Download examination of the patient

EXAMINATION OF THE PATIENT
For orthodontic purposes, the informations needed to find out thediagnosis 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.
Since all possible diagnostic records will not be obtained for all patients, one of the goals of
clinical examination is to determine what additional information is required.
Questionnaire/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:
 impaired dentofacial esthetics that can lead to psychosocial problems
 impaired function, and
 desire to enhance dentofacial esthetics and thereby the quality of life.
Although more than one of these reasons often may contribute to seeking orthodontic
treatment, it is important to establish their relative importance to the patient. At this
stage the objective is to find out what is important to the patient.
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.
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.
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.
Second, 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. For example, orthodontic
treatment would be possible in a patient with controlled diabetes but would require
especially careful monitoring, since the periodontal breakdown that could accompany
loss of control might be accentuated by orthodontic forces. In adults being treated for
arthritis or osteoporosis, high doses of prostaglandin inhibitors or resorption-inhibiting
agents may impede orthodontic tooth movement.
Physical Growth Evaluation
A second major area that should be explored by questions to the patient or parents is
the individual's physical growth status. 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.
On the other hand, the combined surgical – orthodontic treatment is planed in pacients
after growth has stopped.
For normal youths who are approaching puberty, questions about how rapidly the child
has grown recently, whether clothes sizes have changed and whether there are signs of
sexual maturation usually provide the necessary information about where the child is on
the growth curve
Recording height and weight changes in the dental office provides important insight
into growth status.
Occasionally, a more precise assessment of whether a child has reached the
adolescent growth spurt is needed, and calculation of bone age from the vertebrae as
seen in a cephalometric radiograph can be helpful. Hand-wrist radiographs are an
alternative method for evaluating skeletal maturity, but these also are not an acceptably
accurate way to determine when growth is completed. Serial cephalometric radiographs
offer the most accurate way to determine whether growth has stopped or is continuing.
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.
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, on the other hand, 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.
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
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 a
number of dental-digital syndromes.
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 chin or nose that deviates to one side, which
can produce severe disproportion and esthetic problems.
The proportional relationship of facial height to width (the facial index), more than the
absolute value of either, establishes the overall facial type.
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.
Profile Analysis
There are three goals of facial profile analysis, approached in three clear and distinct
steps. These are:
1. Establishing whether the jaws are proportionately positioned in the
anteroposterior plane of space.
This step requires placing the patient in the physiologic 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. 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.
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:
 the lips are prominent and everted, and
 the lips are separated at rest by more than 3 to 4mm (which is sometimes termed
lip incompetence).
3. Re-evaluation of vertical facial proportions
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, and
periodontal disease.
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.
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,
not to establish pocket depths but 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.
The next step is 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
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.
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 almost 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.
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.
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
Jaw function is more than TM joint function, but 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, and 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 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 records fall into three major categories: those for evaluation of the:
 health of the teeth and oral structures
 alignment and occlusal relationships of the teeth
 facial and jaw proportions
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.
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 so that the casts or images can be related to each other.
The rutine examination involves also the intraoral and extraoral photographs.