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Orthodontic Diagnosis
A Peer-Reviewed Publication
Written by Nona Naghavi DDS and Ruben Alcazar DDS

Publication date: November 2010 Go Green, Go Online to take your course

Expiry date: October 2013
This course has been made possible through an unrestricted educational grant. The cost of this CE course is $39.00 for 2 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
Educational Objectives treatment. It is extremely helpful to have a motivated child/
The overall goal of this article is to provide the reader with adult, since the orthodontic results are directly affected by
information on orthodontic diagnosis. Upon completion of compliance. Both you and the patient will be more satisfied
this article, the reader will be able to: at the end of treatment if you take the time at the consulta-
1. List and describe the areas that need to be addressed in tion appointment to assess the patient’s motivation level and
the patient interview/consultation discuss realistic expectations. It is important to know whether
2. List and describe the steps involved in the extraoral the patient recognizes the need for treatment.
examination of patients presenting for orthodontic
diagnosis and treatment Medical and Dental History
3. List and describe the steps involved in the intraoral A careful and full medical and dental history is necessary to
examination of patients presenting for orthodontic provide a thorough background on the patient’s overall health
diagnosis and treatment status and to ascertain whether the patient is currently under a
4. List and describe the types of malocclusions and their genesis physician’s care. It is important to discuss any medications the
patient may be taking, since some may have an effect on orth-
Abstract odontic treatment. Some examples of conditions and medica-
Orthodontic diagnosis must be performed thoroughly prior tions that impact orthodontic treatment include uncontrolled
to orthodontic treatment planning. A number of steps are diabetes, which can exacerbate periodontal breakdown in
involved in the diagnostic process, all of which must be response to orthodontic forces, and bisphosphonates, which
performed to reach an accurate diagnosis. The overall steps can result in very slow orthodontic tooth movement. Similarly,
involved include the patient interview/consultation, clinical chronic use of high-dose prostaglandin inhibitors for manage-
examination and use of diagnostic records. Only after these ment of arthritis in adults may interfere with orthodontic tooth
steps have been performed and analyzed can a treatment plan movement.1 Extractions may be contraindicated in patients
be developed for the individual patient. with hemophilia, while patients with attention deficit hyper-
activity disorder (ADHD) may have less than ideal compli-
Introduction ance. In addition, latex allergic patients must be identified and
An orthodontic diagnosis must be carried out in a series of logi- appropriate measures taken to avoid any incidents.2
cal steps. The combination of three sources of information will
lead to a proper orthodontic diagnosis: the patient interview/ Growth Potential Prediction
consultation; the clinical examination by the clinician; and the The patient (or accompanying adult(s)) should be asked
evaluation of the diagnostic records that include, but may not questions about recent changes in clothes/shoe sizes, signs of
be limited to, dental casts, radiographs and clinical images. sexual maturity (achievement of menarche in girls) and age of
Each of these sources of information is critical to the diagnosis sexual maturation in older siblings. Look for signs of second-
and, ultimately, the patient’s orthodontic treatment.1 ary sexual characteristics, and take note of the patient’s height
and weight compared to siblings and parents, as this will tell
The Patient Interview/Consultation you whether the patient has reached the onset of puberty, is
The three main areas that need to be addressed during the patient at the peak of his or her growth spurt, or if the growth spurt
interview/consultation appointment are the chief complaint, has ceased altogether. Orthodontic correction can benefit from
medical and dental history, and growth potential prediction. rapid growth during adolescence, whereas growth modifica-
tion may not be feasible if a child is over the peak of the growth
Chief Complaint spurt. Cervical vertebral assessment can be made from the pa-
The clinician must identify the main reason why the patient is tient’s cephalometric X-ray (Fig. 1). It is important to note that
seeking treatment, and this should be noted and documented one’s chronological age does not always coincide with skeletal
in the chart in the patient’s own words. This does not have to be or dental age. Serial cephalometric X-rays are the best way to
limited to one item only. The list of chief concerns should be determine whether growth has stopped or is still ongoing.1,3
established and noted in order of importance to the patient,
and nothing should ever be assumed.1 Some leading ques- Figure 1. Cephalometric X-ray and cervical vertebral assessment
tions that will uncover the patient’s chief complaint(s) follow:
“Do you think you need braces?” and “What don’t you like
about your smile/teeth/face?” If the patient is attending the
appointment with one or both parents/guardians, it is always
a good idea to first address the patient and determine his or
her chief concern prior to addressing the accompanying party.
This will both establish a positive rapport with the patient and Stage II-III peak growth, Stage V is at least 2 years post peak growth*
let you know whether or not the patient will be compliant with *(Angle Orthod. 2002 Aug;72(4):316-23. Baccetti, Franci, McNamara)

