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Orthodontic Diagnosis the problem oriented approach
- 1. D O N E B Y . R 2 . M O H A M M A D ORTHODONTIC DIAGNOSIS: THE PROBLEM- ORIENTED APPROACH
- 2. OUTLINE QUESTIONNAIRE/INTERVIEW • Chief Concern • Medical and Dental History • Physical Growth Evaluation • Social and Behavioral Evaluation CLINICAL EVALUATION • Oral Health • Jaw and Occlusal Function • Facial and Dental Appearance Which Diagnostic Records Are Needed? • Analysis of diagnostic records cast analysis: symmetry, space, and tooth size.
- 3. 1. Introduction The diagnostic database is composed of multiple clinical, functional, and record analyses. Facial examination leads to avoidance of potential orthodontic facial balance decline and enhances Diagnosis, Planning, Treatment, and quality of Results. Orthodontic diagnosis requires a broad overview of the patient’s situation and must take into consideration both objective and subjective findings.
- 4. 2. Questionnaire/Interview (1) Chief Concern I. Impaired dentofacial appearance II. Impaired function III. And impaired oral health (2) Medical and Dental History I. long-term medication of any type II. Condylar fracture
- 5. 2. Questionnaire/Interview Classificationof Condyle fracture according to Lindahl classification: 1. Condyle head fracture 2. Condyle neck fracture 3. Subcondyle fracture The most commonly observed type is the displacement of the condyle head to the antero- medial side
- 6. 2. Questionnaire/Interview １) Orthodontic treatment for patient with diabetes • Orthodontic tt possible in a patient with controlled diabetes. • The consequences of the disease in relation to dental treatment is important. • Good oral hygiene has been established as the most potent protective factor against poor dental health among diabetic patients • Dental complications of Diabetes are summarized in (Table 1)
- 7. 2. Questionnaire/Interview 2) Orthodontic treatment for patient with osteoporosis. • Deleterious effect on tooth movement • High tendency to relapse in patients with osteoporosis • Uncoupling of the normal relationship between bone formation and resorption, resulting in a net decrease in bone formation. • Verna et al, found more root resorption in an acute corticosteroid treatment group when compared with the control group. • Orthodontic treatment might best be postponed until a time when the patient is taken off medication.
- 8. 2. Questionnaire/Interview 3) Bisphosphonates and Orthodontic Tooth Movement • Orthodontic tooth movement took longer. • Bodily movements were limited. • Kerishnan et al, Avoid invasive dental procedures in orthodontic treatment plan are recommended.
- 9. 2.Questionnaire/Interview (3) Physical Growth Evaluation Increase in cellular size and number including an increase in specialization or function. Directly and indirectly influence treatment (direct effect is potential growth modification in Class 2 & 3 in case of delay tt ) 1) Chronological Age • Wide differences between individuals of the same age. • Chronological age on its own cannot be used as a valid parameter to estimate facial growth or skeletal maturity.
- 10. 2. Questionnaire/Interview 2) Dental development. o link exists between dental development, skeletal age and chronological age. 3) Height and weight characteristics. - A correlation exists between changes in standing height and the onset of the pubertal growth spurt. - The method of height measurement is standardized using a stadiometer.
- 11. 2. Questionnaire/Interview 4) Hand wrist radiograph - Ossification and union from birth to maturity. - Four groups of bones, : the distal ends of the radius and ulna, Carpals, Metacarpals, Phalanges - Makes it possible to assess whether a patient is early, prepubertal, pubertal or at the growth completion phase of skeletal maturity.
- 12. 2. Questionnaire/Interview 5) Cervical vertebrae Six distinct and consecutive stages of assessment using the shapes of the cervical vertebrae C2, C3 and C4. They suggest that cervical stage (CS3) is the ideal time for orthodontic treatment.
- 13. ３．CLINICAL EVALUATION. (1)Oral Health Medical problems, dental caries or pulpal pathology, and periodontal disease should be under control. (2) Jaw and Occlusal Function - Oral function need and require evaluation: a) Mastication c) sleep apnea related to mandibular b) speech d) TMJ problems
- 14. ３. CLINICAL EVALUATION. (2) Jaw and Occlusal Function
- 15. ３. CLINICAL EVALUATION. 3) Facial and Dental Appearance : 1. Facial Proportions: Macro-Esthetics 2. Tooth–Lip Relationships: Mini-Esthetics 3. Dental Appearance: Micro-Esthetics.
- 16. ３. CLINICAL EVALUATION. 1). Facial Proportions: Macro-Esthetics Dentists should focus on the physical maturity. Physical development is much more important than chronologic age.
