Orthodontic diagnosis

orthodontic diagnosis in children

1. K.SANTOSHI II MDS ORTHODONTIC DIAGNOSIS

2. CONTENTS Introduction Steps in diagnosis and treatment planning Diagnostic aids Essential Aids Case history Clinical examination General examination Extra-oral examination Intra-oral examination Functional analysis Study casts Radiographs- Peri apical , Bitewing,Panoramic . Facial photographs

3. Supplemental Aids The supplemental diagnostic aids include ; 1-Specialized radiographs ex; a- cephlometric radiographs b- occlusal intra-oral films c-selected lateral jaw views d-cone shift technique 2.Electromyographic examination of muscle activity Hand wrist radiographs to assess bone age or maturation age Conclusion References

4. INTRODUCTION Orthodontic diagnosis deals with recognition of the various characteristics of the malocclusion. It involves collection of data in a systematic manner to help in identifying the nature and cause of the problem. Orthodontic diagnosis should be based on sound scientific knowledge combined at times with clinical experience and common sense. A proper diagnosis is essential for better treatment plan . Orthodontic diagnosis – rakosi , graber

5. 3 Contemporary orthodontic 5 th edition proffit

6. Orthodontic diagnosis – rakosi , graber 7 DIAGNOSTIC AIDS

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8. NAME OF THE PATIENT : For identification, For better communication and Medicolegal l egal records. AGE : Chronologica age – Growth modification procedures SEX : Timing of growth spurt and esthetics OCCUPATION: Economic status , Occupational hazards ADDRESS: for correspondance , to know the endemic and pandemic outburts ETHENIC ORIGIN: ethnic facial charecteristics CONTACT NUMBER:

9. CHIEF COMPLAINT: recorded in patients own words and in order of preference & priority. Most common logical reasons for orthodontic treatment will be 1)Impaired dento-facial esthetics leading to psychological problems 2) I m p a i red f unction (che w ing, spe e ch and oral h y giene m ain t e nance ) 3)Concern about alignment & occlusion of teeth. 4)Desire to enhance esthetics to improve quality of life. Contemporary orthodontic 4 th edition proffit 9

10. Medical history H/O of previous hospitalization.  H/O chronic diseases like diabetes, cardiac problems.  H/O allergy specially LATEX & NICKEL.  H/O blood transfusion & drugs  Tonsillectomy/Adenoidectomy  Epilepsy PRENATAL HISTORY Medications during pregnancy Delivery- Full term/ Premature Type- Normal/ Forceps/ Caesarian TMJ ankylosis due to prenatal trauma by forceps delivery POST NATAL HISTORY FEEDING METHODS-(Breast or Bottlle and INJURIES- To Dento-Alveolar and Oro-Facial structures , HABITS ANY ABNORMAL ORAL HABITS.

11. ORAL HABITS

12. THUMB SUCKING EXTRA ORAL EXAMINATION Digits in acute thumb suckers Digits in chronic thumb suckers Reddens Fibrous , rounghened Clean , chapped Hypotonic upper lip

13. EFFECTS OF DIGIT- SUCKING 1. MAXILLA- Proclination of maxillary incisors Increased arch length Increased anterior placement of apical base of maxilla Constricted maxilla Increased clinical crown length of incisors Counter-clockwise rotation of occlusal plane Atypical root resorption of primary incisors Trauma to the incisors

14. MANDIBLE - Retroclination of lower incisors Increased inter-molar width Distal placement of mandible INTER-ARCH RELATIONSHIP – Decreased inter-incisal angle Increased overjet Posterior cross-bite Anterior open-bite Narrow nasal floor

15. TONGUE THRUSTING Placement of the tongue tip forward between incisors during swallowing Proffit SIMPLE TONGUE THRUST Contraction of lips, mentalis and mandibular elevators Teeth are in occlusion as tongue protrudes into open bite Open bite Hypertrophy of tonsils which are not enlarged enough Diminishes with the age Treatment is simple Good prognosis

