Analysis of Diagnostic Records

Dr Mehreen
Senior dental surgeon
 Learning Objective
• Symmetry/asymmetry
• Space analysis
– Principles of space analysis
• Assumptions
– Methods
– Steps
– Estimating size of unerupted teeth
• Tanaka and Johnston
• combination
– Tooth size analysis (Bolton)
 Symmetry.
• An asymmetric position of an entire arch
should have been detected already in the
facial and esthetic examination,
• but an asymmetry of arch form may be
present even if the face looks symmetric.
• Evaluating dental casts from the occlusal view
when the cast bases have been trimmed
symmetrically can make it easier to see a
distortion of arch form.
• Asymmetry within the dental arch but with a
symmetric arch form also can occur. This is
due either to severe crowding or spacing or to
drift of anterior or posterior teeth on one side
of the arch.
• The primary cause of drift is premature loss of
a primary canine followed by lateral
movement of the incisors, or premature loss
of a primary molar on one side and movement
of both anterior and posterior teeth. The ruled
grid also helps in seeing where drift of teeth
has occurred
 Alignment, Crowding, and Spacing :
Space Analysis
• It is important to quantify the amount of
space available for alignment of the teeth
within the dental arches because treatment
varies depending on whether the space is
adequate, deficient, or excessive
 Principles of Space Analysis
• Space analysis requires a comparison between
the amount of space available for the
alignment of the teeth and the amount of
space required to align them properly in the
dental arches .
• The analysis can be done either manually on
plaster dental casts or with a computer system
by using virtual digital casts
 Steps
• Whether the space analysis is done manually
or virtually, the first step is calculation of
space available.
• This is accomplished by measuring arch
perimeter from the mesial of one first molar
to the other, over the contact points of
posterior teeth and the incisal edge of the
anteriors.
 Methods
• There are two basic ways to accomplish this
manually:
• (1) by dividing the dental arch into segments
that can be measured as straight-line
approximations of the arch
• (2) by contouring a piece of wire (or a curved
line on the computer screen) to the line of
occlusion and then straightening it out for
measurement.
• The second step is to calculate the amount of
space required for alignment of the teeth.
• This is done by measuring the mesiodistal
width of each erupted tooth from contact
point to contact point, estimating the size of
unerupted permanent teeth, and then
summing the widths of the individual teeth
• If the sum of the widths of the permanent
teeth is greater than the amount of space
available, there is a space deficiency and
crowding would occur. If available space is
larger than the space required (excess space),
gaps between some teeth would be expected.
 Assumptions
• Space analysis carried out in this way is based on three
important assumptions:
(1) The anteroposterior position of the incisors is correct
(i.e., the incisors are neither excessively protrusive nor
retrusive),
(2) the space available will not change because of growth
and dental compensatory tipping, and
(3) all the teeth are present and reasonably normal in
size.
None of these assumptions can be taken for granted. All
of them must be kept in mind when space analysis is
done
 First assumption
• With regard to the first assumption, it must be
remembered that incisor protrusion is
relatively common and that retrusion, though
uncommon, does occur.
• There is an interaction between crowding of
the teeth and protrusion or retrusion: if the
incisors are positioned lingually (retruded),
this accentuates any crowding; but if the
incisors protrude, the potential crowding will
not be fully expressed.
• Crowding and protrusion are really different
aspects of the same phenomenon. If there is
not enough room to properly align the teeth,
the result can be crowding, protrusion, or
(most likely) some combination of the two.
• For this reason, information about how much
the incisors protrude must be available from
clinical examination to evaluate the results of
space analysis. This information comes from
facial form analysis (or from cephalometric
analysis, if available)
• The second assumption, that space available
will not change during growth, is valid for
most but not all children. In a child with a
well-proportioned face, there is little or no
tendency for the dentition to be displaced
relative to the jaw during growth, but the
teeth often shift anteriorly or posteriorly in a
child with a jaw discrepancy.
• For this reason, space analysis is less accurate
and less useful for children with skeletal
problems (Class II, Class III, long face, short
face) than in those with good facial
proportions
• Even in children with well-proportioned faces,
the position of the permanent molars changes
when primary molars are replaced by the
premolars .If space analysis is done in the
mixed dentition and depending on the molar
relationships, it may be necessary to adjust
the space available measurement to reflect
the shift in molar position that can be
anticipated.
• The third assumption can be checked by
clinical and radiographic examination, looking
at the teeth as a set rather than as individual
units. Anomalies in tooth size have significant
implications for space in the dental arches
• Variation in the width of the upper lateral
incisors or an anomaly of their size (enlarged,
diminutive, or peg-shaped) is the most
common cause, but variations in the size of
premolars or other teeth may be present.
Occasionally, all the upper teeth will be too
large or too small to fit properly with the
lower teeth.
