INTRODUCTION DIAGNOSTIC PROCESS COMPREHENSIVE DIAGNOSIS 1. Case history 2. Clinical examination 3. Functional examination 4. Radiologic examination 5. Photographic analysis Recent advances in diagnosis a. Xeroradiography b. Digi Graph c. MRI d. Tomography e. Occlusograms f. Digital Subtraction Radiography g . Laser Holograph Conclusion References

1. 1

2. CLINICAL DIAGNOSIS IN
ORTHODONTICS
2

3. Contents:-
INTRODUCTION
DIAGNOSTIC PROCESS
COMPREHENSIVE DIAGNOSIS
1. Case history
2. Clinical examination
3. Functional examination
4. Radiologic examination
5. Photographic analysis
3

4. o Recent advances in diagnosis
a. Xeroradiography
b. Digi Graph
c. MRI
d. Tomography
e. Occlusograms
f. Digital Subtraction Radiography
g . Laser Holograph
o Conclusion
o References
4

5. Introduction:-
Definition-
“Orthodontic diagnosis deals with recognition of
the various characteristics of the malocclusion. It
involves collection of pertinent data in a systemic
manner to help in the identifying the nature and cause
of the problem.
Diagnostic aids – comprehensive orthodontic
diagnosis is established by use of certain clinical
implements called diagnostic aids.
5

6. They are of two types –
a. Essential diagnostic aids -
i. Case history
ii. Clinical examination
iii. Study models
iv. Certain radiographs –
Periapical radiograph
bite wing
Panoramic radiograph
v. Facial radiographs
6

7. 7
b. Supplemental diagnostic aids –
i. Specialized radiographs
ii. Electro myographic examination of muscle activity
iii. Hand – wrist radiograph
iv. Endocrine tests
v. Estimation of basal metabolic rate

8. COMPREHENSIVE DIAGNOSIS
CASE HISTORY:-
1. Personal details –
NAME –
Communication
Identification
Psychological benefits
AGE –
Diagnosis and treatment planning
Growth modification procedures
Surgical resective procedures
Developmental considerations
8

9. 2. SEX –
Treatment planning
e. g. the timing of growth events such as growth
spurts are different in males and females
3. Address and occupation –
Evaluation of socio – economic status
In selection of an appropriate appliance
Future correspondence
9

10. 4. CHIEF COMPLAINT –
There are three major reasons for patient concern about the
alignment and occlusion of the teeth:
Impaired dento-facial esthetics that can lead to psychosocial
problems,
Impaired function, and
A desire to enhance dento-facial esthetics and thereby the
quality of life.
10

11. In obtaining the medical history, the orthodontist or assistant
must always ask a few important questions, as
• Hospitalizations,
• Medications.
• Allergies, especially latex or nickel sensitivity;
• Blood transfusions;
• Heart problems such as mitral valve prolapse or rheumatic
fever .
11
5. MEDICAL HISTORY :-

12. 12
6. DENTAL HISTORY :-
The dental history of the patient should include
• Age of eruption of the deciduous and permanent teeth,
• History of extraction, decay, restorations and
• History of trauma to the dentition.

13. 7. PRE – NATAL HISTORY :-
It includes –
The condition of the mother during
pregnancy and the type of delivery.
The use of certain drugs like
thalidomide.
Affection with some infections during
pregnancy like German measles.
13

14. 14

15. 8. POST – NATAl HISTORY :-
It include –
The type of feeding,
Presence of habits and
The milestones of normal development.
15

16. 9. FAMILY HISTORY :-
Congenital conditions like cleft lip and palate, skeletal
Class ii and Class iii malocclusion are hereditary in
nature.
16

17. 17
10. SOCIALAND BEHAVIORAL EVALUATION :-
Social and behavioral evaluation should explore several
related areas –
The patient’s motivation for treatment,
Expectations from treatment and
Compliance of the patient.