16. COMPLEX TONGUE THRUST Contractions of lips , facial and mentalis muscles Lack of contractions of mandibular elevators Teeth apart during swallow History of chronic nasorespiratory disease and allergies More diffuse open bite Inflamed tonsils Does not diminish with age Poor prognosis

17. RETAINED INFANTILE SWALLOW Strong contractions of lips and facial musculature especially buccinator. Anterior and lateral thrusting Inexpressive face Difficulty in mastication Poor prognosis

18. MALOCCLUSION Proclination of upper anteriors Anterior or posterior open bite Protrusion of anterior segment of both arches Constricted maxillary arch Posterior cross bite Spacing

19. MOUTH BREATHING CLINICAL FEATURES Long and narrow face ( Adenoid face) Narrow nose and nasal passage Short and flaccid upper lip Contracted upper arch with possibility of posterior cross bite E x c e s s i v e er u pt i o n o f po ster i o r s Constricted maxillary arch Excessive overjet Anterior openbite Marginal gingivitis

20. LIP HABITS BRUXISM

21. FAMILY HISTORY H/O cleft lip & palate Hereditary dysgnathias include- Class II Div 2 Skeletal open bite Bimaxillary protrusion Skeletal classIII

22. PHYSICAL GROWTH EVALUATION The best clinical effects are achieved in good growers and poorest results are achieved in poor growers. By good growers, clinicians mean a patient with an amount, rate, direction and pattern of growth that facilitates treatment. The most favourable time to attack many orthodontic problems with skeletal manifestation is during growth acceleration in puberty . CONTEMPORARY ORTHODONTICS WILLIAM. R. PROFFIT 5 TH EDITION

23. Thus, predicting nature and timing of onset of pubertal growth is important in planning orthodontic therapy.

24. GENERAL EXAMINATION 1.BUILT : Asthetic : thin built and usually possess narrow dental arches Pletoric : obese built & generally have broad dental arches Atheletic : neither thin nor obese normally built and normal dental arches.

25. GENERAL EXAMINATION 2. BODY TYPE: Sheldon in 1940 described body build as : Endomorphs - short and obese . Ectomorphs- long and thin. Mesomorphs- between endo and ectomorphs .

26. GENERAL EXAMINATION 3.GAIT : This is examined as the patient walks in the clinic. Any neuromuscular defects should be made out in this evaluation . 4.POSTURE: While evaluation of posture; look for kyphosis, lordosis or scoliosis. There has been association of vertebral abnormalities with facial disharmonies. 5.HEIGHT AND WEIGHT: They give a clue to physical maturation and growth of the patient which may have dentofacial correlation .

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28. SHAPE OF THE HEAD: This should be assessed from above the head. It is calculated by : Anthropological index= width of cranium X 100 length of cranium Index value > 81 is termed Brachycephalic . Value < 76 is termed Dolichocephalic . Values between 76 and 81 is termed Mesocephalic . DOLICHOCEPHALY BRACHYCEPHALY MARTIN & SALLER-1957

29. Martin, R., and K. Saller (1957). Lehrbuch der anthropologie. Gustav Fischer Verlag, Stuttgart

30. FACIAL INDEX  Defined as ratio between morphological facial height & bizygomatic distance.  Given by Martin & Saller in 1957.  Morphologic facial index = Morphologic facial height Bizygomatic width Contemporary orthodontic 4 th edition proffit 31

31. FACIAL SYMMETRY The patient’s facial symmetry is examined to determine disproportions of the face in transverse and vertical planes. Gross facial asymmetry can occur as a result of:  A. congenital defects  B.hemi -facial atrophy/hypertrophy  C.unilateral condylar ankylosis and hyperplasia

32. Vertical facial symmetry hair line to midbrow,midbrow to subnasale ,and subnasale to soft tissue menton . 55 to 65 mm . Variation in facial thirds may be due to vertical maxillary excess and deficiency,open bite,deep bite etc

33. Middle fifth of the face - a line from inner canthus should be coincided with ala of nose. Medial two fifths of the face- a line from the outer canthus of the eye should be coincided with the gonial angle of the mandible Outer two fifths of the face- measured from the base of the ear to the helix of the ears TRANSVERSE FACIAL PROPORTIONS 35

