Cephalometric diagnosis

Constituents: Clinical examination, lateral cephalometry, photography, dental cast, additional Xray,

additional data

Lateral cephalometry make quantitative identification of facial harmony and its underlying causes

Patient positioning of lateral Ceph: natural head position, intercuspal position, relaxed lip posture

Tracing

1. Cranial base: S, Ba

2. Orbit & Nasal area: Or, N

3. Maxilla: ANS, A, PNS, Ptm

4. Mandible: B, Pog, Me, Gn, Go, Cd, Ar

5. External auditory meatus: Po

6. Facial soft tissue profile: G, N’, Pn, Cm, Sn, A’, Ls, ULP, Stm, LLP, Li,, B’, Pog’, Me’

Measurement

Skeletal: SNA,SNB,ANB,Wit’s appraisal, A to Nper, Pog to Nper, FMA, Go angle, LAFH ratio

Dental: U1 to SN, U1 to FH, IMPA, FMIA, IIA, U1 to APog, L1 to APog, U1 to Stm

Soft: E line, NLA

Limitation of cephalometry: transverse discrepancy, arch length discrepancy, pathologic condition

Cephalometric diagnosis

Photograph

1. Intraoral photography

F>22 with ring flash, manual focus

V-&U- shaped retractor, Mirror, lip hook

Front view

Occlusal upper

Occlusal lower

Buccal right & left

2. Facial photography

Frontal view (rest)

Frontal view (smile)

Oblique view

Profile view

Photograph

Basic model analysis

1. Bolton ratio

Correction: IPR, restorative build up

Overall 91.3%, Anterior 77.2%

2. Curve of Spee

Flattening the curve of Spee positional change of lower incisor

3. Intermolar width

Correction: palatal expansion, inclination control

Arch perimeter increase is about 0.7 times the intermolar width increase

4. Arch length discrepancy Availab

le space – required space

Correction: incisor advancement, extraction, distalization, lateral expansion, interproximal r

eduction

5. Overjet/overbite

Result of normal occlusion

6. Molar key

Premolar occlusion is more important

7. Qualitative inspection

Basic model analysis

Panorama

*Information

Tooth pathology

TMJ pathology

Maxillary sinus

Bone pathology

CO-CR discrepancy (MI-CO discrepancy)

*Check by

Stabilization splint T

MJ manipulation Or

thodontic leveling

Panorama / CO-CR discrepancy

Bracket & wire

Line of occlusion

1. The line of greatest normal occlusal contact (1906, Angle)

2. A distinctively individual line at the inciso-buccal contact with a location, position & form

to which the teeth must conform to be in normal occlusion (1997, Ricketts)

1st order: lateral inset, canine eminence, molar offset

2nd order: angulation (tip)

3rd order: inclination (torque)

DBS -Bracket height guide objectives

1) Leveling marginal ridges

2) Improve intercuspation of the posterior teeth

3) Define the overbite for the anterior teeth

Recommended vertical axis

1. Incisor center mesiodistally

2. Canine & premolar labial cusp tips

3. Molars buccal grooves

Procedure

1. Tooth surface treatment

2. Bracket placement

Checklist

1. Height

2. Vertical axis error

3. Mesiodistal deviation

4. Adhesive resin thickness

Bracket & wire

Ideal archwire bending

1) 1st, 2nd, 3rd order bending

2) Arch coordination

Six keys to Normal Occlusion

1. Molar relationship

2. Crown angulation

3. Crown inclination

4. Rotation

5. Space

6. Occlusal plane

In Straight Wire Appliance (SWA), we can get a good aligned dentition without wire bending due t

o creation of preadjusted bracket

*Comparison of various commercial preadjusted bracket prescriptions

Bracket & wire

Bracket slot

1. 018 slot: earlier torque control with lighter force, less inventory of wire sizes