18. CLINICAL EXAMINATION :-
GENERAL EXAMINATION :-
a. Height and Weight –
They provide a clue to the physical growth and
maturation of the patient.
18

19. 19
b. Gait –
It is the manner of walking.
Abnormalities of gait are usually
associated with neuro-muscular disorders.

20. 20
c. Posture –
- Posture refers to the way a person stands.
- Abnormal postures can predispose to malocclusion
due to alteration in maxillo-mandibular relationship.

21. o BODY BUILD(PHYSIQUE) :-
a. Aesthetic – they have a thin physique and usually
posses narrow dental arches.
b. Plethoric – they are obese and have large, square
dental arches.
c. Athletic – they are normally built and have normal
sized dental arches.
21

22. 22
SHELDON has classified the general body build into
three types :-

23. EXTRA ORAL EXAMINATION :-
SHAPE OF HEAD –
23
average shape long and narrowbroad and short head

24. 24

25. oFACIAL FORM :-
• simple classification – round, oval or square.
• scientific classification –
a. Mesoprosopic – average or normal face form
b. Euryprosopic – broad and short face form
c. Leptoprosopic – long and narrow face form
25
Euryprosopic
Leptoprosopic
•Orthodontic diagnosis by Thomas Rakosi, Irmtrud Jonas, Thomas M. Graber

26. 26•Orthodontic diagnosis by Thomas Rakosi, Irmtrud Jonas, Thomas M. Graber

27. ASSESMENT OF FACIAL
SYMMETRY :-
In most people the right and left sides are not identical , so
some degree of asymmetry is considered normal.
Gross facial asymmetries can occur as a result of ;
• Congenital defects
• Hemi – facial atrophy/hypertrophy
• Unilateral condylar ankylosis and hyperplasia
27

28. Composite photographs are the best way to indicate
normal facial asymmetry.
The true photograph is in the centre.
On the right is a composite of the two right sides, While
on the left is a composite of the two left sides..
28
William R. Proffit, Henry W.Fields.jr -Contemporary orthodontics, 4th Edition.—2004
Mosby Elsevier publication

29. Facial proportions and symmetry in the
frontal plane.
An ideally proportional face can be divided
into central , medial ,and lateral equal fifths.
The separation of the eyes and the width of
the eyes, which should be equal ,determine
the central and medial fifths.
29

30. Vertical facial proportions in the frontal and lateral views are
best evaluated in the context of the facial thirds, which were
equal in height in well-proportioned faces.
30

31. FACIAL PROFILE :-
The profile is assessed by joining the following two
reference lines:
1. A line joining the forehead and the soft tissue point A.
2. A line joining point A and the soft tissue pogonion.
31

32. Profile convexity or concavity results from a
disproportion in the size of the jaws, but does not by
itself indicate which jaw is at fault.
32

33. Facial divergence :-
Facial divergence is defined as anterior or posterior
inclination of the lower face relative to the forehead.
Facial divergence can be of 3 types :
33
Anterior divergence Posterior divergence Straight divergence

34. Assessment of antero – posterior
jaw relation :-
34
Class I skeletal pattern
The hand is at an level
Class II skeletal pattern
The hands points
upwards.
Class III skeletal pattern
The hand points
downward

35. Assessment of vertical skeletal
relation :-
The angle formed between the lower border of the mandible
and the frankfort horizontal plane.
- Reduced lower facial height - deep bite
- Increased lower facial height -anterior open bites.
35William R. Proffit, Henry W.Fields.jr- contemporary orthodontics,4th edition -2004 mosby elesvier publications.

36. Examination of lips :-
Lip posture – should be evaluated by viewing the profile
with the patient’s lips relaxed.
- upper lip to a true vertical line passing through soft tissue
point A.
- the lower lip to a similar true vertical line soft tissue point
B.
If the lip is significantly forward from this line – it can be
judged to be prominent.
If the lip falls behind the line, it is retrusive.
36

37. Lip length: -
The length of the lips can be examined by gently parting the
lips.
Usually the upper lip covers the entire labial surface of
upper anteriors except the incisal third or 2 to 3 mm and the
lower lip extends on to the incisal one third of the upper
anterior teeth.
37

38. 38
Texture and color:-
usually both the lips are of same color.
When one lips is of a color or texture different from that of
the other , it should be examined further.
Less active or hypoactive upper lip is lighter in color.

