also
has to be distinguished.
3
MO RPHIN G SMO RPHIN G S
H & V G RO WTHH & V G RO WTH

54. Vertical Maxillary
Excess
 Vertical maxillary excess brings about a
clockwise rotation of the mandible and a class II
situation.

55. Decreased Condylar
Growth
 Decreased condylar growth and decreased ramal
height swings the mandible backward.

56. Excess Condylar Growth
 Excessive condylar growth causes forward rotation
of the mandible leading to a class II deep bite
situation.

57.  During the 1940s and 50s even class
II due to vertical maxillary excess
were treated with cervical pullcervical pull
headgearheadgear..
 This accentuated the problem rather
than solve it.
Flash Player Movie

58.  The disastrous results obtained led
to the realization that the traditional
cookbook approach of treating all
class II malocclusions with either
– A bite jumping appliance or
– a kloehn’s cervical headgear
might not be the right approach after
all.

59.  Now the concept changed such that when
facial morphology indicated that vertical
growth had been excessive or that
condylar growth had been deficient, the
plan was to inhibit the downward growth of
the maxillary molars.
 When it is determined that vertical growth
is deficient, the choice is to stimulate the
vertical growth of the alveolar processes.

60.  This quantum shift in knowledge
about the causative factors of class II
malocclusion brought into light an
entirely new gamut of treatment
possibilities.

61.  Now let us look at some class II
cases with predominant verticalvertical
discrepancydiscrepancy and their treatment
options.

65. Pre-expansion Post-expansion

71. PretreatmentA.T.

73. Pre-surgicalA.T.

74. Lefort I Osteotomy Premaxillary setback
Genioplasty

77. A.T. Post-Treatment

78. www.indiandentalacademy.com

84. TRANSVERSE
DISCREPANCY
 It has only been during the last two
decades or so that the role of
transverse dimensiontransverse dimension has been a
topic of interest to the typical
practicing orthodontist.
 Until then it was a classical
illustration of, “the eyes cannot see
what the mind does not know.”

85.  Infact, the skeletal imbalances in the
transverse dimension often were
ignored or simply not recognized,
and thus the treatment options for
such patients by necessity were
more limited than if these transverse
skeletal problems were recognized.

86.  Many class II malocclusions, when
evaluated clinically have no obvious
maxillary constriction.

87.  When a set of study models of the patient
are “hand articulated", how-ever, it
becomes obvious that when the dental
casts are placed with the posterior
dentition in a Class I relationship, a
unilateral or a bilateral cross bitecross bite is
produced.
 This indicates the presence of maxillarymaxillary
constrictionconstriction as a component of class II
malocclusion.

88. FOOT AND SHOE MECHANISM
 Richen Bach and Taatz in 1971 used the
example of a foot and a shoe, with the foot
representing the mandible and the shoe
representing the maxilla.
 If the shoe is too narrow, it is impossible
for the foot to slide fully into the shoe. By
widening the shoe, the foot slides forward
into its usual position.

89.  When treating in the mixed dentition,
the first step in the treatment of mild
to moderate Class II malocclusions
characterized, by mild mandibular
skeletal retraction and maxillary
constriction may be expansion of
maxilla.

90.  The patients can be left in a over
expanded position with contacts still
being maintained between the upper
lingual cusps and lower buccal cusps
of the posterior teeth.

91.  Widening the maxilla often leads to
a spontaneous forward posturing of
the mandible during the retention
period.
 After 6 to 12 months, the
spontaneous correction of the class
II relationship can be seen in many
mild to moderate class II patients.
foot&show.swf

92.  The net result of this change in
outlook has been a reduction in the
number of functional jaw orthopedic
appliances that now are used in the
treatment of mild to moderate class II
malocclusion.

