Post on 08-Jan-2017
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Orthodontic diagnosisIn an orthodontic context, it is important not to characterize the dental
occlusion while overlooking a jaw discrepancy, developmental syndrome, systemic
disease, periodontal problem, psychosocial problem or the cultural milieu in which the
patient is living.
For orthodontic purposes, the database may be thought of as derived from
three major sources: (1) questions of the patient (written and oral), (2) clinical
examination of the patient, and (3) evaluation of diagnostic records, including dental
casts, radiographs and photographs.
Personal details:
The clinical examination starts with asking the patient about his
name ,age ,address ,phone number ,and by whom he was referred . From this fist
contact with the patient we can discover any defect in the patients pronunciation and
to take a good impression about the mentality.
Name:
The patient’s name should be recorded for the purpose of communication
and identification. Addressing a patient by his or her name has a beneficial
psychological effect. It makes the patient more comfortable and arouses a feeling
of familiarity.
Age:
The age of the patient helps in diagnosis, treatment planning and growth
prediction.
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رؤوف. دطعمة
There are certain transient conditions that occur during development are
considered normal for that age.
A brief examination of the developing occlusion should be carried out around 7-8
years to check the presence of permanent teeth, their position, and to detect any
problem which may affect the normal eruption .
In addition ,there are certain treatment modalities that are best carried out during
growing age, like- growth modification using functional and orthopedic appliances.
Surgical corrective procedures are best carried out after the cessation of the
growth.
The patients age is the most important factor in orthodontic treatment planning :
1. If the patient age is one day
what type of dental or orthodontic treatment can be done?
In such age the patient may have either :
a cleft lip and palate which can be treated via the construction of feeding plate
to separate the nasal cavity from the oral cavity and to prevent the suffocation
during feeding process.
Or the patient may have a natal or neonatal teeth which is better to be left
without treatment unless it cause severe trauma to the mother during the
feeding process so in this case it is better to be trimmed or extracted at this age.
2. If the patient age is four years :
the most important treatment in this age is the interceptive treatment which
include filling of the carious teeth especially CLII carious lesions in order to
maintain the space available for the erupting permanent teeth.
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The presence of premature contact should be treated because it can lead to the
development of anterior or posterior cross-bite with a functional shift or a
mandibular displacement that should be corrected as soon as possible to
prevent the development of skeletal problems.
A skeletal CLIII with that can be observed by the presence of negative over-jet
or mandibular prognathism can be treated at this age by the use of chin cap to
retard and redirect the mandibular growth.
3. If the patient age is 8 years:
Interceptive treatment
Correction of cross-bite
Serial extraction which is started at the early mixed dentition to relief the
incisor crowding and facilitate the eruption of the canine
Skeletal CLII due to maxilla?
Skeletal CLIII due to maxilla or mandible?
Supernumerary teeth which can be checked by taking a radiograph (OPG or
peri-apical) and these teeth should be removed as it may interfere with the
eruption of incisors.
4. If the age is 15 years :
All the permanent teeth were erupted, except the third molar, in this period of
age, it is difficult I or not wise to use " the serial extraction " or " the functional
appliances " since the patient passed the maximum growth spurt , So ; The
question is : What we can do for this patient ???... Fixed orthodontic appliances
usually used in cases ' that require rotation of (90'')) , impaction , true intrusion ,
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extrusion , bodily movement , uprightening and tourqing, also removable
appliance can be used when the case require tipping movement , minor
rotation, anterior or posterior dental cross bite.
Race:
Also the race of the patient is very important ?
For a negroid pt. with bimaxillary dentoalveolar protrusion and competent lips
there will be no need for orthodontic treatment as this malocclusion is related to a
genetic factor and there will be little or no change in the pt. esthetic in addition to that
the case is susceptible to relapse.
Address and contact number:
It can affect the spring design for example if you have a patient living in a far
distance away from your clinic so the active components of the appliance should be
from the supported types like sleeved “supported” buccal canine retractor or
modified finger spring which need activation every 3-4 weeks rather than the simple
types which need activation every 2-3 weeks.
Social and Behavioral Evaluation(Referred by):
It should explore – patient’s motivation for treatment, what he or she expects
as a result of treatment and how co-operative or un co-operative the patient is.
Motivation can be external or internal.
External motivation is that’ supplied by pressure from another individual, like child
brought for treatment by mother; older patient by his girlfriend. Internal motivation
comes from within the individual and is based upon his or her own assessment of the
situation and desire for the treatment .
