Essential diagnostic aids in orthodontics

Diagnostic aids , case history recording , essential and non essential aids

1. ORTHODONTIC DIAGNOSIS P r e s e n t e d by : D r . H A R I P R A S A D L

2. CONTENTS -Introduction -Classification of diagnostic aids -Essential diagnostic aids -Case history -Clinical examination -Radiographs- IOPA, Bitewing,Occlusal - OPG, cephalometric radiographs Hand-wrist radiographs -Photographs -Conclusion

3. Diagnosis is defined as ‘ The act/ process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination and review of laboratory data’ Orthodontic diagnosis deals with the recognition of the various characteristics of the malocclusion . It involves collection of pertinent data in a systemic manner to help in identifying the nature and cause of the problem Orthodontic diagnosis should be based on the sound scientific knowledge combined at times with clinical experience and common sense Comprehensive orthodontic diagnosis is established by use of certain clinical implements called diagnostic aids .

4. Orthodontic diagnostic aids are of two types : 1. Essential diagnostic aids 2.Non – essential diagnostic aids / Supplemental diagnostic aids

5. 1 . CASE H I S TORY E S S E NTIAL D I A G N O S T I C A I D S C A S E H I S T O R Y C L I N I C A L E X A M I N A T ION S T U D Y M O D E L S C E R T A IN R A D I O G R A P H S * P E R I A P I C A L * B I T E W I N G * P A N A R O M I C F A C I A L P H O T O G R A P H S

6. S U P L E M E N T A R Y D I A G N O STIC A I D S S P E C I A L I S E D R A D I O G R A P H S . * C e p h a l o m e t r i c R a d i o g r a p h s . * O c c l u s a l I n t r a o r a l F i l m s * S e l e c t e d L a t e r a l J a w V i e w * C o n e S h i f t T e c h n i q u e E l e c t r o m y o g r aphic e x a m i n a t ion H a n d W r i s t R a d i o g r aphy E n d o c r i n e T e s t D i a g n o s tic S e t u p O c c l u sogram E s t i m a t i o n O f B a s a l M e t a b o l i c R a t e

7. C ase history is the information gathered from from the patient or the parent that aids in overall diagnosis of the case. Personal Details Name Age Sex Address Occupation CASE HISTORY

8. C HIEF COMPLAINT (major reason for seeking consultation and treatment) . T here are three major reasons for patient concern about the alignment and occlusion of the teeth : 1. I mpaired dentofacial esthetics that can lead to psychosocial problems 2. I mpaired function and 3. D esire to enhance dentofacial esthetics and thereby the quality of life

9. MEDICAL HISTORY Before orthodontic treatment is undertaken , a full medical history is recorded. Very few medical conditions contraindicate the use of orthodontic appliances

10. Most of these conditions may require certain precautionary measures to be taken prior to or during orthodontic therapy. Some systemic conditions and their orthodontic considerations: 1.Diabetes mellitus - Ortho Rx should be avoided in poorly controlled insulin dependent diabetes mellitus - Morning appointments are advisable

11. 2.Endocarditis Invasive procedures such as extraction, placement of bands, removal of bands and flap procedures should be performed under antibiotic prophylaxis Bonded instruments are preferred over banded ones so as to clear of the gingival bleeding

12. 3.Hemophilia A These patients pose a risk of increased bleeding following extraction. Extraction as a part of orthodontic treatment is not a contraindication Care should be taken during insertion and removal of arch wires in order to avoid any injury to oral soft tissue

13. 4.Asthma Anxiety is a known trigger , therefore the appointment is made as stress free as possible and the patient instructed to have their medication before the appointment Methylmethacrylate is also a trigger factor , fixed appliances are preferred over removable appliances 6.Epilepsy Removable appliances are contraindicated in patients with poorly controlled epilepsy due to airway obstruction during seizures Phenytoin – gingival hyperplasia

14. 5.Chronic renal failure Orthodontic treatment is not a contraindication Kidney transplant patients- immunosuppressive drug- gingival hyperplasia – Ortho Rx is delayed till the overgrowth is reduced either by good oral hegiene or surgically.