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Clinical Examination Figure 4. Evaluation of facial symmetry
Extraoral Examination
The facial analysis is conducted with the patient either sit-
ting upright or standing, not reclining in a dental chair. The
analysis must consider the frontal plane, facial midlines and
lip competency.

Frontal Plane
The proportional relationship between facial height and width
is the first step in facial evaluation. The three characteristic
categories of facial type are dolichofacial (facial height > facial
width, long faces), mesofacial (facial height proportional to
width) and brachyfacial (facial width > facial height, square
faces). The facial thirds are determined by evaluating the dis-
tances from the hairline (trichion) to the prominent ridge be-
tween the eyebrows (gl = glabella), the glabella to the bottom Facial Midlines
of the nose (sn = subnasale), and the bottom of the nose to the First and foremost, the presence of any nasal deviation
chin point (me = menton) (Fig. 2). These distances should be must be identified because this will affect your perception
equal. The mouth should be a third of the way between the of dental midlines. If a deviation exists, then the midlines
base of the nose and the chin (Fig. 3). The facial one-fifths should be examined relative to an imaginary straight line
are determined by vertical lines going through the helix of the (or an actual piece of string held vertical in front of the face)
outer ear, the outer canthus of the eye and the inner canthus of from the soft-tissue glabella. Ideally, this piece of string or
the eye. The line through the inner canthus of the eye should imaginary line should pass through the soft-tissue glabella,
pass through the lateral aspect of the alar base of the nose, and the philtrum of the upper lip and the soft-tissue chin point.
all five segments should be one eye distance in width. This This will aid in determining any asymmetry of the face
can also aid in evaluation of facial symmetry (Fig. 4).1,4 (Figs. 5, 6, 7).

Figure 2. Facial thirds Figure 5. Relationship of facial to dental midlines before treatment

Figure 3. Mouth-nose-chin relationship Note: This patient does not show lower midline upon smiling