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For a patient with a thumb sucking habit it is better to use fixed habit breaker which
contain palatal cribs but if the patient was cooperative it is better to be use a
removable one which is easier to be constructed and cleaned.
What patient expects from the treatment should be explored carefully especially in
case of patients with primarily cosmetic problems.
Chief Complaint
The patient’s chief complaint should be recorded in his or her own words. There are
three logical reasons for patient concern about the alignment and occlusion of the
teeth:
1) psychosocial problems
2) impaired function.
3) esthetics.
It is important to establish their relative importance to the patient and their
desires. The parents’ perception of the malocclusion should be noted.
A series of leading questions, beginning with, "Tell me what bothers you about your
face or your teeth," may be necessary to clarify what is important to the patient. The
orthodontist may or may not agree with the patient’s assessment – the judgement
comes later. But, at this stage, it is necessary to find out what is important to the
patient. This will help in setting treatment objectives and satisfying the patient and or
parents in general.
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.
Sleep apnea may be related to mandibular deficiency, and occasionally this functional
problem is the reason for seeking orthodontic consultation. Both the diagnosis and
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management of sleep disorders requires an interdisciplinary team and should not be
attempted without assessment, documentation, and referral from a qualified
physician. Recent research suggests that oral appliances to advance the mandible can
be effective, but only in patients with mild forms of sleep apnea
Medical History
Patients with rheumatic fever, cardiac anomalies, epilepsy, diabetes and blood
dyscrasias may require special precautions.
The medical history should include information on drug usage. The use of certain
drugs like aspirin (prostaglandin inhibitors) or bone resorption inhibiting agents may
impede orthodontic tooth movement . acute, debilitating conditions such as viral
fever should be allowed to recover prior to initiating orthodontic treatment .
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 and now increasingly also in children with
chronic disease treated with drugs (like glucocorticoids) that can be osteotoxic, high
doses of resorption-inhibiting agents, such as bisphosphonates, often are used. This
impedes orthodontic tooth movement and may increase the chance of complications
History of trauma should be noted. Trauma to the jaws or teeth is often overlooked in
child with other trauma, so a jaw injury may not have been diagnosed at that time.
This is significant as it affects the future development of jaws and teeth?
Dental History :
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The patient’s dental history should include information on the age of eruption and
exfoliation of deciduous and permanent teeth, history of extraction, decay,
restorations and trauma.
The past dental history will also help in assessing the patients and parents’ attitude
towards dental health.
History of Habits
History of abnormal habits like finger, digit sucking, nail biting, lip biting grinding,
clenching, and mouth breathing should be taken as they influence the development of
dento-alveolar structures.
Family History
Many malocclusions like skeletal Class II and Class III, crowding ,spacing over-jet , high
frenal attachments and congenital conditions like cleft lip and palate are inherited.
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Clinical examinationThe aim of clinical examination is to evaluate and document the skeletal, facial
and occlusal characteristics in three planes of space in addition to the function of the
teeth ,lips and the tongue.
The causative factor of malocclusion could be
1) Skeletal factor: jaw mal-relation to each other or to one or both of them to the
cranial base in any plane of space.
2) Soft tissue factor
3) Dental factor
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4) Combination of one or more of the above in one or more than one plane of
space
The most important factor of these is the skeletal factor and the orthodontic
treatment should focuses on which factor that cause the malocclusion?
If the cause was skeletal so the treatment would be either orthopedic treatment for
growing pt. or orthognathic surgery for adult pt. depending on the patients age.
Examination of the skeletal relationship:
The pt. should sit in upright position in a comfortable state because tilting the head
upward or downward may increase or decrease the prominence of the chin so the
Frankfort plane should be parallel to the floor and the teeth in maximum
interdigitation because if the pt. posture the mandible forward it will give a false
result. This skeletal examination should be done in three planes of space.
Assessment of Anteropsterior (sagittal) jaws relationship:
Or is it known as the skeletal pattern that can be assessed by one of these methods:
A. Facial profile
The profile is examined from the side by making the patient view at a distant
object, with the FH plane parallel to the floor. The profile is assessed by the angle
of convexity which is formed by the two reference lines:
A line joining the forehead and the soft tissue point A (deepest point in the
curvature of upper lip)
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A line joining point A and the soft tissue pogonion (most anterior point of the
chin) .
