Download examination in orthodontic

EXAMINATION IN
ORTHODONTICS
For orthodontic purposes, the informations
needed to find out the diagnosis are derived
from three major sources:
1. questions of the patient (written and oral)
2. clinical examination of the patient
3. evaluation of diagnostic records,
including dental casts, radiographs and
photographs. .
Interview
The first step in the interview process should be to
establish the patient's chief complaint (major
reason for seeking consultation and treatment),
usually by a direct question to the patient or
parent.
Further information should be sought in three major
areas:
1. medical and dental history
2. physical growth status
3. motivation, expectations, and other
sociobehavioral factors
Chief Complaint
There are three major reasons for patient concern
about the alignment and occlusion of the teeth:
1. impaired dentofacial esthetics that can lead to
psychosocial problems
2. impaired function, and
3. desire to enhance dentofacial esthetics and
thereby the quality of life
It is important to establish their relative importance to
the patient
Medical and Dental History
A careful medical and dental history is
needed for orthodontic patients both
• to provide a proper background for
understanding the patient's overall
situation and
• to evaluate specific orthodontically
related concerns
Medical and Dental History
Orthodontic problems are almost always
the culmination of a developmental
process, not the result of a pathologic
process.
It is often difficult to be certain of the
etiology, but it is important to establish the
cause of malocclusion if this can be done,
and at least to rule out some of the
possible causes.
Medical and Dental History
• A growth deficit related to an old condylar injury
is the most probable cause of facial asymmetry.
It has become apparent in recent years that
early fractures of the condylar neck of the
mandible occur more frequently than was
previously thought . A mandibular fracture in a
child often is overlooked in the aftermath of an
accident that caused other trauma, so a jaw
injury may not have been diagnosed at the time.
• Although old jaw fractures have particular
significance, trauma to the teeth may also
affect the development of the occlusion and
should not be overlooked.
Medical and Dental History
•
It is important to note whether the patient is
on long-term medication of any type, and if so,
for what purpose.
This may reveal systemic disease or metabolic
problems that the patient did not report in any
other way.
• Chronic medical problems in adults or children
do not contraindicate orthodontic treatment
if the medical problem is under control, but
special precautions may be necessary if
orthodontic treatment is to be carried out.
Physical Growth Evaluation
This is important for a number of reasons:
• rapid growth during the adolescent growth
spurt facilitates tooth movement
• but growth modification may not be
possible in a child who is beyond the peak
of the growth spurt.
• the combined surgical – orthodontic
treatment is planed in pacients after growth
has stopped.
Physical Growth Evaluation
• questions about how rapidly the child has
grown recently, whether clothes sizes have
changed and whether there are signs of
sexual maturation
• recording height and weight changes in the
dental office
• calculation of bone age from the vertebrae
as seen in a cephalometric radiograph
• hand-wrist radiographs are an alternative
method for evaluating skeletal maturity
• serial cephalometric radiographs
Social and Behavioral Evaluation
Social and behavioral evaluation should
explore several related areas:
• the patient's motivation for treatment
• what he or she expects as a result of
treatment
• and how cooperative or uncooperative
the patient is likely to be.
Social and Behavioral Evaluation
• Motivation can be classified as external or internal
• External motivation is that supplied by pressure from
another individual, as with a child who is being brought for
orthodontic treatment by mother or an older patient who is
seeking alignment of incisor teeth because her boyfriend (or
his girlfriend) wants the teeth to look better.
• Internal motivation comes from within the individual and is
based on his or her own assessment of the situation and
desire for treatment. Self-motivation for treatment often
develops at adolescence.
• Nevertheless, even in a child it is important for a patient to
have a component of internal motivation. Cooperation is
likely to be much better if the child genuinely wants treatment
for himself or herself, rather than just putting up with it to
please a parent.
Clinical Evaluation
There are two goals of the orthodontic clinical
examination:
1. to evaluate and document oral health, jaw
function,facial proportions and smile
characteristics; and
2. to decide which diagnostic records are
required.
The clinical examination can be devided to:
– Morphological (extraoral and intraoral)
– Functional
Extraoral examination
• Facial Proportions: Macro-Esthetics
The first step in evaluating facial proportions is to
take a good look at the patient, examining him or
her for developmental characteristics and a
general impression
• Assessment of Developmental Age
The degree of physical development is much
more important than chronologic age in
determining how much growth remains.