34. PROFILE ANALYSIS Drop two lines A line joining the forehead and the soft tissue point A (deepest point in the curvature of upper lip) A line joining point A and the soft tissue pogonion (most anterior point of the chin ) N ’ Sn Pg ’

35. PROFILE ANALYSIS Depending on the angle formed Straight-Class I Convex-Class II Concave-Class III

36. FACIAL DIVERGENCE This term was coined by Milo Hellman in 1921 . It is the anterior or posterior inclination of lower face relative to forehead The facial angle formed by Nasion-Pogonion soft tissue line and the frankfort horizontal line is used to define as facial divergance .

37. FACIAL DIVERGENCE STRAIGHT/ ORTHOGNATHIC-(90) ANTERIOR DIVERGANCE-(more than 90) POSTERIOR DIVERGANCE-(less than 90)

38. ASSESSMENT OF ANTERO- POSTERIOR JAW RELATIONSHIP Estimation is done by placement of the index and the middle fingers at point A and point B respectively. 40 SKELETAL PATTERN

39. ASSESSMENT OF VERTICAL SKELETAL RELATION Average FMA angle - Two planes meet at the occipital region. Low angle- Two planes meet beyond the occipital region. High angle- Two planes meet at the mastoid region in front of the ear. 41 By the angle formed between Lower border of the mandible and Frankfort horizontal plane.

40. MANDIBULAR PLANE ANGLE  Both planes meet at occipital region.  If they meet beyond it- Low angle or horizontal growth pattern.  If they meet anterior- High angle or Vertical growth pattern. Vertical grower Horizontal grower

41. SOFT TISSUE EXAMINATION According to Burstone (AJO April 1967) LIP LENGTH Upper lip length: From: subnasale to upper lip inferior (19 to 22mm) Lower lip length: From: lower lip superior to Menton (38 to 44mm)

42. LIP MORPHOLOGY According to Burstone (AJO April 1967) Lips might be full, thick(12 to 20mm) or might be thin(6 to 10 mm). Full and everted are usually associated with proclined upper and lower labial segments. Lips that are thin are usually associated with retroclined upper and lower labial teeth.

43. KORKHA’S LIP STEPS-HORIZONTAL LIP ANALYSIS POSITIVE LIP STEP NORMAL LIP STEP MARKED NEGATIVE LIP STEP

44. LIP COM PETENCE In child patient, it is common for lips to be apart at rest. As the child progresses through to teens, increase in soft tissue maturation means lips become competent . If older child or certainly adults have incompetent lips they may demonstrate increased contraction of circumoral musculature to habitually keep lips together . This can be seen as puckering in the skin over the chin caused by excessive contraction of mentalis muscle

45. EXAMINATION OF LIPS : 47 Size :Normal\Short\Thin\Thick\Everted Posture : Competent\Incompetent\Potentially Incompetent C o m p e t e n t lips Potentially incompetent lips I n co m pet e n t lips Contemporary orthodontic 4 th edition proffit

46. NASOLABIAL ANGLE Normal (90-100)/ Acute/Obtuse ACUTE ANGLE NASO-LABIAL ANGLE OBTUSE ANGLE Proclined upper anteriors Prognathic maxilla Increased angle - Retrusion of upper lip Retroclined upper anteriors Retrognathic maxilla Contemporary orthodontic 4 th edition proffit Normal 110 Protrusive upper lip Decreased angle -

47. Mentolabial Sulcus 49 It is a fold of soft tissue between lower lip & chin. Affected by- Facial Height Overjet Chin Projection . Deep sulcus – Class II Div 1 Shallow sulcus – Bimaxillary protrusion NORMAL SHALLOW DEEP

48.  Hyperactive mentalis activity produces puckering effect in chin region called as GOLF BALL APPERANCE Contemporary orthodontic 4 th edition proffit 5 1

49. NOSE EXAMINATION 51 Size - One third of total face height.  Microrhinic  Macrorhinic Nostrils - Oval & bilaterally symmetrical Types of nose…1.leptorhine 2.mesorhine3.platyrhine  STRAIGHT BRIDGE CONVEX BRIDGE CROOKED NOSE