Figure 6. Relationship of upper to lower dental midlines

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Figure 7. Relationship of facial to dental midlines after treatment of the maxillary dental midline to the mandibular dental mid-
line, as well as mandibular dental midline to facial midline,
can also be determined. Note that any nasal deviations may
affect perception of the facial midline. The maxillary dental
midline should coincide with the facial midline (see above),
and the maxillary and mandibular dental midlines should
coincide with each other. Finally, the mandibular dental
midline should coincide with the soft-tissue chin point. Devi-
ated chin points may also exist, and this should be taken into
consideration (Figs. 5 - 7).
Gingival display can also be noted in this view. Ideally, there
should be about 1-2 mm of soft tissue apparent on smiling in
this view with 100% of the upper incisor’s crown. Document in
millimeters the upper incisor visible at rest and when smiling,
Note: If the patient does not show her lower dental midline when smiling naturally, and the amount of gingivae shown at rest and when smiling.
any dental correction in the lower arch will not be visible Note that with the aging process, the upper lip will lengthen
Lip Competency and the amount of incisor visible will decrease.4 This can have
The upper and lower lips should ideally be touching or remain a definitive effect on what orthodontic treatment plan is even-
apart up to 3-4 mm while the patient is in a relaxed position tually undertaken. An above-average gingival display may
(i.e., with no straining of lips or chin to close the mouth). Pa- indicate short clinical crowns (dental), short upper lip/short
tients with a short upper lip (short philtrum) tend to “strain” philtrum (soft tissue) or vertical maxillary excess (skeletal). A
their lips in order to close them and have an interlabial gap of below-average gingival display may indicate vertical maxillary
more than 4 mm at rest. Besides indicating a short philtrum, deficiency or long philtrum. Recording lip height at the phil-
this can also be indicative of protrusive incisors (while jaws trum and the commissures can help clarify the problem.1
are in their normal position), normally inclined teeth but Buccal corridors (the dark space between the buccal
mandibular retrognathism (the mandible being farther back mucosa of the cheeks and the posterior maxillary dentition)
than the maxilla), normally inclined teeth but maxillary prog- should also be evaluated. Obliterated corridors can indicate
nathism (the maxilla being farther forward than mandible), a wide arches. Conversely, excessive corridors can indicate
combination of both mandibular retroprognathism and max- crossbites or transverse jaw discrepancies. At any rate, the
illary prognathism, or a longer than normal lower face with or width of the dental arches should be related to the width of
without an anterior open bite. In addition to lip strain, these that individual’s face for optimum esthetics. Lay persons
patients can present with a deep mentolabial sulcus and an can detect this difference and have shown a preference for
accompanying hyperactive mentalis. Hyperactive mentalis narrower buccal corridors.5 The smile arc is basically the
typically shows up as an “orange peel” appearance of the soft contour of the incisal edges of the maxillary incisors relative
tissue around the chin point (Fig. 8).1,3,4 to the curvature of the lower lip while smiling. If these two
lines match each other, the smile arc is called “consonant”
Figure 8. Orange peel appearance (Fig. 9).4 It has been shown that lay people prefer a consonant
smile arc to one that is considered flat.6 The golden proportion
of teeth width when viewed from the front is another aspect
of dental appearance to take note of. In an attractive smile, the
apparent width of the lateral incisor is 62% of the central and
the apparent width of the canine is 62% of the lateral and so
on. The width of the maxillary central incisor should ideally
be 80% of its height. Obviously, incomplete tooth eruption
in children and dental attrition in adults will affect this ratio.
In terms of gingival heights, the contour of gingival height
of the central incisors and canines should be equal, with this
gingival height being about 1.5 mm higher than that of the
lateral incisor. The contact points of the maxillary teeth move
up gingivally, progressively from central incisor to premolars
Smile Analysis, Smiling View and Dental Midlines with the incisal embrasures also getting larger. It is important
Typically, the relationship between maxillary dental midline to inform patients with triangular-shaped incisors that once
and facial midline can be determined with this view. If the the teeth are aligned and overlaps cleared, “black triangles”
patient shows lower teeth upon smiling, then the relationship will appear as the contact points move incisally.1

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Figure 9. Consonant smile arc Lip strain can also be seen in these cases as the patient strug-
gles to achieve a lip seal (see above). In these patients, retracting
the protruded teeth into a normal position improves lip posture.
What is interesting to note is that if the incisors are protruded
in the absence of lip strain, retraction of the incisors has little
effect on lip function or prominence. To establish whether the
jaws are proportionally positioned in the anteroposterior plane,
a line is drawn on the profile from the bridge of the nose to the
base of the upper lip, and another one from that point down
to the chin. These two lines should form a straight line. If the
angle formed between these is less than 180 degrees, the patient
has a convex profile with the chin being behind the bridge of
the nose (posterior divergence), while a wider angle indicates
The ¾ View a concave profile (anterior divergence). Facial divergence is
This view best aids assessment of the relative projections of directly influenced by ethnic background, with American
the upper and lower jaw and gives an impression of the depth Indians and Asians presenting with anteriorly divergent faces
of the face. The patient must be positioned at a 45-degree an- while Northern Europeans typically present with posterior
gle. Some features that can be studied in this view are midface divergence. Vertical facial proportions can also be assessed with
deformity, including nasal deformity; prominence of gonial the profile image. By placing a finger or an instrument along
angle; length and definition of the border of the mandible; lip the lower border of the mandible, the mandibular plane angle
fullness; and vermilion display.3 (the angle formed by the inclination of the mandibular plane
to true horizontal) can be evaluated. Patients with long vertical
Profile facial dimensions (dolichofacial) usually have steep mandibu-
The same three lines drawn on the frontal plane can be lar plane angles and a skeletal open bite tendency. Conversely,
extended to this photograph. Additionally, the Esthetic patients with short vertical facial dimensions (brachyfacial)
line of Ricketts (E-line) should be drawn from the tip of usually have flat plane angles and deep bite malocclusions.1
the nose to the chin. This helps determine the positions of The nasolabial angle (NLA) is very helpful in determin-
the upper and lower lip in relation to the E-line. Note that ing the final treatment plan customized for the patient. This
this relationship is directly affected by the size of the nose angle is produced by two lines: one tangential to the columella
and chin anteroposteriorly. Patients should be asked to have of the nose (the part of the nose between the base of nose and
their lips relaxed when taking this image. Typically, the up- the nasal tip) and the other tangential to the stomion superius
per lip should be 4 mm, and the lower lip 2 mm, behind the (the highest point on the upper lip). Wherever these two lines
E-line.1,3 The prominence of the incisors can affect the pa- meet forms the NLA. This angle relates the upper lip to the
tient’s profile appearance. Bimaxillary dentoalveolar protru- columella line. Typically, the measurement in a Caucasian
sion explains the situation where the incisors are protruded patient is between 90 and 120 degrees. Anything less than
beyond their normal inclination, while the jaws are in their 90 degrees is considered an acute NLA and anything greater
normal position (Fig. 10). than 90 degrees an obtuse NLA (Fig. 11).4