39. 39
Tonicity: - Feel the lip for consistency,
Normal lip – minimal tonicity,
Hypertonic lip – tend to be firm and redder,
Hypotonic lip is flaccid.

40. 40

41. oLIP STEP ACCORDING TO KORKHAUS :-
Positive lip Slightly negative lip Marked negative lip 41

42. Examination of the nose :-
Nose size : normally the nose is 1/3rd of the total facial
height.
Nasal contour : the shape of the nose can be straight,
convex or crooked as a result of nasal injuries.
Nostrils : they are oval and should be bilaterally
symmetrical.
42•Orthodontic diagnosis by Thomas Rakosi, Irmtrud Jonas, Thomas M. Graber

43. Alar base width: - The width of the alar base should be
approximately the same as intercanthal distance,which
should be the same as the width of an eye.
Collumella :- between nasal tip and base of the nose.
Divide into anterior lobular, intermediate and basal
portions.
All segments – equal.
43•Orthodontic diagnosis by Thomas Rakosi, Irmtrud Jonas, Thomas M. Graber

44. Examination of chin :-
Mentolabial sulcus : the mento – labial sulcus is a
concavity seen below the lower lip.
Mentalis activity : hyperactive mentalis activity is seen in
some malocclusion cases. It causes puckering of the chin.
44
Deep mento labial sulcus and hyperactive
mentalis activity in Class II div. 1Mentolabial sulcus

45. oNASOLABIAL ANGLE :-
•This angle is normally 110◦ .
• Proclined upper anteriors or prognathic maxilla.
• Retrognathic maxilla or retroclined maxillary anteriors.
45

46. oEXAMINATION OF TONGUE :-
•Abnormalities of the tongue can upset
the muscle balance and equilibrium
leading to malocclusion.
•Macroglossia - scalloping on the lateral
margins of the tongue.
• Tongue–tie as it alters the resting tongue
position and impairs the tongue
movement.
46

47. Examination of the palate :-
The palate should be examined for the following findings :
•Variation in palatal depth
•Presence of swelling
•Mucosal ulceration and indentations
•Presence of clefts
47

48. oEXAMINATION OF GINGIVA :-
•Anterior marginal gingivitis - mouth breathers due to
dryness of the mouth caused by the open lip posture.
•Bleeding on probing indicates active disease, which must be
brought under control before treatment is undertaken.
48

49. oEXAMINATION OF FRENAL ATTACHMENTS :-
•A heavy maxillary labial frenum.
•An abnormally high attachment of the mandibular labial
frenum
49

50. Assessment of the dentition :-
 Status of dentition i.e. erupted and missing teeth.
 Presence of caries, restorations, malformations,
hypoplasia, wear and discoloration.
50

51. Antero – posterior relation :
Angle’s class I (neutrocclusion, normal antero-posterior relationship)
Angle’s class II div. 1( distoclusion with labioversion of the maxillary
incisors)
51

52. Angle’s class II div. 2 (distoclusion with linguo-version of
the upper incisors)
Angle’s class III (mesioclusion)
52

53. Over jet and overbite :
Transverse malrelations, like cross bite and shift of midline :
53

54. Individual tooth irregularities such as rotations,
displacements, intrusion and extrusion.
Rotation Transposition
Arch form and symmetry.
54

55. Functional examination :-
a. Assessment of postural rest position and inter occlusal
space
b. Path of closure
c. Assessment of respiration
d. Examination of TMJ
e. Examination of swallowing
f. Examination of speech
55