101. Class III malocclusionClass III malocclusion
www.indiandentalacademy.com

102. SAGITTAL PLANE
Retrognathic maxilla
Prognathic mandible
Combination of the two
C LA S S – IIIrotC LA S S – IIIrot
ANIMATIONANIMATION

103. Retrognathic Maxillary
Dentition

104. 2
Retrognathic Maxilla

105. 2
Prognathic Mandible

106. 2
Combination

107.  During the1940’s and 50’s
mandibular prognathism was
believed to be the sole etiological
cause for Class III malocclusions.

108.  All clinical efforts were concentrated
in correcting the mandibular
prognathism using Chin cup therapy
or surgical correction by mandibular
set back was the only alternative
practiced.

109.  A lack of a clear understanding of the
underlying etiology often compounded
by adressal of wrong treatment
objectives resulting in disastrous
treatment results often accentuating the
problem rather than solving it.

110.  With the advent of newer diagnostic
aids such as cephalometrics
identification of the role of maxilla in
the development class III
malocclusion came into picture
completely revolutionizing the
present treatment philosophy.

124. BSSO-Setback

125. Genioplasty

136. 8 mm.Downward & 6.5mm. Advancement of Maxilla

143.  Till now you have seen some patients
who have undergone growth modulation
& Orthognatic surgical correction with
good to excellent results.
 But a “coin” always has two sides.
 Now let us look at the other side of the
coin.

144. www.indiandentalacademy.com

149. Why is it that this patient has
ended up with a less than
optimum treatment result?
 As you can see,
the cephalogram
shows all features
of a good growing
mandible.
Pre Treatment Ceph

150. GOOD GROWING AND
POORLY GROWING MANDIBLE

151.  In general, the success of treatment
depends as much on the skill of the
orthodontist as on a favorable
pattern of facial growth.
 Lack of sufficient and/or favorable
growth during treatment will make it
difficult to correct the skeletal
malrelationship or significantly
improve the profile.

152.  At the present juncture, we lack a
reliable method of predicting growth.
 A cephalometric evaluation will
reveal the nature of growth that has
taken place, but will not accurately
predict future growth.

153. All these years we depended on educated
guess work.

154.  But today, the research has gone to
molecular and genetic level.
 We have entered the 21st
century– a
century likely to be remembered as
the biotechnology century.
 The individual genes and the
combinations required for the
exquisite stages of human
craniofacial morphogenesis soon will
be known.

155.  The enormous human craniofacial
genomic library will enable the
translation of this genetic lexicon into
improved diagnostics and the
products of biomimetics applied to
growth modifications of the
craniofacial-oral-dental complex.

156.  Within the past decade, an
explosion of discoveries in
developmental biology and
genomics has direct relevance to
understanding the
development,growth,and adaptation
of craniofacial skeletal tissues.

157.  Once greater understanding of the
molecular mediators of growth and
adaptation of skeletal tissues in
craniofacial regions and of their normal
pattern of expression during the lifespan
has been achieved, it will become
possible to develop treatment methods to
target specific tissues and time periods for
growth modification.

158.  It is reasonable to imagine that within
the next several decades,
orthodontists will be using molecular
kits to diagnose growth related
problems and to determine precisely
maturational, hormonal status.

159.  Advances in genetic engineering
may provide a means for local
introduction of novel isoforms of key
growth factors as a kind of
“molecular bullet.”

160.  As understanding of the epigenetic factors
that turn on regulatory genes and other
morphogenetic factors improves,
treatment of specific growth discrepancies
will be precisely targeted, using
orthopedic approaches alone or in
combination with systemic and local
interventions.

161. Conclu

162.  But as the philosopher Fredrick
Jensen has said, “What we think we
know today shatter the errors and
blunders of yesterday and is
tomorrow discarded as worthless.
So we go from larger mistakes to
small mistakes so long as we do not
loose courage. This is true of all
therapy, no method is final”.

163.  Thus even with tremendous progress
in basic research and mind boggling
improvement in appliance systems,
class II & III malocclusion has still
remained an enigma

164. ORTHODONTICS
AS OF TODAY
CreatesCreates WONDERSWONDERS