Figure 10. Bimaxillary dentoalveolar protrusion Figure 11. Nasolabial angle

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Intraoral Examination shifts (although determining CR in children is not easy, due
Oral Health to undeveloped articular eminences). Detection of a CO-CR
Ascertain whether the patient is currently under a dentist’s discrepancy is needed to rule out “Sunday bites.” A Sunday
care. The patient must have clearance from the general dentist bite can exist in two situations: 1) a patient who shifts his or her
stating that a full clinical examination, including any needed mandible forward into a Class I to get closure when there truly
X-rays, has been conducted; that any dental caries has been exists a Class II mandibular deficiency if he or she were to bite
treated; and that a cleaning as well as fluoride treatment, if down on the posterior teeth in CO; or 2) a patient who shifts
needed, has been completed. All teeth must be accounted his or her mandible forward into a Class III to get closure but
for to rule out any missing or supernumerary teeth. A thor- does so in order to bypass an incisor interference when there
ough examination of the lips, oral mucosa, tongue and floor truly exists an end-on relationship if the patient were to bite
of the mouth and visual caries detection must be performed down on his or her posterior teeth. This latter condition is also
for every patient. Any disease or pathology (medical issues, called a Pseudo Class III. Any history of trauma to the face,
caries, pulpal pathology, periodontal disease, or soft-tissue jaws or teeth must be explored and further followed up on.1,3
disease or conditions) must be under control prior to the The patient’s overbite and overjet must be determined.
commencement of orthodontic services. Generalized probing Overbite – the vertical distance in millimeters between the
is typically performed to evaluate bleeding on probing, and incisal edges of the lower incisors and the incisal edges of the
inadequately attached gingival areas must be noted to avoid upper incisors (Fig. 13) – can be measured using a periodon-
treatment that could result in further dehiscence. Any history tal probe or ruler. In open-bite cases, the resulting number
of prior orthodontic treatment must be explored and will help is negative. Overjet is the horizontal distance in millimeters
determine a more precise chief concern of the patient as well between the facial surface of the lower anterior teeth and the
as provide insight about the patient’s attitude and compliance lingual surface of the upper anterior teeth (Fig. 14). Based on
with orthodontic treatment. Any oral habits such as digit or the amount of overlap, you may get different overbite and
object sucking, as well as tongue thrust, must be evaluated, overjet values, depending on which incisor you do your mea-
as these can be associated with the etiology and have a direct surement from. Typically, the largest number is recorded.
effect on the prognosis of orthodontic treatment (Fig. 12).1
Figure 13. Overbite measurement
Figure 12. Tongue thrust

Occlusion Figure 14. Overjet measurement

Mastication, speech and temporomandibular joint disorder
(TMD) must be evaluated. Although it is difficult to evaluate
masticatory efficiency, some patients report better chewing
ability after orthodontic treatment. In children with speech
problems, speech therapy in conjunction with orthodontics
may help. The most important indicator of joint function is
the amount of maximum opening, since restricted opening
usually indicates a functional problem.7 Therefore, any pain
and/or click on opening and/or closing, as well as crepitation
on movement, must be evaluated and assessed. If the jaws lock
on opening and closing, this must be confirmed and followed
up on. The muscles of mastication must be palpated as part of
the routine examination. Any anterior or lateral shift on clo-
sure must be recorded, as it may have an effect on orthodontic
diagnosis (true unilateral vs. bilateral crossbites). It is impor-
tant to determine centric occlusion-centric relation (CO-CR)