 Others methods
• Carey’s analysis
• Ashley Howe’sanalysis
• Ponts analysis
• Boltons analysis
 Tooth size analysis,Boltan analysis
• For good occlusion, the upper and lower teeth
must be proportional in size. If large upper
teeth are combined with small lower teeth, as
in a denture set-up with mismatched sizes,
there is no way to achieve ideal occlusion
• Although the natural teeth match very well in
most individuals, approximately 5% of the
population have some degree of disproportion
among the sizes of individual teeth. This is
termed tooth size discrepancy
• Bolton analysis is carried out by measuring the
mesiodistal width of each permanent tooth. A
standard table is then used to compare the
summed widths of the maxillary to the
mandibular anterior teeth (canine to canine)
and the total width of all upper to lower teeth
(excluding second and third molars).
 Measurements
• Sum of mandibular 12.
• Sum of maxillary 12.
• Sum of mandibular 6.
• Sum of maxillary 6.
• Overall Ratio.
• Anterior Ratio.
Mixed dentition space analysis
 Estimating the Size of Unerupted
Permanent Teeth
• In adolescents and adults, the amount of
available space and the amount required to
align all the teeth can be measured directly,
but in the mixed dentition there is a difference
between the apparent crowding at one point
in time and the true ultimate crowding after
the transition from the mixed to permanent
dentition.
 AIM OF MIXED DENTITION ANALYSIS
• To evaluate the amount of space available in
the arch for succeeding permanent teeth and
necessary occlusal adjustment.
• Determine whether the dental arch will
accommodate the permanent teeth or not.
 CLASSIFICATION
• RADIOGRAPHIC
– Nance analysis,
– Huckaba’s
• NONRADIOGRAPHIC SPACE ANALYSIS
– Moyer’s
– Tanaka Johnston
• COMBINATION OF RADIOGRAPHS &
PREDICTION CHARTS
– Hixon and Old father
– Staley kerber-combination
 Nance method
Material used
• Sharp divider
• Set of periapical films
• Millimeter ruler
• Brass wire 0.026 inch
• Set of study models
 PROCEDURE
• Actual width of four mandibular incisors
measured on the cast.
• The width of unerupted canine,premolars is
measured from the radiograph.
• In case one of the premolar is rotated,the
width of the premolar on the opposite side
may be used.
• The total value indicates
the amount of the space
needed to accommodate
all the permanent teeth
anterior to first
permanent molar.
• The space available for
the permanent teeth is
determined with a brass
wire passing over the
buccal cusp and incisal
edges of teeth from first
molar to first molar.
• From the measurement of the arch length in
mixed dentition we subtract:
• Lower arch -3.4 mm ( 1.7mm x2 )
• upper arch -1.8 mm ( 0.9mm x2 )
• Substract 3.4mm (in mandibular arch) and
1.8mm (in maxillary arch)from the total space
available to accommodate a decrease in the
arch length as a result of the mesial drift (late
mesial shift-leeway’s space) of the permanent
first molars.
• Space available- space required = amount of
discrepancy
ADVANTAGES :
• It results in minimal errors
• It can be performed with reliability
• It allows analysis of both arches
LIMITATION :
• It is time consuming
• Complete mouth radiograph is needed
 Hukaba’s method
• Hukaba’s mixed dentition analysis,
Principle-If we measure an object,which can be
seen both in the radiograph as well as on a
cast, then we can compensate for the
enlargement of the radiographic image.
The amount of distortion can be calculated and
the correct mesiodistal width of the crown of
the unerupted tooth can be calculated by
using the formula:
X1/X2=Y1/Y2
• X1=width of the unerupted tooth whose width
is to be determined
• X2=width of the unerupted tooth on the
radiograph
• Y1=width of erupted tooth as measured on
the cast
• Y2=width of erupted tooth as measured on a
radiograph
Advantage:
• Very easy,practical and relatively accurate
method.
• Not require any prediction table.
• Can be used in maxillary and mandibular arches.
Disadvantage:
• Inherent distortion of radiographic image causes
error
 3 :MOYER’S MIXED DENTITION
ANALYSIS
• Basis- high co relation among groups of teeth ,
thus measuring one group of teeth, prediction
of size of other group of teeth can be done.
• Armamentarium-:
• 1. Dental cast
• 2. Boley’s guage
• 3. Probability chart
• Measure the greatest mesiodistal widths of
each of four permanent mandibular incisors .
The mandibular incisors have been chosen for
measuring,since
• a) they are erupted into the mouth early in
the mixed dentition,
• b) are easily measured accurately, and
• c) are directly in the midst of most space
management problems.
The maxillary incisors are not used in any of the
predictive procedures, since
• i. they show too much variability in size
(especially max. lat incisor),
• ii. their correlations with other groups of
teeth are,of lower predictive value.
• Therefore, the lower incisors are measured to
predict the size of upper as well as lower
posterior teeth
• Total the M-D widths of mandibular incisors.
• Using prediction chart for space available in
mandibular arch,locate the value closest to
the sum of four mandibular incisors.
• On the study cast, determine and mark the
midline of mandibular arch.