15. DENTAL HISTORY -Should include information on the age of eruption of the deciduous and permanent teeth, H/o extraction, decay, restorations and trauma to the dentition. -Gives information about the attitude of the patient towards dental treatment

16. PRENATAL HISTORY -condition of the mother during pregnancy -type of delivery- forceps delivery-TMJ Injuries- mandibular growth retardation POSTNATAL HISTORY -type of feeding,presence of habits and h/o trauma

17. FAMILY HISTORY Many malocclusions are inherited such as skeletal class II and class III, congenital conditions such as clefts of lip and palate

18. GENERAL EXAMINATION Height And Weight -Provide a clue to the physical growth and maturation of the patient Gait - It is the way a person walks. Abnormalities of gait are usually associated with neuromuscular disorders that may have a dental correlation A

19. Posture -refers to the way the a person stands. -abnormal postures can predispose to malocclusion due to alteration in maxillo-mandibular relationship Body build (Physique) 1. Aesthetic : thin physique and usually posses narrow dental arches 2. Plethoric : obese persons, they generally have large, square dental arches 3. Athletic : normally built, being neither thin nor obese,they have normal sized dental arches

20. Sheldon classification of general body build 1.Ectomorphic- tall and thin physique 2.Mesomorphic-Average physique 3.Endomorphic- short and obese physique

21. EXTRA ORAL EXAMINATION Shape of head 1. Mesocephalic - average shape of the head,they posses normal dental arches. 2. Dolicocephalic -long and narrow head, they have normal dental arches 3 .Brachycephalic -broad and short head,they have broad dental arches

22. Facial form Round,Oval & Square 1.Mesoprosopic- average or normal face form 2.Euryproscopic – broad and short 3.Leptoproscopic – long anf narrow face form

23. Assessment of facial symmetry Asymmetries that are gross and are detected easily should be recorded. Congenital defects Hemifacial atrophy/hypertrophy Unilateral condylar ankylosis and hyperplasia

24. Facial profile It examined by viewing patient from side. 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 the point A and soft tissue pogonion Based on the relationships between these two lines, three types of profiles exist

25. 1 .Straight profile – two lines form a nearly straight line 2. Convex profile –two lines form an angle with the concavity facing the tissue - Prognathic maxilla, retrognathic mandible -Seen in class II division I malocclusion 3. Concave profile- the two reference lines form an angle of convexity towards the tissue - Prognathic mandible & retrognathic maxilla - Seen in class III malocclusion

26. Facial divergence It is defined as an anterior or posterior inclination of the lower face relative to the forehead. 1. Anterior divergent – A line drawn between the forehead and the chin is inclined anteriorly towards chin 2. Posterior divergent – A line drawn between the forehead and chin slants posteriorly towards th chin 3. Straight or orthognathic - The line between the forehead and the chin is straight or perpendicular to the floor

27. Examination of lips 1. Competant lips : The lips are in slight contact when the musculature is relaxed 2. Incompetant lips : They are morphologically short lips that do not form a seal 3. Potentially incompetant lips : They are normal lips that fail to form a lip seal due to proclined upper incisors 4. Everted lips : they are hypertrophied lips with weak musculature

28. Examination of nose 1. Nose size : Normally the nose is one third of total facial height 2. Nose contour : Straight ,convex or crooked as a result of nasal injuries 3. Nostrils : Oval and bilaterally symmetrical

29. Examination of chin 1.Mentolabial sulcus -Deep mentolabial sulcus : Class 2 division 1 malocclusion -Shallow mentolabial sulcus:Bimaxillary protrusion 2.Mentalis activity -Hyperactive mentalis activity –Class 2 division 1 malocclusion

30. Chin position and prominence 1.Prominent chin – Class 3 malocclusion 2.Recessive chin - Class 2 malocclusion Nasolabial angle : Normally its 110 degree 1.Increased – In patients with retrognathic maxilla 2. Decresed – In patients with prognathic maxilla