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Figure 15. Total amount of crowding per arch Figure 17. Skeletal deep bite

The amount of crowding or spacing in each arch must be

measured and documented in millimeters. A gauge or intra-
oral ruler as well as visual analysis only can be used for this
purpose. In crowded cases, each area of overlap between two
teeth must be measured in millimeters and added together
to give the sum total amount of crowding per arch (Fig. 15).1
The presence or absence of a crossbite can be evaluated
by bringing the teeth into occlusion. Posterior crossbite ex- Diagnostic Records
plains the position of the upper molars in relation to the low- It is important to recognize that records are considered an
er, and in a bilateral posterior crossbite, both upper molars adjunct and are not to be used as a replacement for clini-
are lingual to the lower molars. In unilateral crossbite, only cal examination.8 Cephalograms are usually not required
one side manifests this problem. A crossbite can be either as adjuncts for orthodontic diagnosis and treatment in
purely dental or skeletal in nature. A skeletal crossbite exists adults, or for cases involving the correction of minor prob-
due to inadequate palatal widths of the maxilla – this can be lems in children. However, if jaw relationships and incisor
seen by examining the palatal vault on the casts; if the vault positions are being changed with treatment, one should
is narrow and maxillary teeth lean out to reach the mandibu- definitely consider a cephalogram an integral part of the
lar teeth, the problem is skeletal. Conversely, a normal-sized diagnostic records. Trimmed dental casts (or electronic
vault with tipped molars signifies a dental crossbite (Fig. casts), a panoramic X-ray supplemented with appropriate
16). With teeth in occlusion, vertical problems such as ante- periapicals and facial form analysis constitute the minimum
rior or posterior open bites, and deep bites, can be evaluated. records needed.1
Once again the origin could be dental only or skeletal (for
which the cephalometric X-ray needs to be evaluated). A Cast Analysis
patient with a skeletal open bite will usually have excessive Symmetry
eruption of the posterior teeth but may or may not have an A transparent ruled grid is the simplest tool to use to estab-
anterior open bite (if the anterior teeth have super-erupted lish symmetry. When it is placed over the maxillary cast and
in order to compensate, the patient will not have an anterior lined up with the midpalatal raphe, any distortion of arch
open bite). In a skeletal deep-bite patient, the posterior teeth form and shifts of dental units can be determined quickly
are usually under-erupted and the patient presents with a (Fig. 18).3
deep anterior dental bite (Fig. 17).1,3
Figure 18. Establishing symmetry
Figure 16. Anterior and posterior crossbites

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Space Analysis Figure 19. Relationship of first molars and tooth alignment
Space analysis is essentially the difference between “space
available” and “space needed.” Space available is measured
as arch perimeter from the mesial of one first molar in an arch
to the opposite first molar in the same arch. There are two
ways of doing this – either by measuring the contact point
by contact point of each tooth and adding all the numbers
or by placing a wire/string on the line of occlusion molar to
molar and then measuring its length. Space required is mea-
sured by estimating the size of the unerupted permanent
teeth and comparing that to the size of the erupted primary
teeth. If the space required for the unerupted teeth exceeds
that of the erupted teeth or space available, space deficiency
exists and crowding is imminent (and vice versa) (Fig. 15).
The size of unerupted teeth can be estimated by measuring
the teeth on individual periapical radiographs (the enlarge- Figure 20. Normal Class I molar relationship
ment factor of the X-ray must be taken into account) or
by using proportionality tables fabricated using data from
white American children by Moyers as well as the Tanaka
and Johnston table.1

Tooth Size Analysis

Also known as the Bolton analysis, this measurement iden-
tifies any discrepancy between the sizes of the upper teeth
and those of the lower teeth. If the teeth themselves are mis-
matched in size between the two arches, it is not possible to
achieve an ideal occlusion and anterior coupling of the teeth. Figure 21. Class I malocclusion-Class I molar relationship
An anomaly in size of the maxillary lateral incisors is the most
common cause of Bolton discrepancy, but variations in the
size of premolars or other teeth can also be present. Typically,
upper lateral incisors should be larger than lower lateral inci-
sors and all second premolars must be of equal size. Ideally,
the sum of the mesiodistal width of the lower six anterior teeth
is about 77.2% that of the upper six anterior teeth (anterior
Bolton) and the sum of the mesiodistal width of all the lower
teeth (excluding second and third molars) is about 91.3% that
of the upper teeth (overall Bolton).9