- 18. ３. CLINICAL EVALUATION. ① Establishing whether the jaws are proportionately positioned in the anteroposterior plane of space. 1). Facial Proportions: Macro-Esthetics
- 19. ３. CLINICAL EVALUATION. ② Evaluation of lip posture and incisor prominence 1). Facial Proportions: Macro-Esthetics Incisors flare forward/lingually
- 20. ３. CLINICAL EVALUATION. ③ Reevaluation of vertical facial proportions and evaluation of mandibular plane angle. Observed during the full-face examination or profile. Visualized readily by placing a finger or mirror handle. A steep MPL usually accompanies long anterior facial vertical dimensions and a skeletal open bite tendency. 1). Facial Proportions: Macro-Esthetics
- 21. ３. CLINICAL EVALUATION. A steep MPL usually accompanies long anterior facial vertical dimensions and a skeletal open bite tendency. 1). Facial Proportions: Macro-Esthetics
- 22. ３. CLINICAL EVALUATION. 2) Tooth–Lip Relationships: Mini-Esthetics - Evaluation begins with an examination of symmetry. - Relationship of dental midline of each arch to the skeletal midline must be recorded.
- 23. ３. CLINICAL EVALUATION. ① Smile Analysis. o Social smile ( is the one that is presented to the world routinely). o Enjoyment smile (the enjoyment smile varies with the emotion being displayed). ② Amount of Incisor and Gingival Display. up to 4 mm lip coverage of the incisor crown, is acceptable. Beyond that, the smile appearance is less attractive. 2) Tooth–Lip Relationships: Mini-Esthetics
- 24. ３. CLINICAL EVALUATION. ① Tooth Proportions. ② Height–Width Relationships. ③ Gingival Heights, Shape, and Contour ④ Embrasures: Black Triangles. 3) Dental Appearance: Micro-Esthetics. The maxillary centrals and canines should exhibit a gingival shape that is more elliptical and oriented distally to the long axis of the tooth.
- 25. (4) Which Diagnostic Records Are Needed? 1) Health of Teeth and Oral Structures. 2) Dental Alignment and Occlusion . ① Physical versus Virtual Casts. - Gives maximum displacement of the lips and cheeks - The ideal way to generate digital casts would be from an intraoral laser scan. ② Articulator Mounting. - Record discrepancy between the occlusal relations at the initial contact of the teeth and the habitual occlusion. - Record the lateral and excursive paths of the mandible. - Display the orientation of the occlusal plane to the face. ③ Virtual Articulators. Software used for surgical treatment planning, e virtual articulator still is some distance from reality as this is written because it requires not only accurate dental casts but also an accurate way to relate them to each other and to the jaws.
- 26. 4. ANALYSIS OF DIAGNOSTIC RECORDS 1) Symmetry. - Asymmetry of arch form may be present even if the face looks symmetric. - Asymmetry within the dental arch but with symmetric arch form also can occur.(results either from lateral drift of incisors or early loss of a primary molar has occurred). 2) Alignment (Crowding): Space Analysis - The size of the teeth versus the space available for them - Valuating the likely degree of crowding for a child in the mixed dentition. 3) Tooth Size Analysis - Measuring the mesio-distal width of each permanent tooth, then used to compare the summed widths of the maxillary to the mandibular anterior teeth and the total width of all upper to lower teeth . (1) Cast Analysis
Editor's Notes
- Good morning dear professors and colleges my presentation will talk about orthodontic diagnosis
- Outline of the leacture
- introduction The diagnostic database is composed of multiple clinical, functional, and record analyses hat allow the clinician to formulate a comprehensive diagnosis and begin to work toward a treatment plan that is most beneficial to the patient to enhance the quality of results.
- Chief Concern For an individual with reasonabl normal function and appearance and reasonable psychosocial adaptation, the major reason for seeking treatment may well be THE NEED to enhance appearance beyond the normal, thus potentially improving quality of life (QOL). (2) Medical and Dental History Two areas deserve a special comment. First long-term medication of any type . Secound condylar fracture of the mandible 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 concerns.
- Condyle fracture can be classified as shown on the slide . It has become in recent years that early fractures of the condyle occur more frequently than was previously thought . A mandibular fracture in a child can easily be overlooked in the aftermath of an accident that caused other trauma, so a jaw injury may not have been diagnosed at the time
- Orthodontic treatment for patient with diabetes patient with controlled diabetes require especially careful monitoring. When treating DM patients, the practitioner must understand the consequences of the disease in relation to dental treatment. Good oral hygiene has been established as the most potent protective factor against poor dental health among diabetic patients and one of the major considerations before going to active orthodontic treatment
- Orthodontic treatment for patient with osteoporosis. high risk of bone resorption (osteoporosis), due to systemic problems, may have a NAGATIVE effect on tooth movement . Corticosteroid-induced osteoporosis involves the uncoupling of the normal relationship between bone formation and resorption, resulting in a net decrease in bone formation
- Bisphosphonates and Orthodontic Tooth Movement New studies recommend to Avoid invasive dental procedures in orthodontic treatment with this drugs BECOUSE BODILY MOVMENTS WERE LIMITED
- Physical Growth Evaluation One of the major area that should be explored by questions to the patient or parents is the individual’s physical growth. It is certainly an important factor in orthodontics as it can both directly and indirectly influence treatment , for example, a Class III skeletal pattern may become more severe IN CASE OF DELAY TREATMENT. And becouse of Wide differences between individuals of the same age, Chronological age on its own cannot be used as a valid parameter to estimate facial growth or skeletal maturity
- Dental development. A technique has been described whereby dental age is correlated with skeletal age using a radiological assessment of the degree of development of root of the lower canine and its stage of eruption
- The hand and wrist comprise a number of small bones that all show a predictable and uniform pattern of appearance, ossification and union from birth to maturity. Therefore, it is a region that has been extensively studied in relation to the assessment of growth
- Cervical vertebrae six distinct and consecutive stages of assessment using the shapes of the cervical vertebrae C2, C3 and C4, which correlate to the peak mandibular growth and with a range of two years before and two years after it has occurred . cervical stage (CS3) is the ideal time for orthodontic treatment
- CLINICAL EVALUATION. The general guideline is that before orthodontic treatment begins, any disease or pathology must be under control. Four aspects of oral function need and require evaluation: mastication, speech, the possibility of sleep apnea related to mandibular deficiency, and the presence or absence of temporo-mandibular joint problems.
