Orthodontic diagnosis

Orthodontic Diagnosis
Dr.Saurabh Goel
10/17/2014 3:13 PM Dr.Saurabh Goel 1

OUTLINE

Diagnostic Aids
• These are of two types
1. Essential Diagnostic Aids
2. Supplemental Diagnostic Aids
• Essential Diagnostic Aids- Required for all cases, simple, inexpensive equipment
• Supplemental Diagnostic Aids- not required in all cases, specialized equipment

Essential Diagnostic Aids
1. Case history
2. Clinical examination
3. Study models
4. Certain radiographs
a) Lateral Cephalogram
b) Panoramic views
5. Facial photographs

Supplemental Diagnostic Aids
1. Specialized Radiographs
a) Frontal Cephalometric radiographs
b) Occlusal intraoral films
c) Bitewing radiographs
d) Cone shift technique
2. Electromyographic examination of muscle activity
3. Hand wrist radiographs to assess bone age or maturation age
4. Endocrine tests
5. Estimation of BMR
6. Diagnostic set-up
7. Occlusograms

Case History
1. Personal Details
a) Name
b) Age
c) Sex
d) Address and Occupation
2. Chief complaint
3. Medical history
4. Dental history
5. Prenatal history
6. Postnatal history
7. Family history

General Examination
1. Height and weight
2. Gait
3. Posture
4. Body build
a) Aesthetic- thin physique, usually narrow dental arches
b) Plethoric- obese, generally have large, square arches
c) Athletic- normally built, normal arches
Sheldon classified general body build into
a) Ectomorphic- Tall and thin
b) Mesomorphic- Average
c) Endomorphic- Short and Obese

Extra Oral Examination
1. Shape of the head
a) Mesocephalic- average shape of head, normal dental arches
b) Dolicocephalic- long and narrow heads, narrow dental arches
c) Brachycephalic- broad and short , broad dental arches

2. Facial form
a) Mesoprosopic- average / normal face form
b) Euryprosopic- broad and short
c) Leptoprosopic- long and narrow face form

3. Assessment of facial symmetry
a) Congenital defects
b) Hemi-facial atrophy/ hypertrophy
c) Unilateral condylar ankylosis and hyperplasia

4. Facial Profile
• It is assessed on the basis of two reference lines-a)
A line joining forehead and soft tissue point A ( Deepest point in curvature of upper lip)
b) A line joining point A and soft tissue pognion ( Most anterior part of chin)
• Based upon relationship of these two lines , 3 types of profiles are observed
a) Straight
b) Convex
c) Concave

5. Facial Divergence
a) Anterior divergent
b) Posterior divergent
c) Straight or orthognathic

6. Assessment of antero-posterior jaw relationship

7. Assessment of vertical skeletal relationship
8. Evaluation of facial proportions
9. Transverse facial proportions

10. Evaluation of Lips
a) Competent
b) Incompetent
c) Potentially incompetent
d) Everted lips
11. Evaluation of Lip prominence
12. Examination of Nose
a) Nose size
b) Nasal Contour
c) Nostrils

13. Examination of chin
a) Mentolabial sulcus
b) Mentalis activity
c) Chin position and prominence
14. Nasolabial angle

Intra-Oral Examination
1. Examination of Tongue
a) Size
b) Lingual frenum
2. Examination of Palate
a) Variation in palatal depth
b) Swelling in the palate can be indicative of an impacted tooth ,cyst or other bony pathologies
c) Mucosal ulceration and indentations are feature of a traumatic deep bite
d) Presence of clefts

3. Examination of Gingiva
a) Anterior marginal gingivitis in mouth breathers
b) Presence of traumatic occlusion is indicated by localized gingival recession

4. Examination of Frenal Attachments
a) According thickness and height of attachment

5. Examination of tonsils and adenoids
a) Size and degree of inflammation causes alteration in tongue and jaw posture thereby upsetting oro-facial balance
leading to malocclusion
6. Assessment of dentition
a) Teeth present
b) Teeth unerupted
c) Teeth missing
d) Status of dentition – teeth that have erupted and not erupted quadrant wise
e) Presence of caries, restorations, malformations, hypoplasia, wear and discoloration
f) Molar relationship- Angle’s
g) Overjet
h) Overbite
i) Transverse malrelations- crossbite and shift in upper and lower midlines
j) Individual tooth irregularities
• Rotations
• Displacements
• Intrusion
• Extrusion
k) Arch forms- Normal, narrow , square

Functional Examination
1. Assessment of postural rest position and Inter Occlusal space
2. Path of closure
3. Assessment of respiration
4. Examination of TMJ
5. Examination of swallowing
6. Examination of speech