Angle’s Classification of Malocclusion

Angle’s classification is based on the relationship of the first
molars and the alignment of the teeth relative to the line of Figure 22. Class II, div 1 relationship
occlusion. Normal occlusion consists of a Class I molar rela-
tionship – the mesiobuccal cusp of the upper first molar fits
in the buccal groove of the lower first molar, with teeth on the
line of occlusion (Fig. 20). A Class I malocclusion–Class I
molar relationship consists of crowded and rotated teeth (Fig.
21). In a Class II, division 1 malocclusion, the mesiobuccal
groove of the upper molars is mesial to the buccal groove of
the lower molars and the anterior teeth are protruded (Fig.
22), while in a Class II, division 2 malocclusion, the upper
central incisors are more retroclined than the lateral incisors
(Fig. 23). Last, in a Class III malocclusion, the mesiobuccal
groove of the upper molars is distal to the buccal groove of
the lower molars (Fig. 24).1,2

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Figure 23. Class II, div 2 relationship radiographs, it is immensely helpful when a facial asymmetry
is observed in a patient and an underlying skeletal component
is suspected and needs verification (Figs. 25-27).10

Figure 25. Orthognathic maxilla, mandible and dental arches

Figure 24. Class III malocclusion

Figure 26. Maxillary dental protrusion, normal maxilla and mandible

Cephalometric Analysis
The cephalogram helps with the analysis of the relationship
of the major functional components of the face, namely
cranial base, jaws and teeth. For every malocclusion, there Figure 27. Prognathic mandible, protrusive mandibular arch,
may exist a dental and a skeletal contributor, and it is pos- normal maxilla
sible to have identical dental relationships but very different
skeletal discrepancies (the dental cast analysis is incapable of
telling the clinician anything about the skeletal relationship
of the patient that can be pertinent in the ultimate treatment
plan chosen for that case). The Steiner Analysis has been the
most widely used cephalometric analysis to date, and while
not perfect, it can certainly help the clinician understand the
underlying basis for a patient’s malocclusion. A Class II or
III Angle malocclusion can be the result of a skeletal discrep-
ancy or just a displacement within dental units with ideal
jaw relationships; it is also possible to have a combination
of jaw discrepancy and dental displacement.1 It is important
to realize that solely comparing individual measurements to
a norm is not as important as also looking at the soft-tissue
presentation of that patient. Measurements are a means to an
end, not an end unto themselves. One other type of cepha- Panoramic X-ray
logram, a posteroanterior or frontal cephalogram, is used to An overview of all the tissues present in a panoramic X-ray
evaluate whether skeletal asymmetry exists. Although this should confirm or eliminate the possible presence of any
radiograph is not considered a part of the routine diagnostic pathology. The sinuses, nasal airways, coronoid and condyle