Based on the relationship between these two lines, three types of profile exists-
Straight : The two lines form a nearly straight line
Convex : The two lines form an angle with the concavity facing the tissue. It
occurs in cases of prognathic maxilla or retrognathic mandible as seen in Class II
Div I.
Concave : The two reference lines form an angle with the convexity towards the
tissue. This type of profile is seen in Class III patients.
Facial divergence:
It is defined as an anterior or posterior inclination of the lower face relative to the
forehead. Facial divergence is determined by a line drawn from forehead to the
chin -
Anterior divergence : The line is inclined anteriorly .
Posterior divergence : The line is inclined posteriorly.
Straight or orthognathic : The line is perpendicular to the floor ,no slanting.
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B. Palpation method:
by placing index and middle fingers at the approximate A and B points after lip
retraction or directly on the soft tissue A and B. Ideally the maxillary skeletal
base is 2-3mm forward of the mandibular skeletal base when the teeth are in
occlusion.
In skeletal Class II patients, the index finger is anterior to the middle finger
or the hands point upward.
In skeletal Class III patients, the middle finger is anterior to the index finger or
the hands points downwards.
In skeletal Class I patients, the hand is at even level.
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This method does not indicate where is the cause of malocclusion (in maxilla or in
the mandible) , it relates the jaws to each other not to the cranial base.
This method can be done intra-orally or extra-orally but the intra-oral method is
better?
C. Cephlometric analysis:
The skeletal pattern can be assessed by measuring the ANB angle from a lateral
cephalometric radiograph as follow:
If ANB is =2-4 the skeletal pattern is CLI
If ANB is >4 the skeletal pattern is CLII
If ANB is <2 the skeletal pattern is CLIII
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Assessment of vertical jaw relationship:
1. Normally, the distance between glabella to subnasale is equal to the distance
between the subnasale to the underside of the chin (lower facial height).
Reduced lower facial height is associated with deep bite while the
increased facial height is with anterior open bite.
2. The vertical skeletal relationship can also be assessed by studying the angle
formed between the lower border of the mandible and the Frankfort
horizontal plane either:
clinically by placing a ruler at the lower border of the mandible and another
one at the Frankort plane(from external auditory meatus to the lowest point
of the infra-orbital margin)if the angle between the above lines ranged
between 28-30 so it is normal
or radiographical by measuring the angle formed between two lines the
Frankfort plane which extend from the porion to orbitale and the mandibular
plane which extend from gonoin to menton .
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Assessment of transverse jaw relationship :
A certain degree of asymmetry between right and left sides of the face is seen in most
of the individuals. The face should be examined in the transverse and vertical planes
to determine a greater degree of asymmetry than the normal. Gross facial
asymmetries may be seen in patients with-
• Hemifacial atropy/hypertrophy
• Congenital defects
• Unilateral condylar hyperplasia
• Unilateral Ankylosis
There are many ways to assess the facial asymmetry
a) Bird look :by looking to the patient from above
b) Composite Photograph
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c) Tongue spatula
d) Radiographically(OPG or PA)
The most significant jaw mal-relation in transverse plane include the presence of
posterior cross-bite and whether this cross-bite is skeletal or dental in origin.
-*+
Lips:
Normally, the upper lip covers the entire labial surface of upper anteriors
except the incisal 2-3mm. The lower lip covers the entire labial surface of the lower
anteriors and 2-3 mm of the incisal edges of the upper anteriors.
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Lips can be classified into:
Competent: Slight contact of lip when the musculature is relaxed.
Potentially competent: Anatomically short lips which do not contact when
musculature is relaxed. Lip seal is achieved only by active contraction of the
orbicularis oris and mentalis muscle.
In competent: Normal lips which fail to form the lip seal due to proclined upper
incisors.
Everted lips: Hypertropied lips with weak muscular tonicity
Teeth are protruded excessively when two conditions are met:
1. The lips are prominent and everted
2. Lips are separated at rest by more than 3-4 mm(incompetent)
So there is protruded incisors that’s revealed by prominent and separated lips
when they are relaxed. so for such a patient retracting the teeth tend to improve the
esthetic and function.
But if the lips are prominent and closed over the teeth without strain so in this
case the lip position is independent on the tooth position and the retraction of the
incisors will have a little if no change in lip function and position and esthetic as in
negroid patient in addition to the high possibility of relapse.