1. Assessment of postural rest position and Inter Occlusal space
a) Patient should be seated in upright position
b) Back unsupported
c) Asked to look straight ahead
Following methods can be used for recording-a)
Phonetic method – pronouncing some consonants “M” or “C” or words like “Mississippi”
b) Command method wherein patient is asked to perform certain functions such as swallowing
c) Non Command method- Simple observation
d) Direct intraoral procedure using vernier calipers
e) Direct extraoral procedure using marks on nose and chin ; measuring distance between two at rest and at occlusion
f) Indirect extraoral procedure- radiography

2. Evaluation of path of closure
a) Forward path of closure
b) Backward path of closure
c) Lateral path of closure
3. Assessment of respiration- Nasal, oral, oro-nasal
a) Mirror test
b) Cotton test
c) Water test
d) Observation
4. Examination of TMJ
a) Auscultation and palpation of TMJ
b) Musculature associated with mandibular opening
c) Clicking, Crepitus, pain in masticatory muscles
d) Limitation of jaw movement
e) Hypermobility and morphological abnormalities
f) Normal interincisal distance- 40 to 45 mm

5. Examination of Swallowing
a) Infantile swallow
- In a newborn tongue is of relatively larger size and it protrudes between the gum pads and forms a lip seal.
b) Mature swallow
- it replaces the infantile swallow on eruption of buccal teeth.
c) Persistence of infantile swallow can lead to malocclusion.
Infantile swallow is indicated by presence of following features
• Presence of tip of the tongue
• Contraction of peri-oral muscles during swallowing
• No contact at molar region during swallowing
6. Speech
a) Lisping is quite frequent in patients with tongue thrust
b) Nasal tone is quite evident in cleft palate patients

Orthognathic study models
• It is an Essential Diagnostic aid
• Uses of the same are as follows
a) Enables study of malocclusion from all aspects
b) Enables accurate measurements to be made in a dental arch
c) Assessment of treatment progress by the dentist
d) Assessing the nature and severity of malocclusion
e) Helpful in motivation of patient and to explain treatment plan as well progress
f) It helps in simulating treatment procedures on the cast such as mock surgery
g) Useful to transfer records in case the patient is to be treated by another clinician

Uses of Intraoral Periapical Radiographs (IOPA)
1. To confirm the presence or absence of teeth
2. To establish the presence or absence of supernumerary teeth
3. To assess the extent of calcification and root formation of teeth
4. To confirm the presence and study of any Periapical pathology and root fractures
5. To study the alveolar bone and periodontal ligament space
6. To study the height and contour of alveolar bone crest
7. To assess the axial inclination of roots
8. To detect the retained root fragments and root stumps
9. To determine the size and shape of unerupted teeth

Disadvantages of IOPA
1. Assessment of entire dentition requires too many radiographs
2. Children may not allow placement of intraoral films
3. Cannot be used in patients having high gag reflex and trismus

Bitewing Radiographs
1. To detect proximal caries
2. To study height and contour of interdental alveolar bone
3. To detect secondary caries below restorations
4. To detect overhanging proximal restorations
5. To detect periodontal changes
6. To detect interproximal calculus

Occlusal Radiographs
1. To locate impacted or unerupted teeth
2. To locate supernumerary teeth
3. To locate foreign bodies in the jaws and stones in salivary ducts
4. To study bucco-lingual expansions of cortical plate due to pathology of jaw
5. To diagnose presence and extent of fractures
6. They are useful in orthodontics to study the effects of arch expansion procedures

Extraoral Radiographs
1. Panoramic radiographs
2. Cephalometric radiographs
3. Hand wrist radiographs
4. Recent advances ( Learn any 5 names)
a) Xeroradiography
b) MRI (Magnetic Resonance Imaging)
c) Tomography
d) Computed tomography ( CT or CAT – Computed axial tomography)
e) Digital subtraction radiography
f) Laser holography
g) Photocephalometry
h) Cineradiography
i) CBCT- Cone beam computed tomography

GUESS WHO
and
DIAGNOSE

• Anna Paquin : An actress , who played the role of ROGUE
in X-MEN Franchise
• A case of midline diastema due to thick frenal attachment and a case
of deep bite

• Alia Bhatt- A case of deep bite

VIVA-VOICE
1. Enumerate various diagnostic aids
2. Name few essential diagnostic aids
3. How do u check for antero-posterior jaw relationship?
4. Importance of frenal attachment
5. What is the significance of examination of the tongue for orthodontic diagnosis ?

Orthodontic diagnosis

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