315-fall-2.pdf

DIAGNOSIS OF THE ORTHODONTIC PROBLEM Dre Julia Cohen –Lévy DDS, Msc, PhD, FRCD(C), Diplomate of the ABO 2023 -2024 DENT 315 LEARNING OBJECTIVES • At the end of this 3 parts presentation you should be able to : 1. Distinguish between normal occlusion and malocclusions 2. Classify orthodontic anoma...

DIAGNOSIS OF THE ORTHODONTIC PROBLEM Dre Julia Cohen –Lévy DDS, Msc, PhD, FRCD(C), Diplomate of the ABO 2023 -2024 DENT 315 LEARNING OBJECTIVES • At the end of this 3 parts presentation you should be able to : 1. Distinguish between normal occlusion and malocclusions 2. Classify orthodontic anomalies between and within the jaws as well as categorise different malpositions and abnormalities of teeth 3. Understand the dynamic aspect of occlusion in relation to temporomandibular joints 4. Understand the physiologic changes of the occlusion in the perspective of growth and development of the face 5. Understand different malocclusions, their dental, skeletal and facial/soft tissue components and know their frequencies 6. Recognize growth problems PART ONE Diagnosis of orthodontic problem (1) Abnormalities of Teeth & Intra-Arch examination PART TWO Diagnosis of orthodontic problem (2) Dentition process Angle’s classification Andrew’s six keys of occlusion Occlusion & TMJ PART THREE Diagnosis of orthodontic problem (3) Facial & Skeletal analysis : Growth anomalies, Skeletal discrepancies, Dental compensations ; Review of cephalometrics Soft tissue analysis (Intra- Extra oral) FIRST CONTACT WITH A PATIENT • Chief Complaint • Medical history • Behavior https://dentrixdentalcare.com/prepare-child-first-dentist-visit/ Questionnaires IN REAL LIFE… • Interview, History • Medical Conditions • Growth status Clinical Examination & Xrays • First impression (Facial esthetics) • Dental & Periodontal Heath • Static & Functional examination • Extraoral & Intraoral photos, • Casts, Panorex, Lateral Ceph… Analysis of Records • Measurements (intra & interarch) • Classifications (3D) • Problem list PART ONE Diagnosis of orthodontic problem (1) Abnormalities of Teeth & Intra-Arch examination 1. INTRA-ARCH ABNORMALITIES 1.1. Abnomalities of tooth number 1.2. Abnormalities of tooth shape, size & structure Thilander et al. Essential Orthodontics. Wiley 2018 Deniz A, Ayna E Journal of Prosthetic Dentistry 93(6):526-9 1.3.Abnormalities of position, eruption 2. INTRA-ARCH STUDY 2.1 . Archform & symmetry http://www.dent-wiki.com/dental_technology/orthodonticmodel-analysis/ 2.2 compensating curves 2.3 spacing/crowding 1.1 ABNORMALITIES OF TOOTH NUMBER https://www.flickr.com/photos/lebousou/7359288478 DENTAL ABNORMALITIES : NUMBER • Reduction in the number of teeth (agenesis) • Hypodontia refers to the condition where there is absence of one or a few teeth only • Oligodontia is usually used to describe large numbers of missing teeth, six or more • Anodontia, the complete absence of teeth. • • • • • Supernumerary teeth Supplementary teeth Incisor region : mesiodens Premolar region Molar region: Distomolar, Paramolar, Fourth Molar OLIGODONTIA • Genetic disorder : Ectodermal dysplasia Dental phenotype in a patient with hypoidrotic ectodermal dysplasia and severe immunodeficiency December 2010 Journal of International Dental and Medical Research 4(1):17-20 ANODONTIA Severe hypodontia in Ectodermal dysplasia • Partial anodontia is a meaningless term and should not be used. • Oligodontia is seen more frequently in cases where there are other systemic conditions Nunn, J., Carter, N., Gillgrass, T. et al. The interdisciplinary management of hypodontia: background and role of paediatric dentistry. Br Dent J 194, 245–251 (2003). https://doi.org/10.1038/sj.bdj.4809925 Cohen-Levy