- 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. Specific relationships are outlined in (Table ). If a child has a speech problem and the type of malocclusion related to it, a combination of speech therapy and orthodontics may help
- Facial and Dental Appearance A systematic examination of facial and dental appearance should be done in the following three steps. 1-Facial Proportions 2-Tooth–Lip Relationships: 3-Dental Appearance: .
- 1)Facial Proportions: Macro-Esthetics The first step in evaluating facial proportions is to take a good look at the patient. the dicesion should be on the physical maturity. physical development is much more important than chronologic age in determin how much growth remains as shown in (Table ). evaluating dental and facial esthetics is an important part of the clinical examination to enhance social well-being and quality of life.
- 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. Oral-facial-digital syndrome is actually a group of related conditions that affect the development of the oral cavity . facial features, Some people with oral-facial-digital syndrome have bands of extra tissue (called hyperplastic frenula) that abnormally attach the lip to the gums, Another common feature is (a cleft palate).
- Establishing the jaws are positioned in the antero-posterior plane of space. done with the patient either sitting upright or standing in a dental chair and looking at the horizon or a distant object. The first line 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 as shown in figure. convex profile therefore indicates a skeletal Class II jaw relationship, whereas a concave profile indicates a skeletal Class III jaw relationship.
- Evaluation of lip posture and incisor prominence If the incisors flare forward, they can align themselves along the arc of a larger circle, which provides more space to accommodate the teeth and relife the crowding. Conversely, if the incisors move lingually, there is less space and crowding becomes worse. crowding and protrusion of incisors must be considered. Lip prominence is evaluated by observing the distance that each lip projects forward from a true vertical line through the depth of the concavity at its base (soft tissue points A and B) . it can be helpful to draw the E-line (esthetic line) from the nose to the chin, and look at how the lips relate to this line. The guideline is that they should be on or slightly in front of the E-line,
- Evaluation of mandibular plane angle. The mandibular plane angle can be visualized clinically by placing a mirror handle or other instrument along the border of the mandible. For this patient, the mandibular plane angle is normal, neither too steep nor too flat.
- A steep MPL usually associated with long anterior facial vertical dimensions and a skeletal open bite tendency.
- Evaluation of tooth–lip relationships begins with an examination of symmetry. it is important to note the amount of incisor display. For patients with excessive incisor display, the usual cause is a long lower third of the face. IT is important to note up-down transverse rotation of the dentition is revealed when the patient smiles or the lips are separated at rest. In the figure A the occlusal plane can be seen in both frontal and oblique views. This is a “roll deformity” that results from the orientation of the jaws and teeth rather than their position
- Smile Analysis. it is important to analyze the characteristics of the smile and to think about how the dentition relates to the facial soft tissues dynamically, as well as statically. According to Amount of Incisor and Gingival Display. Using computer-altered photographs, recent research has established a range of acceptability for incisor and gingival display .some display of gingiva is acceptable and can be both esthetic and youthful appearing. in figure A, Display of all the maxillary incisors and some gingiva on smiling is a youthful and appealing characteristic. In figure B, Less display is less attractive,
- Dental Appearance: Micro-Esthetics the tooth widths in relation to each other and the height–width proportions of the individual teeth. The apparent widths of the maxillary anterior teeth on smile, and their actual mesiodistal width differ because of the curvature of the dental arch.width of the canine should be 62% of that of the lateral incisor, and the width of the first premolar should be 62% of that of the canine .This ratio of recurring 62% proportions appears in a number of other relationships in human anatomy and sometimes is referred to as the (golden proportion).
- Diagnostic Records Physical and Virtual Casts Gives maximum displacement of the lips and cheeks and The ideal way to generate digital casts would be from an intraoral laser scan. Virtual Articulators. Software used for surgical treatment planning,. virtual articulator it requires not only accurate dental casts but also an accurate way to relate them to each other and to the jaws
- FINALLY, according to the cast analysis the focus is on four things: (1) dental cast analysis to evaluate space excess or deficiency and symmetry within the dental arches, (2) cephalometric analysis of dentofacial relationships, (3) analysis of 3-D CBCT images, and (4) integration of information from all sources into the problem-oriented format that facilitates treatment planning. Asymmetry within the dental arch but with symmetric arch form also can occur.(results either from lateral drift of incisors or early loss of a primary molar has occurred).