50. Projection - Depends on  Bone over inferior border of mandible  Soft tissue over chin  Overdevelopment of chin height alters position of lo wer lip & Interferes with lip closure.  Influence on profile- -Protruding chin with deep mentolabial sulcus- Retrusive lip profile. -Negative chin formation with absence of sulcus- Protrusive lip profile. Orthodontics – current principles and technique 5 th edi tion C HIN

51. A d equa te chin E xcessive chin R e cess ive chin 54 Orthodontics – current principles and technique 5 th edition

52. VISUALIZED TREATMENT OBJECTIVE This examination help s us deciding whether any functional appliance that postures the mandible forward will improve the facial profile and appearance. Patient is instructed to swallow ,lick the lips and then relax. His profile with teeth in habitual occlusion is observed . He is then asked to bring the mandible forward into a correct sagittal relationship reducing the overjet

53. Profile doesnot improve when Excess anterior facial height Deficient symphyseal development Steep mandibular plane Improved profile seen in Anteriorly rotated growth patterns Functional retrusion Deep overbites Excessive inter occlusal clearence with normally positioned maxilla

54. It helps in predicting treatment changes that would occur in the future for the patient. The accuracy of prediction is a combination of the effect of treatment procedures and accuracy of predicting future growth They are not very accurate but may act as rough estimate of acurate outcome

55. INTRA-ORAL EXAMINATION In general any investigation of the teeth and jaws aims to determine 3 p’s Presence Position Pathology Other features of teeth needed to be ascertained are Shape Size Developmental stage (if this is related to patient’s age)

56. PRESENCE In mixed dentition mobility of deciduous teeth must be tested . At beginning of intra oral examination it is essential to count the teeth as it is easy to overlook developmental absence. Symmetry in components of occlusion must be determined i.e., if a primary tooth is mobile on one side then other side must be checked for.

57. POSITION Position of erupted and unerupted teeth Unerupted teeth -location. Darkened toothand if infarction line is on a tooth found on transillumination , then special investigation like electric pulp testing should be done. Also presence of large restorations, crowns, bridges, implants, root canal fillings, ankylosed teeth and other dental anomalies should be noted.

58. Attrition on incisal edge and a displacement is a functional indication of orthodontic treatment. Other health considerations also to look for are: Dental caries Periodontal disease Traumatic injury to teeth Tonsils The patient is asked to say A-a-h and the tongue is depressed with a mouth mirror, it is possible to examine size colour and form of pharyngeal tonsils.

59. EXAMINATION OF TONGUE  Abnormalities Of Tongue Can Upset The Muscle Balance And Equilibrium Leading To Malocclusion.  A Patient Whose Tongue Can Reach The Tip Of The Nose Is Said To Have A Long Nose.  The Lingual Frenum Should Be Examined For Tongue Tie

60. EXAMINATION OF THE PALATE Dolicofacial patients have deep palate. Presence of swellings in the palate Mucosal ulcerations and indentations are a feature of traumatic deep bite. Presence of cleft in the palate. The third rugae is usually in line with canines. This is useful in the assessment of maxillary anterior proclination.

61. EXAMINATION OF GINGIVA  Gingiva Should Be Examined For Inflammation Recession Mucogingival Lesions  Anterior Gingivitis Common In Mouth Breathers Due To Dryness Of Mouth Caused By Open Lip Posture .

62. EXAMINATION OF FRENAL ATTACHMENTS  The maxillary labial frenum sometimes be thick fibrous and attached relatively low.  This may lead to midline diastema.  Abnormal frenal attachment are diagnosed by blench test .