J. Unpublished. SUPERNUMERARY TEETH • Supplemental • Tuberculate ILONA, 8 • Barrel shaped • Conical Cohen-Levy J. Unpublished. Cohen-Levy J. Unpublished. Radiologist specialist : Dr R. Cavézian MAXIME, 7 Cohen-Levy J. Unpublished. Cohen-Levy J. Unpublished. Radiologist specialist : Dr R. Cavézian Orthodontic traction in a patient withcleidocranial dysplasia: 3 years of follow-upRoberto Rocha, Manuela Batistella Zasso, Gilberto Floriano, Carla Derech, Gerson Ulema Ribeiro,ArnoLocks, and Daltro Ritterc Source Netflix (From Stranger Things) https://rarediseases.info.nih.gov/diseases/6118/cleidocranial-dysplasia 1.2 ABNORMALITIES OF TOOTH SIZE, SHAPE & STRUCTURE Increase the size of the peg tooth Decrease size of opposite dentition GOLDEN PROPORTIONS (DAVID SARVERS’ MINI & MICRO ESTHETICS) MACRODONTIA • Definition: Macrodontia is a type of localized gigantism in which teeth are larger than normal for the particular type(s) of teeth involved. The three types of macrodontia are true generalized macrodontia, relative generalized macrodontia, and macrodontia of a single tooth. • Prevalence : more in permament dentition (1,1%)compared to primary dentition • Often bilateral • Affects : lower molars lower second molars. Upper central incisors MICRODONTIA • Definition: Microdontia is a condition in which one or more teeth appear smaller than normal. In the generalized form, all teeth are involved. In the localized form, only a few teeth are involved. The most common teeth affected are the upper lateral incisors and third molars. • Generalized microdontia occurs in pituitary dwarfism (decreased levels of growth hormone ) • Localized microdontia more common, often associated with hypodontia maxillary lateral incisor, which may also be shaped like an inverted cone (a "peg lateral").Peg laterals typically occur on both sides, and have short roots (1%) Alrejaie M, Ibrahim NM, Malur MH, AlFouzan K. Type II dens evaginatus of maxillary central incisor: An alternative approach. Saudi Endod J 2015;5:61-4 DENS EVAGINATUS (OR DE) Definition: Dens evaginatus is a rare odontogenic developmental anomaly that is found in teeth where the outer surface appears to form an extra bump or cusp. Prevalence : ranges from 0.06% to 7.7% More frequent in the mandible, in premolars (incisor region : talon cusps) Dens Evaginatus: Literature Review, Pathophysiology, and Comprehensive Treatment Regimen Marc E. Levitan, and Van T. Himel. J Endod 2006;32:1–9 DENS EVAGINATUS (DE) PHOTOS, STUDY CASTS AND ? Dens Evaginatus: Literature Review, Pathophysiology, and Comprehensive Treatment Regimen Marc E. Levitan, and Van T. Himel. J Endod 2006;32:1–9 Lin CS, Llacer-Martinez M, Sheth CC, Jovani-Sancho M, Martín Biedma B. Prevalence of Premolars with Dens Evaginatus in a Taiwanese and Spanish Population and Related Complications of the Fracture of its Tubercle. Eur Endod J 2018; 2: 118-22 Cohen-Lévy J. Turned in on itself. Journal of DentoFacial Anomalies and orthodontics. 2013 DENS IN DENTE (DENS INVAGINATUS OR DI) Definition: Deepening or invagination of the enamel organ into the dental papilla prior to calcification of the dental tissue Prevalence : 0,3 % Type I, II & IIIa. IIIb Dens invaginatus is a developmental malformation, in which there is an infolding of enamel into dentine. These infolds represent stagnation sites for bacteria and can predispose to dental caries. The carious infection can spread via enamel and dentine to contaminate the pulp and cause soft tissue necrosis. The altered and sometimes complex anatomy of affected teeth can make endodontic management challenging https://www.nature.com/articles/sj.bdj.2016.724 DENS INVAGINATUS (DI) PHOTOS, STUDY CASTS AND ? Australian