56. Assessment of postural rest
position and inter – occlusal
clearance :-
Normally the freeway space is 3mm in canine region.
Methods :
•Phonetics : ‘m’ or ‘c’ or ‘Mississippi’
•Command method : e.g. swallowing
•Non command method :
e.g. visual examination
56

57. Measurement of inter occlusal clearance;
•Direct intra oral procedure : vernier caliper
•Direct extra oral procedure
•Indirect extra oral procedure : e.g. radiographs, Kinesiography
57

58. 58
The mandibular kinesiographic, according to jankelson(1984),
allows the mandibular rest position to be registered three
dimensionally.
The position of the mandible is recorded electronically by:
• A permanent magnet, which is fixed with rapid-setting acrylic
to the lower anterior teeth.
• A sensor system of six magnetometers mounted on the
spectacle frames.

59. Evaluation of path of closure :-
The path of closure is the movement of the mandible from
rest position to habitual occlusion.
a. Forward path of closure : occurs in patients with mild
skeletal prenormalcy or edge to edge incisor contact.
b. Backward path of closure : class II div.2 cases exhibit
premature incisor contact due to retroclined maxillary
incisors.
c. Lateral path of closure : it is associated with occlusal
prematurity and a narrow maxillary arch.
59

60. Assessment of respiration :-
Humans may exhibit 3 types of breathing : nasal, oral and
oro-nasal.
Tests to diagnose the type of respiration :
a. Mirror test
b. Cotton test
c. Water test
d. observation
60

61. Examination of T.M.J. :-
The maximum mouth opening is determined by measuring
the distance between the maxillary and mandibular incisal
edges with the mouth wide open.
The normal inter – incisal distance is 40 – 45 mm.
61

62. oSPEECH :-
Certain malocclusions may cause defects in speech
due to interference with movement of the tongue
and lips.
62
William R. Proffit, Henry W.Fields.jr- contemporary orthodontics,4th edition -2004 mosby elesvier publications.

63. Evaluation of swallowing :-
The persistence of the infantile swallowing can be a cause
for malocclusion.
The persistence of infantile swallow is indicated by the
presence of the following features :
a. Protrusion of the tip of the tongue.
b. Contraction of perioral muscles during swallowing.
c. No contact at the molar region during swallowing.
63

64. Orthodontic study model :-
Orthodontic study models are accurate plaster reproduction
of the teeth and their surrounding soft tissues.
Uses of the study models :-
•The study of the occlusion from all aspects.
•Accurate measurements.
•Assessment of treatment progress.
64

65. •Assessing the nature and severity of malocclusion.
•Motivation of the patient.
•To simulate treatment procedures on the cast.
•Useful in transfer of records.
65

66. Diagnostic set up :-
First proposed by H. D. Kesling.
Made from an extra set of trimmed and polished study
model.
Uses of diagnostic set up :-
• Useful in visualizing and testing the effects of
complex tooth movements and extractions on
occlusion.
•The patient can be motivated by simulating the various
corrective procedures on the cast.
•Tooth size – arch length discrepancies can be
visualized.
66

67. Facial photographs :-
Facial photographs offer a lot of information on the soft
tissue morphology and facial expression.
The extra oral photographs :-
These are taken by positioning the patient in such a manner
that the F – H plane is parallel to the floor.
67
Frontal view Profile view Oblique

68. oThe intra oral photographs :-
Frontal view Right lateral
view
Left lateral view
Maxillary occlusal view Mandibular occlusal
view
68

69. Electromyography :-
Electromyography is a procedure used for recording the
electrical activity of the muscles.
The electromyograph is a machine that is used to receive,
amplify and record the action potential during muscle
activity.
The action potential is picked up by electrodes that are of
two types : a) surface electrodes and b) needle
electrodes
69

70. EMG is used to detect the abnormal muscle activity in
certain forms of malocclusion.
For e.g. in severe class II, div. 1 malocclusion the upper lip is
hypo-functional, Abnormal buccinator activity.
• EMG can be carried out after orthodontic therapy to see if
muscle balance is achieved.
70

