EXAMINATION IN ORTHODONTICS

1. EXAMINATION IN ORTHODONTICS

2. For orthodontic purposes, the informations needed to find out the diagnosis are derived from three major sources: • questions of the patient (written and oral) • clinical examination of the patient • evaluation of diagnostic records, including dental casts, radiographs and photographs. .

3. 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: • medical and dental history • physical growth status • motivation, expectations, and other sociobehavioral factors

4. 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 It is important to establish their relative importance to the patient

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

12. 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.

13. Clinical Evaluation There are two goals of the orthodontic clinical examination: • to evaluate and document oral health, jaw function,facial proportions and smile characteristics; and • to decide which diagnostic records are required. The clinical examinationcan be devided to: • Morphological (extraoral and intraoral) • Functional

14. 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.

15. 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

16. 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.

17. 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.

18. 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)

19. 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

20. Extraoral examination • Profile Analysis There are three goals of facial profile analysis: • Establishing whether the jaws are proportionately positioned in the anteroposterior plane of space. • Evaluation of lip posture and incisor prominence • Re-evaluation of vertical facial proportions

21. Extraoral examination • 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

22. 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

23. 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: • 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), so that the patient must strain to bring the lips together over the protruding teeth.

24. 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.

25. 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

26. 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.

27. 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.

28. 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

29. Intraoral examination Evaluation of Jaw and Occlusal Function Three aspects of function require evaluation: • mastication (including but not limited to swallowing), • speech, and • the presence or absence of temporomandibular (TM) joint problems.

30. 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.

31. 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.

32. 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

33. 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.

34. 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.

35. Orthodontic diagnostic records 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

36. 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.

37. 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.