Dental Journal, Volume: 62, Issue: 3, Pages: 261-275, First published: 17 March 2017, • The presence of a palatal pit or groove • Barrel-shaped or cone-shaped teeth. • Dilated crown • Microdontic teeth • Possibly associated with DE • Labial groove Australian Dental Journal, Volume: 62, Issue: 3, Pages: 261-275, First published: 17 March 2017, Australian Dental Journal, Volume: 62, Issue: 3, Pages: 261-275, First published: 17 March 2017, Cho Sy. Talon cusps in mandibular incisors: Report of eight rare cases. J Indian Soc Pedod Prev Dent 2014;32:185-9 CONCRESCENCE • Definition : Concrescence is a condition of teeth where the cementum overlying the roots of at least two teeth join together. It usually involves only two teeth. The most commonly involved teeth are upper second and third molars. • Prevalence is 0.04% • Involved teeth may have difficulty erupting or may not erupt completely. • May possibly cause localized periodontal destruction due to aetiological factor Paramolar concrescence and periodontitisSanjay Venugopal, B. V. Smitha, and S. Prithyani Saurabh. J Indian Soc Periodontol. 2013 May-Jun; 17(3): 383–386. FUSION • The phenomenon of tooth fusion arises through union of two normally separated tooth germs • TOOTH NUMBER IS FEWER • Could also be the union of a normal tooth bud and a supernumerary Pr Edith Lejoyeux, private collection Cohen-Levy J, Etienne D and Tuil P (2020). In progress GEMINATION (FALSE MACRODONTIA) • Definition :Tooth gemination is a dental phenomenon that appears to be two teeth developed from one. There is one main crown with a cleft in it that, within the incisal third of the crown, looks like two teeth, though it is not two teeth. The number of the teeth in the arch will be normal. • Prevalence :The prevalence of gemination or fusion is 2.5% in primary dentition and 0.1 - 0.2% in permanent dentition • Complications : esthetic problem Crowding, impaction of adjacent teeth Difficulties in RCT Pulpal & endodontic complications • TOOTH NUMBER IS THE SAME (but extra big tooth) Cohen-Levy J. Unpublished. Radiologist specialist : Dr R. Cavézian Cohen-Levy J. Unpublished. Periodontal surgeon : Dr Daniel Etienne, France Cohen-Levy J, Etienne D and Tuil P (2020). In progress Dr R. Cavézian CHNO XV-XX HOW COULD IT AFFECT TREATMENT ? • Extraction choice • Dens evaginatus and pulp exposure/pulp necrosis & complications • Dens invaginatus and pulp necrosis & complications (prevention) • Gemination : endodontic restorative & orthodontic issues (esthetics symmetry) • Microdontia of lateral incisors & eruption disturbances of canine teeth DENTAL ABNORMALITIES : SHAPE/SIZE • Macrodontia • Microdontia • Concrescence • Fusion & Gemination • Dens evaginatus (occlusal tuberculum – excluded Carabelli) • Dens invaginatus (dens in dente) • Palatal grooves • Peg shapes (Conical) incisors • Shovel Shaped Incisors • T shaped incisors OTHER DENTAL ABNORMALITIES OF SHAPE/SIZE • Hitchinson teeth • Premolarisation • Abnormal tubercula & enamel pearls • Taurodontism • Other… https://www.pinterest.com/pin/693343305119635715/ DENTAL ABNORMALITIES : STRUCTURE Motteled Teeth (Excluded deposits/accretions on teeth &Turner’s Tooth) • Endemic (fluoride) mottling of enamel (dental fluorosis) • Non endemic mottling of enamel (non fluoride enamel pacities) Disturbances in tooth formation • Enamel hypoplasia • Prenatal enamel hypoplasia • Neonatal enamel hypolasia • Aplasia & hypoplasia of cementum • Dilaceration • Odontodysplasia • Turners’ Tooth • A cocktail of abnormalities (atypical dental dysplasia associated with agenesis, extreme microdontia and segmental ankylosis) J. Cohen-Lévy, F. Aloé-Tavernier, G. Mer JDAO 2014 Cohen-Levy J. Parry Romberg