31. INTRA ORAL EXAMINATION Examination of tongue : The lingual frenum should be examined for tongue tie Examination of palate 1. Variation in palatal depth 2. Presence of swelling in the palate 3. Mucosal ulceration and indentation 4. Presence of clefts in the palate

32. Examination of gingiva -Inflammation ,recession, pockets -Anterior marginal gingivitis-in mouth breathers -Traumatic occlusion- localised gingival recession -Gingival hyperplasia- certain drugs

33. Examination of frenal attachment -Maxillary labial frenum :Thick fibrous and attached relatively low – midline diastema -Abnormal frenal attachment – Blanch test: Upper lip is streched upwards and outwards for a period of time .The presence of blanching in the interdental papilla is diagnostic of an abnormal frenum . - Lingual frenum :Tongue tie or ankyloglossia –Unrestrained buccinator activity –narrowing of maxillary arch

34. Examination of tonsils and adenoids -Abnormal inflamed tonsils cause alteration in tongue and jaw posture there by upseting the orofacial balance leading to malocclusion Assessment of dentition 1.Teeth present inside oral cavity 2.Teeth unerupted 3.Teeth missing 4.Status of dentition 5.Presence of caries ,restorations ,malformations ,wear and discolouration

35. 6.Molar relation –Angles class 1 ,2,3 7.Overjet,overbite,deepbite,openbite and cross bite should be examined 8.Look for shift in midline 9.Individual tooth irregularities –rotations displacements intrusion and extrusion are noted 10.See for arch form – Normal,narrow,square

36. FUNCTIONAL EXAMINATION 1.Assessment of postural rest position and interocclusal space The postural rest position with the position of mandible at which the muscles that close the jaws and open them are ,in a state of minium contraction to maintain the posture of mandible At the postural rest position space exist between upper and lower jaws .This interocclusal clearance is called freeway space .Normally the freeway space is 3mm in canine region

37. There are various methods of assessing the postural rest position . During examination the patient should be seated upright ,with the back unsupported and ask to look straight ahead The following are some of the methods used to record postural rest position 1.Phonetic method 2.Command method 3.Non command method 4.Direct intra oral procedure 5.Direct extra oral procedure 6.Indirect extraoral procedure

38. 2.Evaluation of path of closure The path of closure is the movement of mandible from rest position to a habitual occlusion. Abnormalities of path of closure are seen in some form of malocclusions 1.Forward path of closure 2.Backward path of closure- class 2 division 2 malocclusion 3. Lateral path of closure seen in occlusal prematurities and a narrow maxillary arch

39. 3.Assessment of respiration a. Mirror test b. Cotton test c. Water test d. Observation 4.Examination of TMJ -Auscultation and palpation of TMJ - Look for clicking, crepitus pain of the masticatory muscles, limitation of jaw movement , hypermobility and morphological abnormalities. Normal inter- incisal distance is 40-45 mm

40. 5. Evaluation of swallowing Persistance of infantile swallow can be a cause for malocclusion. It is indicated by the following features: a. Protrusion of tip of the tounge b. Contraction of perioral muscles during swallowing c. No contact at the molar region during swallowing

41. 6. Speech Certain malocclusions may cause defects in speech due to interference with movement of the tongue and lips. The patient can be asked to read out from a book or asked to count from 1-20 while observing the speech. Patients with cleft palate may have a nasal tone.

42. These are the accurate plaster reproductions of teeth and their surrounding tissues. They are an essentail diagnostic aid that makes it possible to study the arrangement of teeth and the occlusion from all directions. Uses of study models They enable the study of the occlusion from all the aspects They enable accurate measurements to be made in dental arch ORTHODONTIC STUDY MODELS

43. 3. They help in assessment of treatment progress by dentist as well as the patient 4. They help in assessing the nature and severity of malocclusion 5. It makes possible to simulate treatment procedures on the cast such as model surgery 6. Study models are useful to transfer records in case the patient is to be treated by another clinician 7. They are helpful in motivation of the patient.