2. 022 slot: less wire deformation

Torquing play

Tube

1. Single

2. Double

3. Combination

4. Triple

Banding preparation

1. Separating plier

2. Band remover

3. Band pusher

4. Positioning gauge

5. Separation ring

6. Orthodontic molar band set

Bracket & wire

Welding: contacting metal surfaces are joined by the heat obtained from resistance to electric curr

ent

Soldering: Two metals are joined together by melting and putting a filler material (solder) into the

joint

Orthodontic wire

Cross-sectional shape: round, square, rectangular Gro

ss shape: straight, preformed, posted, loop, curved M

aterial: SS, TMA, NiTI

Ligation

1. Metal ligature

2. Elastomeric module (O-ring)

3. Self-ligation bracket

Bracket & wire

Leveling and Aligning

Flow of comprehensive orthodontic treatment

Leveling & alignment Space closure (key correction) finishing &retention

Checklist

1. Leveling

1) Intra-arch leveling phase 1: marginal ridge continuity of all the intra-arch teeth

2) Intra-arch leveling phase 2: vertically straightened continuity of teeth

3) Inter-arch leveling: upper and lower dental arch parallelism

2. Aligning

1) Intra-arch aligning: parabolic archform with smoothly connected contact points

2) Inter-arch aligning: arch coordination with optimal intermolar width difference

General principles

1. Size increasement

2. Stiffness increasement

Verification of leveling & alignment

: passive insertion of working wire into all the brackets

022 slot: 018X025 SS or 019X025 SS

018 slot: 016X022 SS or 017X025 SS

Archwire sequence

022 slot: 014 NiTi 016 NiTi 018 NiTi 018X025 NiTi 019X025 NiTi working wire

018 slot: 014 NiTi 016 NiTI 016X022 NiTI 017X025 NiTI working wire

Leveling and Aligning

Strategy

1. Aligning

1) Inter-arch: expansion

2) Intra-arch: align except severely displaced teeth anchorage reinforcement

*friction during aligning:

A: interproximal friction open coil, IPR, arch expansion, extraction

B: interocclusal friction: scissor bite & crossbite correction

2. Leveling

1) Intra-arch: selective leveling

2) Inter-arch: deep bite control

A: align upper dentition first

B: bracket height modification

C: bite raising: posterior bite turbo, anterior bite plate, stabilization splint

D: intrusion of anterior teeth: reverse curve of archwire, anterior TADs

Leveling and Aligning

Space closure

Extraction is determined according to following 2 factors

1. Upper incisor position at present

2. Crowding amount

Upper extraction strategy ; Decision Flow

1. Determine virtual upper incisor position & required space

2. Determine the method of space creation

3. Determine the method of anchorage

4. Determine the timing of extraction

How to get maximum anchorage

1) Increase the mass of posterior segment

2) Restrict the movement of posterior segment

3) Use other anchorage during space closure instead of posterior segment

Lower extraction strategy:

we should get molar Class 1 in lower dentition related to final upper molar position

Occlusal finish: Class 1 finish, Class 2 finish, Class 3 finish

Method of space closure: one step or two step closure

Retraction force control

1. Continuous force

2. Interrupted force

3. Intermittent force

Space closure

How to prevent vertical bowing of archwire during space closure?

1. Working wire

2. Posted archwire

3. Slight curvature

4. Light force (150~250g for en masse retraction, 70~100g for canine retraction)

5. Postpone space closure

Sliding mechanic

Loop mechanic: sectional loop , continuous loop

Space closure

Finish & Debond

The key to stability is Occlusion (Kingsley, 1880)

Cast-Radiograph evaluation guideline by ABO (2012)

1. Alignment : wire bending or bracket re-bonding

2. Marginal ridge: wire bending or bracket re-bonding

3. Buccolingual inclination: wire torquing

4. Overjet: expansion, archwire exchange, elastic

5. Interproximal contact

6. Occlusal relationship: screw-assisted distalization or protraction, elastic

7. Root angulation: wire bending or bracket re-bonding

8. Occlusal contacts: occlusal adjustment, settling (sectionalization)

Deband & Debond

Removal of residual resin (high speed diamond bur, tungsten carbide fissure bur)

Cause of relapse

1) Elasticity of periodontal fiber

2) Growth

3) Neuromuscular balance

Hybrid (Dual) retention: fixed retainer & removable retainer

Flow of debonding

1. LBR impression

2. Debond, LBR bonding, removable retainer impression

3. Removable retainer delivery

Finish & Debond