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processes, and hyoid bone area as well as the maxillary and Figure 31. Congenitally missing teeth
mandibular bone proper must be checked to rule out ab-
normalities. Any dental pathology such as cysts, traumatic
fractures, or abnormal bone pattern or destruction should be
evaluated. The number of teeth present must be confirmed
and supernumerary or missing teeth accounted for. The
location of impacted canines is best viewed in a panoramic
radiograph (Fig. 28), and can be backed up with a periapical
radiograph (Fig. 29) of that area.1,3 Lately, even better evalu-
ation has become possible with the use of a Cone Beam CT
scan (Fig. 30). Any retained primary teeth and/or congenital Summary
absence of the succedaneous teeth can be confirmed using a The overall steps involved in orthodontic diagnosis are the
panoramic radiograph (Fig. 31). Next, the condition of the patient interview/consultation, clinical examination and
roots and the presence of periodontal ligament should be use of diagnostic records. All are crucial in the attainment of
noted. The presence of already short roots should instill cau- an accurate diagnosis, which is a prerequisite for successful
tion in the clinician. In addition, the status of the wisdom teeth orthodontic planning and treatment. The automatic compi-
and unerupted second molars must be determined and taken lation of all diagnostic findings helps the clinician create the
into account in the patient’s overall treatment plan.1 Posterior list of problems present, from which the treatment plan will
crowding can be readily viewed on a panoramic radiograph be developed.
and must be confirmed with additional data from the occlusal
casts and intraoral examination. References and Resources
1. Proffit WR, Fields Jr. HW, Sarver DM. Contemporary Orthodontics. 4th ed.
St. Louis: Mosby; 2007. Chapter 6.
Figure 28. Panoramic radiograph showing impacted canines 2. Patel A, Burden DJ, Sandler J. Medical disorders and orthodontics. J Orthod.
36:1-21, 2009.
3. Grabber TM, Vig KWL, Vanarsdall Jr. RL. Orthodontics: Current Principles
and Techniques. 4th ed. Elsevier Health Sciences; 2005. Chapter 1.
4. Ackerman MB. Enhancement Orthodontics, Theory and Practice. 1st ed.
Ames: Blackwell Munksgaard; 2007. Chapters 3, 4.
5. Moore T, Southard KA, Casko JS, et al. Buccal corridors and smile esthetics.
Am J Orthod Dentofac Orthop. 127:208-213, 2005.
6. Parekh J, Fields HW, Beck FM, et al. Attractiveness of variations in the smile
arc and buccal corridor space as judged by orthodontists and laymen. Angle
Orthod. 76:557-563, 2005.
7. Okeson JP. Management of Temporomandibular Disorders and Occlusion,
ed. St. Louis: Mosby; 2002.
8. Atchison KA, Luke LS, White SC. An algorithm for ordering pretreatment
orthodontic radiographs. Am J Orthod Dentofac Orthop. 102:29-44, 1992.
9. Bolton WA. The clinical application of a tooth-size analysis. Am J Orthod.
48:504-529, 1962.
Figure 29. Periapical showing impacted canines 10. Trpkova B, Prasad NG, Lam EW, et al. Assessment of facial asymmetries
from posteroanterior cephalograms: Validity of reference lines. Am J Orthod
Dentofac Orthop. 123:512-520, 2003.

Author Profiles
Nona Naghavi DDS
Dr. Naghavi graduated from the University of Toronto Dental School in
2004. She completed an AEGD residency at the University of Maryland,
Baltimore in 2005 and a Clinical Research Fellowship at Jacksonville
University School of Orthodontics in 2008. She is currently a second year
resident at Jacksonville University School of Orthodontics.

Ruben Alcazar DDS

Dr. Alcazar obtained his dental degree from the University of San Martin,
Peru in 1995.He received his training in Orthodontics from the University
Figure 30. Cone beam CT scan of San Marcos, Peru, earning a Certificate in Orthodontics in 2003. Dr.
Alcazar is currently a resident at Jacksonville University, School of Ortho-
dontics, Class of 2011.

Disclaimer
The author(s) of this course has/have no commercial ties with the sponsors
or the providers of the unrestricted educational grant for this course.

