Orthodontic diagnosis

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 GOOD MORNING

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. Recent advances in diagnosis a. Xeroradiography b. Digi Graph c. MRI d. Tomography e. Occlusograms f. Digital Subtraction Radiography g . Laser Holograph Conclusion 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:- 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: I mpaired 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

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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. SOCIAL AND 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 :- Height and Weight – They provide a clue to the physical growth and maturation of the patient. 18

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

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

21. BODY BUILD(PHYSIQUE) :- Aesthetic – they have a thin physique and usually posses narrow dental arches. Plethoric – they are obese and have large, square dental arches. 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 narrow broad and short head

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25. FACIAL FORM :- simple classification – round, oval or square. scientific classification – Mesoprosopic – average or normal face form Euryprosopic – broad and short face form 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: A line joining the forehead and the soft tissue point A. 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,4 th 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.

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

42. Examination of the nose :- Nose size : normally the nose is 1/3 rd 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. 1 Mentolabial sulcus

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

46. EXAMINATION 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. EXAMINATION 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. EXAMINATION 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 :- Assessment of postural rest position and inter occlusal space Path of closure Assessment of respiration Examination of TMJ Examination of swallowing 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. 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 : 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 : Mirror test Cotton test Water test 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. SPEECH :- 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,4 th 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 : Protrusion of the tip of the tongue. Contraction of perioral muscles during swallowing. 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 view

68. The 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 – General development of the dentition, presence, absence and state of eruption of the teeth. The presence or absence of supernumerary teeth. Extent of root resorption of deciduous teeth. To study the extent of root formation of the permanent teeth. 71

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

73. Radiographs routinely used for diagnosis in orthodontics can be classified into two groups :- 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 :- 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 :- D ecreases 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,4 th edition -2004 mosby elesvier publications. Graber,Vanarsdall,orthodontics:current principles and techniques.4 th edition. Elsevier mosby 2005. Orthodontic diagnosis by Thomas Rakosi, Irmtrud Jonas, Thomas M. Graber Dentistry for the child – Mc Donald 85

86. 86 THANK YOU