44. PLASTER STUDY MODELS Disadvantages 1.Plaster study models break 2.Continued use for measurements and display can wear away plaster, decreasing accuracy and increasing likelihood of fracture. 3. Storage in another area presenting both time and space problems 4. They may undergo physical changes during handling 5. Portability problem

45. 6. Communication is difficult when only one set of models exist DIGITAL STUDY MODELS These are obtained by laser scanning of impressions or the plaster study models. Once the scanning is done the digital models are obtained by using computer aided design and manufacturing ( CAD/CAM) where it is transferred into a digital, 3-D image of the dentition. Softwares enable the digital models to be viewed from all aspects and manipulated.

46. Advantages of digital study models: 1. Reduction in space needed to store the models 2. Easy retrievel and transmission of the image to other computers 3. Measurement of dental cast can be carried out without the use of caliper. 4. The digitized models can be viewed from any angle and also opened to allow upper and lower models to be viewed seperately 5. Possibility of viewing digital models at multiple locations allowing patients to be treated at multiple sites.

47. Gnathostatic set up They are the orthodontic study models where the base of maxillary cast is trimmed to correspond the Frankfort horizontal plane.

48. 1.Intra oral radiographs The techniques used in intra oral periapical radiography are a. Paralleling technique b. Bisecting angle technique USES OF IOPAs 1.To confirm the presence or absence of teeth 2.To study the extent of periapical pathology 3.To study the alveolar bone and pdl 4.To study the height of alveolar bone crest 5.To assess the axial inclination of roots 6.To detect retained root fragments and root stumps 7.To determine the size and shape of unerupted teeth. RADIOGRAPHS

49. Disadvantages of IOPAs Assessment of the entire dentition requires too many radiographs Children may not allow placement of intra oral films They cannot be used in patients with high gag reflex and trismus . Advantages of IOPAs 1.Low radiation dose 2.Possible to obtain the localised areas of interest 3.They offer excellent clarity of teeth and their supporting structures.

50. 2.Bitewing radiographs 1. To detect proximal caries 2. To study the height and contour of interdental bone 3. To study secondary caries 4. To detect overhanging proximal restorations 5. To detect interproximal calculus

51. 3. Occlusal radiographs Uses of occlusal radiographs To locate impacted and unerupted teeth To locate supernumerary teeth To locate foreign bodies in salivary ducts To study bucco -lingual expansion of cortical plates due to pathology of jaw To study the arch expansion procedures

52. EXTRA ORAL RADIOGRAPHS These are useful whenever large areas of face and skull are to be visualised Panoramic Radiographs Uses They are useful in assessing dental development by studying deciduous root resorption and root development of permanent teeth Used to view ankylosed and impacted teeth

53. 3. To study the path of eruption of teeth 4. To diagnose the extent of fractures 5. To diagnose the presence of supernumerary teeth Advantages 1. A broad anatomic area can be visualised 2. The patient radiation exposure is low 3. Can be used in patients with trismus

54. Disadvantages 1.Distortion, magnifications and overlapping of structures occur 2.Inclination of anterior teeth cannot be visualised 3.Requires equipment that is expensive Other radiographs Cephalometric Radiographs Hand-wrist Radiographs TMJ views- Transcranial view, Transorbital view Transpharyngeal view

55. Facial photographs offer a lot of infromation on the soft tissue morphology and facial expression Three extraoral views are routinely taken Frontal view Profile view Oblique facial view FACIAL PHOTOGRAPH AS A DIAGNOSTIC AID

56. Photographs are taken in such a manner that FH plane is parallel to the floor

57. Intra oral photograph include Left and right lateral view Frontal view Maxillary and mandibular view

58. USES 1.They are useful in assessment of facial symmetry, facial type and profile 2.They serve as diagnostic records 3.They help in assessing the progress of the treatment.

59. The problem-oriented approach for diagnosis and treatment planning has been widely advocated in medicine and dentistry. The essence of 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. CONCLUSION

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