Extraoral examination
• Facial Esthetics versus Facial Proportions
Whether a face is considered beautiful is greatly
affected by cultural and ethnic factors, but
whatever the culture, a disproportionate face
becomes a psychosocial problem.
Distorted and asymmetric facial features are a
major contributor to facial esthetic problems,
whereas proportionate features are
acceptable if not always beautiful.
An appropriate goal for the facial examination
therefore is to detect disproportions
Extraoral examination
• Frontal Examination
The first step in analyzing facial proportions is to
examine the face in frontal view.
Low set ears, or eyes that are unusually far apart
(hypertelorism) may indicate either the presence
of a syndrome or a microform of a
craniofacial anomaly. If a syndrome is
suspected, the patient's hands should be
examined for syndactyly, since there are
anumber of dental-digital syndromes.
Extraoral examination
• In the frontal view, one looks for bilateral symmetry and for
proportionality of the widths of the eyes/nose/mouth. A small degree of
bilateral facial asymmetry exists in essentially all normal individuals. This
can be seen most readily by comparing the real full face photograph with
composites consisting of two right or two left sides.
• This "normal asymmetry," which usually results from a small size
difference between the two sides, should be distinguished from a severe
disproportion and esthetic problems.
Extraoral examination
The proportional relationship of facial height to
width (the facial index), more than the
absolute value of either, establishes the facial
type and the basic proportions of the face.
Index Measurements Male
Female
Facial n-gn/zy-zy
88.5 (5.1) 86.2 (4.6)
Extraoral examination
• Finally, the face in frontal
view should be examined
from the perspective of the
vertical facial thirds the
distance from the hairline to
the base of the nose, base
of nose to bottom of nose,
and nose to chin should be
the same.
• Farkas' studies show that in
modern Caucasians of
European descent, the
lower third is very slightly
longer
Extraoral examination
•
Profile Analysis
There are three goals of facial profile analysis:
1. Establishing whether the jaws are
proportionately positioned in the
anteroposterior plane of space.
2. Evaluation of lip posture and incisor
prominence
3. Re-evaluation of vertical facial proportions
Extraoral examination
1. Establishing whether the
jaws are proportionately
positioned in the
anteroposterior plane of
space.
This step requires placing
the patient in the natural
head position. With the
head in this position, note
the relationship between
two lines:
• one dropped from the
bridge of the nose to the
base of the upper lip, and
• a second one extending
from that point downward to
the chin
Extraoral examination
These line segments should form a nearly straight line.
An angle between them indicates either profile convexity
(upper jaw prominent relative to chin) or profile concavity
(upper jaw behind chin).
A convex profile therefore indicates a skeletal Class II jaw
relationship, whereas a concave profile indicates a skeletal
Class III jaw relationship
Extraoral examination
2. Evaluation of lip posture and incisor prominence
Determining how much incisor prominence is too much can be difficult but is
simplified by understanding the relationship between lip posture and the
position of the incisors.
The teeth protrude excessively if (and only if) two conditions are met:
(1) the lips are prominent and everted, and
(2) the lips are separated at rest by more than 3 to 4mm (which is
sometimes termed lip incompetence), so that the patient must strain to
bring the lips together over the protruding teeth.
Extraoral examination
3. Re-evaluation of
vertical facial
proportions, and
evaluation of
mandibular plane angle.
Vertical proportions can be
observed during the full
face examination but
sometimes can be seen
more clearly in profile.
Intraoral examination
• Evaluation of Oral Health
The health of oral hard and soft tissues must be
assessed for potential orthodontic patients as for
any other.
The general guideline is that any problems of
disease or pathology must be under control
before orthodontic treatment of developmental
problems begins. This includes:
• medical problems
• dental caries or pulpal pathology
• periodontal disease
Intraoral examination
It sounds trivial to say that the dentist should not overlook
the number of teeth that are present or forming - and yet
almost every dentist, concentrating on details rather than the
big picture, has done just that on some occasion. It is
particularly easy to fail to notice a missing or supernumerary
lower incisor.
At some point in the evaluation, count the teeth to be sure
they are all there.
In mixed dentition the orthopantomogram is necesary to
see:
• if all permanent teeth are present
• their position
• stage of development and
• order of eruption.
Intraoral examination
In the periodontal evaluation, there are two major points of
interest:
• indications of active periodontal disease and
• potential or actual mucogingival problems
Any orthodontic examination should include gentle probing
through the gingival sulci to detect any areas of bleeding.