71. RADIOGRAPPHIC
EXAMINATION :-
A valuable tool in orthodontic diagnosis.
Uses of radiographs in orthodontics –
i. General development of the dentition, presence, absence
and state of eruption of the teeth.
ii. The presence or absence of supernumerary teeth.
iii. Extent of root resorption of deciduous teeth.
iv. To study the extent of root formation of the permanent
teeth.
71

72. i. The presence and extent of pathological and traumatic
conditions
ii. Character of alveolar bone.
iii. Axial inclination of the roots of teeth.
iv. Morphologically abnormal teeth.
72

73. o Radiographs routinely used for diagnosis in
orthodontics can be classified into two groups :-
1. Intra oral radiographs –
• Intra oral periapical radiographs
• Bitewing radiographs
• Occlusal radiographs
73

74. 2. EXTRA ORAL RADIOGRAPHS :-
a. Panoramic radiographs –
b. Cephalometric radiographs –
74

75. 3. Other radiographs :-
Hand wrist radiographs
75

76. Recent advances in diagnostic
aids :-
1. XERORADIOGRAPHY :-
• Xeroradiography is a completely dry, non – chemical
process that makes use of the electrostatic process as in
Xerox machine.
• It was invented by Chaster f. Carlson in 1937.
• It makes use of an aluminium plate that is coated with a
layer of vitreous selenium.
76

77. • The unique feature of it is that it is possible to have both
positive and negative image.
• It exhibit high edge contrast due to a phenomenon called
edge enhancement.
• The xeroradiographic image is on paper and is viewed in
reflected light.
77

78. 78
2. DIGI GRAPH :-
•The digi graph is a synthesis of video imaging, computer
technology and sonic digitizing.
•The digi graph enables the clinician to perform non – invasive
and non – radiographic cephalometric analysis.
•The system allows cephalometric evaluation and treatment
progress as often as necessary without radiographic exposure.

79. 79
3. MRI (Magnetic Resonance Imaging) :-
•MRI makes use of two fundamental properties of
protons, i.e. spin and small magnetic movement.
•The advantages of MRI are:
It does not have hazards as it uses non ionizing
electromagnetic radiation.
Anatomical details are good as in CT scan.
Greater tissue characterization is possible.
Imaging of blood vessels, blood flow, visualization
of thrombus is possible.

80. 80
4. TOMOGRAPHY :-
• Tomography can be used to visualize a section or slice of the
object and thereby eliminate undesirable overlap.
• Tomography can be conventional or computed tomography.

81. 81
5. OCCLUSOGRAMS :-
•It is a tracing of a photograph or a photocopy of a
dental arch.
•It is used for the following purposes :
To estimate occlusal relationship.
To estimate arch length & width.
To estimate the required tooth movement in all 3 planes
of space.
To estimate anchorage requirements.

82. 82
6. DIGITAL SUBTRACTION RADIOGRAPHY :-
•Decreases the amount of distracting background
information and by allowing the eye to focus on the actual
change that has occurred between two images.
•Technically this is an image enhancement method that
removes the structured noise from the image.

83. 83
7. LASER HOLOGRAPHY :-
•Holography is a photographic technique for recording
and reconstructing images in such a way that the 3
dimensional aspect of an object can be obtained.
•The recorded image is called a hologram.

84. Conclusion :-
•The essence of the problem-oriented approach is the
development of a comprehensive database of pertinent
information so that no problems will be overlooked.
•From this database, the list of problems that is the diagnosis
is abstracted.
84

85. References :-
William R. Proffit, Henry W.Fields.jr- contemporary
orthodontics,4th edition -2004 mosby elesvier publications.
Graber,Vanarsdall,orthodontics:current principles and
techniques.4th edition. Elsevier mosby 2005.
•Orthodontic diagnosis by Thomas Rakosi, Irmtrud Jonas,
Thomas M. Graber
•Dentistry for the child – Mc Donald
85

86. 86