The sagittal relationship of the lips is almost entirely determined by the
relationship of the basal bone of the jaws, to which they are attached. The lower lip
tends to be further back than the upper lip in a skeletal Class II relationship, and
further forward in a skeletal Class III relationship.
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This not only increases the difficulty of putting the lips together, but also may
cause the lower lip to modify the eruptive path of the upper incisors? For example,
with a skeletal Class II relationship the lower lip may function completely or partly
behind the upper incisors. If the skeletal discrepancy is not severe, the lip is
functioning partly behind the upper incisors and may procline the upper incisors so
that the occlusal relationship is more severely Class II than the skeletal
relationship(low lip line as in CLII division 1 (b) . If the skeletal discrepancy is severe,
the lower lip may function completely behind the upper incisors without causing them
to be proclined(c) . In other instances, with skeletal Class II, the lower lip functions
entirely in front of the upper incisors ,causing them to be retroclined into the Class II
Division 2 incisor relationship (d) . Ideally the upper and lower lip shuold meet at the
center of upper cenrals crown which is called the lip line (a).
The Ricketts‘ E-line, the reference line connecting the tip of the nose with the soft
tissue pogonion, passes about 4 mm in front of the upper lip and 2 mm in front of the
lower lip.
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Nasolabial angle :
It is the angle formed between the lower border of the nose and a line joining
the subnasale with the tip of the upper lip (labiale superius). The angle is normally 110
.
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It is reduced in patients with proclined upper anteriors or prognathic maxilla.
Intra-oral Examination:
Tongue:
Abnormalities of tongue can upset the muscle balance and equilibrium leading
to malocclusion. Presence of excessively large tongue is indicated by the presence of
imprints of teeth on the lateral margins of the tongue giving a scalloped appearance.
Short lingual frenum called tongue tie leads to impaired tongue movement.
Frenal attachments :
The maxillary labial frenum can be thick, fibrous and have low attachment. Such
attachments prevent the two maxillary central incisors from approximating each other
leading to midline diastema .Mandibular labial frenum if with high attachment, may
lead to recession of gingiva .Abnormal frenum attachments can be diagnosed by
blanch test (when the upper lip is stretched upwards and outwards ,blanching in the
region of the interdental papilla indicates abnormal frenum attachment).
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Dentition and dental arch
i. Status The numbers of teeth present, deciduous or permanent ,missing ,
unerupted , extracted
ii. Presence of caries, restoration, malformation, hypoplasia ,wear and
discoloration.
iii. Molar relation :Molar relation is defined as the relation between maxillary
and mandibular first molars.
Molar relation (Angle classification)
Class I: Mesio-buccal cusp of maxillary first molar occludes in the buccal groove
of the mandibular first molar.
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Class II: Mesio-buccal cusp of maxillary first molar occludes in the groove
between mandibular 2nd premolar and 1st molar. (or half or more cusp width
mesial to the buccal groove according to Angle).it has two subdivisions:
○Div 1: With proclined maxillary incisors.
○Div 2: this also can be classified into:
Typical: Lingually inclined maxillary central incisors with labially tipped lateral
incisors .
Atypical: Lingual inclination of central and lateral incisors with canines labially tipped .
Class III: Mesio-buccal cusp of maxillary first molar occludes in the groove
between mandibular 1st and 2nd molar. (or half or more cusp width distal to the
buccal groove according to Angle).
When there is Class II molar relation on one side, and Class I on other side, it is
called Class II subdivision.
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When there is Class III molar relation on one side and Class I on other side, it is
called Class III subdivision.
Incisor relation : ( According to the British standards )
Class I : Lower incisor edges occludes with or lie immediately below the
cingulum plateau of upper central incisors.
Class II : Lower incisor edges lie posterior to cingulum plateau. Two subdivisions
of this category are –
Div 1 – The upper central incisors are proclined or of average inclination
and there is an increase in over-jet.
Div 2 – The upper central incisors are retroclined .Over-jet is usually
minimal or may be increased.
Class III : The lower incisor edges lie anterior to cingulum plateau. The over-jet
may be reduced or reversed.
Canine relation:
Class I : The mesial incline of upper canine overlaps the distal slopes of the lower
canine.
Class II : Distal slope of maxillary canine occludes or contact the mesial slope of lower
canine.
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Class III : Lower canine is displaced anteriorly to the upper canine with no overlapping
of upper and lower canine.
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