Bleeding on probing indicates active disease, which must be
brought under control before other treatment is undertaken.
Fortunately, aggressive juvenile periodontitis occurs
rarely, but if it is present, it is critically important to note this
before orthodontic treatment begins.
Inadequate attached gingiva around crowded incisors
indicates the possibility of tissue dehiscence developing
when the teeth are aligned, especially with nonextraction
(arch expansion) treatment.
Insertion of the frenulum labii sup. and inferior should be
evaluated.
Intraoral examination
The evaluation of the malocclusion :
• Angle´s classification
• malposition of individual teeth
• overjet
• ovebite
• examination of symmetry, in which it is
particularly important to note the
relationship of the dental midline of each
arch to the skeletal midline of that jaw
Intraoral examination
Evaluation of Jaw and Occlusal Function
Three aspects of function require evaluation:
1. mastication (including but not limited to
swallowing),
2. speech, and
3. the presence or absence of
temporomandibular (TM) joint
problems.
Intraoral examination
Patients with severe malocclusion often have
difficulty in normal mastication, not so much in
being able to chew their food (though this may
take extra effort) but in being able to do so in a
socially acceptable manner.
These individuals often have learned to avoid
certain foods that are hard to incise and chew, and
may have problems with cheek and lip biting
during mastication.
Unfortunately, there are no reasonable diagnostic
tests to evaluate masticatory efficiency, so it is
difficult to quantify the degree of masticatory
handicap and difficult to document functional
improvement.
Intraoral examination
It has been suggested that lip and tongue lip
incompetence - lips that are separated when
they are relaxed, so that the patient must strain
to bring the lips together over the protruding
teeth may indicate problems in normal
swallowing, but there is no evidence to support
this contention.
In the case of anterior open bite or big overjet the
adaptive type of swalloving may be present.
Intraoral examination
Speech problems can be related to malocclusion,
but normal speech is possible in the presence of
severe anatomic distortions.
Speech difficulties in a child, therefore, are unlikely to
be solved by orthodontic treatment.
If a child has a speech problem and the type of
malocclusion related to it, a combination of
speech therapy and orthodontics may help.
If the speech problem is not listed as related to
malocclusion, orthodontic treatment may be
valuable in its own right but is unlikely to have any
impact on speech
Intraoral examination
Evaluation of the TM joints is an important aspect of the
diagnostic workup.
As a general guideline, if the mandible moves normally, its
function is not severely impaired, and by the same token,
restricted movement usually indicates a functional problem.
For that reason, the most important single indicator of
joint function is the amount of maximum opening.
Palpating the muscles of mastication and TM joints
should be a routine part of any dental examination.
It is important to note any signs of TM joint problems such as
joint pain, noise, or limitation of opening.
The path of closure, espetialy the final part must be
examined and any occlusal interferences with functional
mandibular movements recorded.
Orthodontic diagnostic records
Orthodontic diagnostic records are taken for two
purposes:
• to document the starting point for treatment
• and to add to the information gathered on
clinical examination
It is important to remember that the records are
supplements to, not replacements for, the most
important source of information for clinical
diagnoses, the clinical examination.
Orthodontic diagnostic records
Orthodontic records fall into three major
categories.
Those for evaluation of the:
1. health of the teeth and oral structures
2. alignment and occlusal relationships
of the teeth
3. facial and jaw proportions
Orthodontic diagnostic records
A panoramic radiograph is valuable for orthodontic
evaluation at most ages. The panoramic image has
two significant advantages over a series of intraoral
radiographs:
• it yields a broader view and thus is more likely to
show any pathologic lesions and supernumerary or
impacted teeth and
• the radiation exposure is much lower
It also gives a view of the mandibular condyles,
which can be helpful as a screening image to
determine if other TM joint radiographs are needed.
The panoramic radiograph should be supplemented
with periapical and bitewing radiographs only
when greater detail is required.
Orthodontic diagnostic records
A cephalometric radiograph is important in
evaluation of the skeletal and dental relationship.
Radiographs of the temporomandibular joint
should be reserved for patients who have
symptoms of dysfunction of that joint that may be
related to internal joint pathology.
Evaluation of the occlusion requires impressions for
dental casts and a record of the occlusion.
The rutine examination involves also the intraoral
and extraoral photographs.