63. EXAMINATION OF TONSILS AND ADENOIDS  Abnormaly Inflamed Tonsils Cause Alterations In Tongue And Jaw Posture There By Upsetting The Oro-facial Balance Leading To Malocclusion

64. Hard tissue Teeth present Un-erupted teeth Supernumerary teeth Missing teeth Retained teeth Crowding 66

65. Rotated teeth Spacing Texture Caries Endodontically treated teeth Occlusal warefacets 67

66. PALATAL CONTOUR 68 PALATAL HEIGHT INDEX ( Korkhaus ) Palatal height X 100 Posterior arch width Normal value is 42 39.3 51.3

67. Relation of mandibular to maxillary arch Maximum incisal opening Freeway space Curve of spee Midline Upper Lower At rest In occlusion 69

68. Anterio-posterior relationship Molar relation Canine relation Incisor relation Over Jet & Bite 70 Class I Class II Class III

69. Canine relation 71

70. Incisor Relationship 72 BSI1983 BSI1983 BSI1983 BSI1983 Mageet AO. Classification of Skeletal and Dental Malocclusion: Revisited. StomaEduJ . 2016;3(2)

71. SAGITTAL PLANE MALOCCLUSION Pre-normal occlusion -mandibular dental arch is placed anteriorly in centric occlusion Post-normal occlusion -mandibular dental arch is placed more posteriorly in centric occlusion

72. VERTICAL PLANE MALOCCLUSION Deep bite Vertical overlap between the maxillary & mandibular teeth is in excess than normal Open bite Exist in anterior or posterior

73. TRANSVERSE PLANE MALOCCLUSION includes various types of CROSS BITES mainly due to constriction of dental arches

74. Infra-occlusion Supra occlusion Rotations

75. FUNCTIONAL EXAMINATION Improper functioning of the stomatognathic system can result in various malocclusions. The functional examination should include : Assessment of postural rest position and inter occlusal space Path of closure Assessment of respiration Examination of TMJ Examination of swallowing Examination of speech 77

76. Assessment of postural rest position and inter – occlusal clearance The postural rest position is the position of the mandible at which the muscles that close the jaws and those that open them are in a state of minimal contraction to maintain the posture of the mandible. At the postural rest position, a space exist between the upper and lower jaws. This space is called the inter occlusal clearance or freeway space . Normally the freeway space is 3mm in canine regions . 78

77. Methods : Phonetics : ‘m’ or ‘c’ or ‘Mississippi’ Command method : e.g. swallowing Non command method : e.g. visualize Measurement of inter occlusal clearance Direct intra oral procedure : vernier caliper Direct extra oral procedure Indirect extra oral procedure : e.g. radiographs, Kinesiography 79

78. Laterognathy 80 Center of mandible is not aligned with facial midline in rest & in occlusion True neuromuscular or anatomical asymmetry Lateral cross bite with laterognathy is True Cross bite.

79. LATERO OCCLUSION 81 Skeletal midline shift of mandible can be observed only in occlusion In postural position midlines are well aligned Deviation is due to tooth guidance. Known as Functional non true malocclusion .

80. EVALUATION OF PATH OF CLOSURE P ath of closure: Movement of the mandible from Rest position  Habitual occlusion. Forward path of closure : occurs in patients with mild skeletal prenormalcy or edge to edge incisor contact. Backward path of closure : Class II div 2 cases exhibit premature incisor contact due to retroclined maxillary incisors. Lateral path of closure : Associated with occlusal prematurity and a narrow maxillary arch. 82

81. ASSESSMENT OF RESPIRATION Humans may exhibit 3 types of breathing : -Nasal -Oral -Oro-nasal Tests to diagnose the type of respiration : Mirror test Cotton test Water test Observation 83

82. Mirror Test Cotton Test Water Test 84

83. EXAMINATION OF TMJ Patient is examined for symptoms of Temporomandibular joint problems such as Clicking & Crepitus sounds Pain in the masticatory muscles Limitation of jaw movement Hyper mobility and morphological abnormalities. The maximum mouth opening (Normal: 40 – 45 mm) 85

84. SPEECH -Certain malocclusions may cause defects in speech due to interference with movement of the tongue and lips. Speech sounds Problem Related malocclusion /s/,/z/-sibilants Lisp Anterior open bite, large gap between incisors /t/, /d/ linguoalveolar stops Difficulty in production Irregular incisors, especially lingual position of maxillary incisors /f/, /v/ labiodental fricatives Distortion Skeletal class III t h , sh , ch linguodental fricatives Distortion Anterior open bite 86