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Questions

1. The three main areas that need to be 11. The presence of any nasal deviation will 21. In open-bite cases, the overbite number
addressed during the patient interview/ ________. is ________.
consultation appointment are ________. a. determine the position of dental midlines a. greater
a. all complaints, the medical history and the compli- b. affect your perception of dental midlines b. positive
ance potential prediction c. determine the amount of medial tooth movement c. negative
b. the chief complaint, the medical and dental history, that is required d. none of the above
and the compliance potential prediction d. all of the above 22. In a bilateral posterior crossbite, both
c. the chief complaint, the medical and dental history,
and the growth potential prediction 12. An above-average gingival display may upper molars are ________ to the lower
d. all complaints, the medical and dental history, and indicate _________. molars.
the growth potential prediction a. short clinical crowns a. distal
b. short upper lip/short philtrum b. inferior
2. The main reason why the patient is c. vertical maxillary excess c. lingual
seeking orthodontic treatment should be d. all of the above d. none of the above
noted and documented _________.
a. in the chart in the clinician’s words 13. The width of the maxillary central 23. In a skeletal deep-bite patient, the
b. in a separate file in the clinician’s words incisor should ideally be ________ of its posterior teeth are usually ________.
c. in a separate file in the patient’s own words height. a. over-erupted
d. in the chart in the patient’s own words a. 60% b. under-erupted
b. 70% c. early to erupt
3. If the patient is attending the appointment d. late to erupt
c. 88%
with one or both parents/guardians, it is
________ to first address the patient and
d. 90% 24. _________constitutes the minimum
determine his or her chief concern prior to 14. The ¾ view _________. orthodontic record needed.
a. best aids assessment of the relative projections of a. Dental casts
addressing the accompanying party. b. A panoramic X-ray with appropriate supplemental
a. sometimes a good idea the upper and lower jaw
b. must be performed with the patient positioned at a periapicals
b. always a good idea
45-degree angle c. A facial form analysis
c. never a good idea
c. gives an impression of the depth of the face d. all of the above
d. not necessary
4. It is important to know whether _______
d. all of the above 25. Space required is measured by estimat-
recognizes the need for treatment. 15. ________ explains the situation where ing the size of the ________ and compar-
a. the patient himself or herself the incisors are protruded beyond their ing that to the size of the ________.
b. the parent or guardian normal inclination, while the jaws are in a. erupted permanent teeth; unerupted permanent
c. friends teeth
their normal position. b. erupted permanent teeth; erupted primary teeth
d. all of the above a. Maxillary dentoalveolar protrusion c. unerupted permanent teeth; erupted primary teeth
5. ________ can impact orthodontic b. Maxillary dentoalveolar retrusion d. all of the above
treatment by resulting in very slow c. Bimaxillary dentoalveolar protrusion
orthodontic movement. d. Bimaxillary dentoalveolar retrusion 26. The _________ analysis identifies any
a. The use of antihistamines discrepancy between the sizes of the upper
16. If the incisors are protruded in the
b. The use of bisphosphonates teeth and those of the lower teeth.
absence of lip strain, retraction of the a. Munsell
c. Uncontrolled diabetes
incisors has _________. b. Morton
d. all of the above
a. little effect on lip function but a great effect on c. Boston
6. Chronic use of ________ may interfere prominence d. Bolton
with orthodontic tooth movement. b. a prominent effect on lip function
a. high-dose prostaglandins c. little effect on lip function or prominence 27. In a Class I molar relationship, the
b. low-dose prostaglandins d. none of the above mesiobuccal cusp of the upper first molar
c. high-dose prostaglandin inhibitors fits in the buccal groove of the _________,
d. low-dose prostaglandin inhibitors 17. American Indians and Asians present with teeth on the line of occlusion.
with _________while Northern Europeans a. lower second molar
7. Chronological age ________. typically present with _________.
a. always coincides with skeletal or dental age b. lower second bicuspid
a. anteriorly divergent faces; posterior divergence c. lower first molar
b. always coincides with skeletal age b. medially divergent faces; posterior divergence
c. always coincides with dental age d. any of the above
c. posteriorly divergent faces; anterior divergence
d. does not always coincide with skeletal or dental age 28. The ________ analysis has been the most
d. anteriorly divergent faces; distal divergence
8. Serial ________ are the best way to widely used cephalometric analysis to date.
18. Patients who are brachyfacial usually a. Stettler
determine whether growth has stopped or
have _________ . b. Steiner
is still ongoing. a. steep plane angles and overjet malocclusions
a. periapical X-rays c. Scheiner
b. occlusal X-rays b. flat plane angles and overjet malocclusions d. Steiger
c. flat plane angles and deep bite malocclusions
c. cephalometric X-rays
d. steep plane angles and deep bite malocclusions
29. Posterior crowding can be readily viewed
d. panoramic X-rays on a panoramic radiograph and must be
9. The facial analysis is conducted with the 19. _________ can have a direct effect on the confirmed with additional data from the
patient ________. prognosis of orthodontic treatment. _________.
a. sitting upright a. Digit sucking a. occlusal casts and extraoral examination
b. standing b. Object sucking b. occlusal casts and intraoral examination
c. reclining in a chair c. Tongue thrust c. occlusal casts and films
d. a or b d. all of the above d. all of the above
10. The three characteristic categories of 20. The most important indicator of joint 30. The overall step involved in orthodontic
facial type are ________. function is the amount of _________. diagnosis is the _________.
a. dolichofacial, mesofacial and brachyfacial a. maximum protrusion a. patient interview/consultation
b. mesotheliofacial, distofacial and brachyfacial b. maximum retrusion b. use of diagnostic records
c. mesiocclusal, distobuccal and brachyfacial c. maximum opening c. clinical examination
d. none of the above d. maximum overbite d. all of the above

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Orthodontic Diagnosis
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2. List and describe the steps involved in the extraoral examination of patients presenting for orthodontic diagnosis
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