• Total the M-D widths of right mandibular
incisors & set the boley’s gauge to this value..
• Measure from midline to right side. Place one
point of the gauge at the midline between the
central incisor and let the other end lie along
the line of the dental arch on the right side.
• Mark on the point where the precise point
where the distal tip of boley’s gauge touched.
• Repeat for the left side
• Measure the distance between the point
marked on the cast to the mesial surface of
permanent 1st molar
• Record that value and calculate the difference
• Repeat the process on the maxillary arch.
Compute the amount of space available.
Measure the distance from the point marked
on the cast to mesial surface of the 1st molar,
and calculate space difference
 Merit
• Minimal systematic error and the range of such
error is known.
• It can be done with equal reliability by the
beginner and the expert, as it does not pressure
sophisticated clinical judgement.
• It is not time consuming.
• It requires no special equipment or radiographic
projections.
• Although best done on dental casts, it can be
done with reasonable accuracy in the mouth.
• It can be used for both dental arches.
 Demerit
• Moyer’s Mixed Dentition Analysis over
predicts the tooth size of the unerupted
canines and premolars, hence it may convert a
borderline case into an extraction case.
 Limitation
• Moyer’s analysis is probability analysis.
• It does not account for tipping of mandibular incisor
either lingually or facially.
• Moyers advised caution in using any analysis, as none
was able to compensate for the biological variation in
individuals during the transition from primary to
permanent dentition
• Moyers equation does not mention the population
group from which they were calculated
• Moyer’s method of prediction may have population
variations. For one to be sure of the accuracy while
using Moyer’s method it may be safer to develop
prediction tables for specific populations. Thus Moyer’s
method cannot universally be applied.
TANAKA AND JOHNSION METHOD
• Tanaka and Johnson developed another way
to use the width of the lower incisors to
predict the sizes of the unerupted canines and
premolars.
• This method has good accuracy despite a
small bias toward overestimating the size of
unerupted tooth
• Tanaka and Johnston developed a simple
variation of the proportionality method, using
a single equation and the width of the lower
incisors to predict the size of unerupted
canines and premolars.
• For children from a European population
group, the method has good accuracy despite
a small bias toward overestimating the
unerupted tooth sizes
• It requires neither radiographs nor reference
tables (once the equation is memorized),
which makes it very convenient, but two
specific problems now are recognized:
• It tends to overestimate the required space
for Caucasian females in both arches
• and underestimate the space required in the
lower arch for African-American males
• Prediction Values
• One half the mesiodistal width of four lower
incisors + 10.5 = Estimated width of
mandibular canine and premolar in one
quadrant.
• One half the mesiodistal width of Four lower
incisors + 11.0 = Estimated width of maxillary
canine and premolars in one quadrant
• Note that
• (1) a correction for mesial movement of the
lower molars following the exchange of the
dentition is included,
• (2) the Tanaka-Johnston method for predicting
the size of unerupted canines and premolars is
used, and
• (3) the result from facial form analysis is
requested to check for appropriateness of the
analysis and for interpretation of the results
Advantages
• Technique involves simple, easily repeated
procedure with minimum material
requirement
• Prediction chart and radiograph is not
required
Limitations
• Error in predicted size if patients are not from
North western European descent.
• Which of these methods is best for an
individual patient depends on the
circumstances.
• The prediction tables work surprisingly well
when applied to the population group from
which they were developed: white school
children of northern European descent.
• On balance, the Tanaka-Johnston method
probably is most practical for manual
calculation because no radiographs are
required and the simple ratio can be printed
right on the space analysis form or
memorized, so no reference tables must be
consulted
A screen capture from a commercial
computer analysis
• Computer analysis is faster and easier, but it is
important to remember that its accuracy will
depend on the accuracy of the digitized input
and how well the patient meets the
assumptions that underlie a correlation
approach
• One advantage of measuring individual tooth
widths into a computer template during space
analysis is that the computer then can quickly
provide individual tooth and interarch and
intra-arch measurements, and the computer
can calculate a tooth size analysis
 Quick Check
• A quick check for anterior tooth size
discrepancy can be done by comparing the
size of upper and lower lateral incisors. Unless
the upper laterals are wider, a discrepancy
almost surely exists.
• A quick check for posterior tooth size
discrepancy is to compare the size of upper
and lower second premolars, which should be
about equal size. A tooth size discrepancy of
less than 1.5 mm is rarely significant, but
larger discrepancies create treatment
problems in achieving ideal interdigitation,
overjet and overbite, and must be included in
the orthodontic problem list.
• The space analysis results must be considered
in the context of the profile because reducing
protrusion reduces the amount of available
space. Conversely, when teeth are retroclined
and then moved facially to the correct
position, more space is available.
• The vertical dimension also has an impact on
space. It is generally contraindicated to
expand when there is limited overbite
because tipping teeth facially usually moves
them vertically as well and an anterior open
bite may develop. In a child with a deep
overbite and an accentuated curve of Spee,
leveling the arch will make teeth more
protrusive