85. EVALUATION OF SWALLOWING The persistence of the infantile swallowing can be a cause for Malocclusion Retained infantile swallow is indicated by the presence of the following features : Protrusion of the tip of the tongue. Teeth occlude on only one molar in each quadrant Violent contraction of perioral muscles during swallowing. 87

86. Infantile swallow (Visceral swallow) Jaws are apart, with the tongue between the gum pads Mandible is stabilized by contraction of the facial muscles and the interposed tongue Swallow is guided & controlled by sensory interchange between the lips and the tongue. 88

87. Mature swallow (Somatic swallow) Teeth are together Mandible is stabilized by contraction of the mandibular elevators. Tip of the tongue is held against the palate, above and behind the incisors 89

88. Methods of examination Electronic recording Electromyographic examination Recording of pressure exerted by the tongue intraorally Roentgenocephalometric analysis Cineradiography Palatography Neurophysiologic examination 90

89. Palatographic examination 91

90. STUDY CASTS Orthodontic study models are accurate plaster reproductions of teeth and their surrounding soft tissues . that are essential diagnostic aid that make it possible to study the arrangement of teeth and the occlusion from all directions .

91. Uses of study model include : They enable study of occlusion from all aspects Enable accurate measurements to be made in dental arch.they help in the measurement of arch length, arch width ,and tooth size Help in assessment of treatment progress by dentist as well as by patient Help in assessing the nature and severity of malocclusion Helpful in motivation of patient and to explain the treatment plan as well as progress to patient and parents Useful to transfer records in case patient is treated by another clinician

92. RADIOGRHIC ANALYSIS 94

93. Lateral cephalometry 95 CVMI Degree of proclination of maxillary and mandibular Incisors Soft tissue analysis Supplementary diagnostic aid Types Lateral cephalogram : This is taken with the head in a standardized reproducible position at a specified distance from x ray source Frontal cephalogram Provides the Anterior – Posterior view of skull It helps in diagnosing Anterio posterior jaw relation Growth pattern Details of maxilla and mandible

94. C V MI 96 Vertrebral growth takes place from the cartilagenous layer on the superior and inferior surfaces of the vertrebra.. Hassel and Farman (1995) found that the shapes of c er vical v e rtebrae werefound to differ with different level of skeletal development Cervical vertrebra maturation indices were determined based on the presence of curvature in the inferior border, shapes of bodies of the dens, C3 and C4 and intervertrebral spacing.

95. Panoramic radiograpgh Helps in diagnosing presence of any impacted teeth TMJ problems any pathology Enlarged Panoramic- Accurate imaging in anterior region. Distortion in posterior region. Contemporary orthodontic 4 th edition proffit 98

96. Occlusal View  Supplementary projection to locate malposed unerupted teeth.  Palatal cleft  Expansion Contemporary orthodontic 4 th edition proffit 99

97. M P3 1 68

98. CONCLUSION The patient assessment forms the essential basis of orthodontic treatment. It is taken in steps starting from a history/questionnaire and proceeding to a clinical examination that includes extra-oral and intra-oral examination. The extra-oral examination is carried out first as this can fundamentally influence the treatment options. The skeletal pattern, soft tissue form and the presence or absence of habits must all be considered. The intra-oral assessment examines the oral health, individual tooth positions and inter- occlusal relationships. When this has been completed in conjunction with the extra-oral examination, a treatment plan can then be formulated

99. Contemporary orthodontic 4 th edition proffit Orthodontic diagnosis – rakosi , graber Orthodontics – current principles and technique 5 th edition Dentistry of child mcdonald Šidlauskienė M . Relationships between Malocclusion, Body Posture, and Nasopharyngeal Pathology in Pre-Orthodontic Children. Med Sci Monit . 2015;21:1765-1773 . Martin,R ., and K.saller (1957). Leherbuch der anthropologie . Gustav Fisher Verlag , Stuttgart. REFERENCES