Syndrome. JDAO Cohen-Levy J. Unpublished DENTAL ABNORMALITIES : STRUCTURE • Amelogenesis imperfecta • Dentinogenesis imperfecta • Dentinal Dysplasia/ Shell teeth Bonan Ifi Naulin & Cohen Levy J JDAO 2012. https://www.jdao-journal.org/articles/odfen/pdf/2012/03/odfen2012153p309.pdf 1.3 ABNORMALITIES OF TOOTH POSITION, ERUPTION Cohen-Levy J. Unpublished Cohen-Levy J. Unpublished Cohen-Levy J. Unpublished Cohen-Levy J. Unpublished DENTAL ABNORMALITIES : ERUPTION • Disturbances in tooth eruption • • • • • Natal teeth, Neonatal teeth Premature eruption Retained (persistent) primary teeth Late eruption Premature exfoliation of teeth (excluded attributable to disease of surrounding tissues) • Embedded and impacted teeth • Embedded • Impacted • Disturbances in tooth formation • Hypercementosis • Ankylosis DENTAL ABNORMALITIES : POSITION OTHER (RELEVANT) • Excessive attrition (occlusal, Approximal) • Excessive Abrasion (Habit, Traditional, occupational) • Excessive Erosion (persistent regurgitating or vomiting, diet, drugs, occupational….) • Cracks • Color changes • Deposits on teeth • Disorders of the gingiva 5 YEARS-OLD BOY Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 6 YEARS OLD BOY Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 12 YEARS-OLD BOY Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 13 YEARS-OLD LADY Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 21 YEARS-OLD LADY Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 40 YEARS-OLD WOMAN Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 OTHER 40 YEARS-OLD WOMAN • Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Anders Johansson Dental Erosion and Its Growing Importance in Clinical Practice: From Past to Present International Journal of Dentistry Volume 2012, Article ID 632907 PERIODONTIUM HEALTH & BIOTYPE… LOCALIZED GINGIVITIS GENERALIZED GINGIVITIS INADEQUATE ATTACHED GINGIVA GINGIVAL RECESSIONS 2.1 ARCHFORM & SYMMETRY ARCHFORM • Position and relationships teeth have with each other in 3 dimensions • Reflect reaction of teeth to environment forces in the oral cavity • Determined by both skelettal pattern and muscular forces • Neutral zone (Mills 1968) • When intercuspid and intermolar widths have been changed during orthodontic treatment, there is a strong tendency for these teeth to return to their pretreatment position • The greater the treatment change, the greater the tendency for post retention change DENTAL ARCH ASYMMETRY • Midline deviation • Arch form deviation • Asymmetry of dental crowding • Unilateral impacted tooth • Missing teeth • Shape & size variations of teeth • Unilateral Mesial migration of distal teeth Dental arch symmetry analysis in orthodontic treatment (Irsan Kurniawan, et al.) 1/3 2/3 ARCHFORMS Ricketts pentamorphic archforms ™ Ormco(TM) 1.5 COMPENSATION CURVES CURVE OF SPEE (1) • • Definition : Graf Von Spee (Germany) • AnteroPosterior curvature of the occlusal surfaces • Definition : Depth of the curve of spee is defined as the distance from the vertex of the curvature to the side of a ruler placed over le lower arch. The ruler or template touches anterorly the incisal edges and posteriorly the distal molar cusps. • The meaurements are carried ot separately on both the left and right sides of the arch. CURVE OF SPEE (2) • CURVE OF SPEE : NORMAL CURVE OF SPEE : CLINICAL EXAMPLE CURVE OF WILSON (1) • • Curve that contacts the buccal and lingual cusps tips On both sides of the mandibular posterior teeth (mediolateral curve) (Some call it « Curve of Monson » on the upper arch But Monson refers to a sphere in reality) WILSON CURVE Transverse molar movements during growth.AmJ Orthod Dentofacial Orthop 2003;124:615-24 1.6 SPACING & CROWDING INTRA-ARCH ORTHODONTIC PROBLEMS • Crowding (3 dimensions) • Abnormal position : Ectopic position within the arch , Transposition • Spacing • Rotations : be specific (direction, intensity) • Abnormal inclination, Tipping • Extrusion / Relative intrusion • Also evaluate : Dental Arch symmetry and shape, • Space analysis • Level of marginal ridges Thilander et al. Essential Orthodontics. Wiley 2018 Deniz A, Ayna E Journal of Prosthetic Dentistry 93(6):526-9 LIGHT CROWDING : 0-3 MM PER ARCH MODERATE CROWDING : 3-5 MM PER ARCH SEVERE CROWDING : MORE THAN 5 MM PER ARCH CROWDING (NANCE METHOD) : Sum of the mesio distal dimension of teeth minus the length of the ideal arch Could be + (spacing) or - ARCH FORM METHOD (NANCE) Measure the length of the ideal arch : Available space ARCH FORM METHOD (NANCE) ∑ of mesio distal dimensions of teeth Measure the MD width of all aligned teeth : Required space ANALYSIS BY NANCE • Space analysis : First Method • Required space: • Measuring the mesio-distal width of each tooth mesial to the first permanent molar. • The total sum of the mesio-distal width corresponds to the space REQUIRED for the alignement of teeth. • Available space: • Measuring the actual length by contouring a soft wire to the individual arch shape, OVER the contact points of the posterior teeth towards the incisal edges of the anteriors. • The distance of the straightened wire is the AVAILABLE space for the aligment of teeth. ANALYSIS BY NANCE • Space analysis : Second Method (Segments) • Divide the dental arch into four segments : • from mesial aspect of first molar to distal aspect of the canine, • from distal aspect of the canine (same side) to mesial of centrals; • From mesial of centrals to distal of canine of the other side; • Thenfrom distal of canine to the mesial of permament molar • Arch Length can be measured as straight line approximations of the arch. HOW TO MEASURE CROWDING IN THE MIXED DENTITION ? HOW MUCH CROWDING ? NANCE’S ANALYSIS (RADIOGRAPHIC) • Choose one tooth erupted in the mouth • Measure it mesio-distally both in the radiograph and in the cast • Measure the enlargement of the radiographic image • Use the same coefficient for estimation of other unerupted teeth Actual Width of primary molar (X1) Apparent Width of primary molar (X2) = Actual Width of unerupted premolar (Y2) Apparent Width of unerupted premolqr(X2) EDEN 147 MOYER RE: HANDBOOK OF ORTHODONTICS. ANALYSIS OF THE DENTITION AND OCCLUSION. 4TH ED. YEAR BOOK MEDICAL PUBLISHERS;1988235–8 NON RADIOGRAPHIC 148 TANAKA MM, JOHNSTON LE: THE PREDICTION OF THE SIZE OF UNERUPTED CANINES AND PREMOLARS IN A CONTEMPORARY ORTHODONTIC POPULATION. J AM DENT ASSOC. 1974;88(4):798–801 10.4103/09709290.118389 NON RADIOGRAPHIC 1.7. Tooth size discrepancies BOLTON ANALYSIS (1) • Inventor • Ratio of mesiodistal widths of maxillary versus mandibular teeth • Helps to estimate the overbite and overjet relationships • Overall ratoio of 12 mandibular versus 12 maxillary teeth (excludes second and 3d molars) BOLTON ANALYSIS (2) • Overall (from first molar to first molar) • 91.3 % • (sum of inferior teeths divided by sum of superior) • If > 91.3% mandibular excess relative to the upper teeth • If < 91.3 % maxillary excess relative to the lower teeth BOLTON ANALYSIS (2) • Anterior : from canine to canine • 77.2 % • (sum of inferior teeths divided by sum of superior) • If > 77.2.% mandibular excess relative to the upper teeth • If < 77.2 % maxillary excess relative to the lower teeth BOLTON ANALYSIS (3) • Clinical significance ? • If less than 1 (until 1.5 mm…. ) • Not really significant • Might help decision making whereas to reduce teeth or rebuild. • Let’s work on an example: Gabrielle