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GOOD MORNING

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ORTHODONTIC DIAGNOSIS

Presented by:-

Manish kumar

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CONTENTS:-

INTRODUCTION DIAGNOSTIC PROCESS COMPREHENSIVE DIAGNOSIS 1. Case history 2. Clinical examination 3. Functional examination 4. Radiologic examination 5. Photographic analysis 6. Model analysis

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o Recent advances in diagnosis a. Xeroradiography b. Digi Graph c. MRI d. Tomography e. Occlusograms f. Digital Subtraction Radiography g . Laser Holograph h. Photocephalometry i. Cineradiographyo Conclusiono References

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INTRODUCTION:- Dia – gnosis – Greek word Dia – Apart and Gnosis – to come to know Definition- “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 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.

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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 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

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DIAGNOSTIC PROCESS

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COMPREHENSIVE DIAGNOSIS

CASE HISTORY:-1. Personal details –

NAME – Communication Identification Psychological benefitsAGE – Diagnosis and treatment planning Growth modification procedures Surgical resective procedures Developmental considerations

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2. SEX – Treatment planning e. g. the timing of growth events such as growth spurts are different in males and females, Females precede males in onset of growth spurts, puberty and termination of growth

3. Address and occupation – Evaluation of socio – economic status In selection of an appropriate appliance Future correspondence

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4. CHIEF COMPLAINT –

The patient’s chief complaint should be recorded in his/her own words.

This helps the clinician in identifying the priorities and desires of the patient.

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.

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5. MEDICAL HISTORY :- In obtaining the medical history, the orthodontist or assistantmust always ask a few important questions, as the last time a physician was seen, any hospitalizations, any medications currently being taken. information regarding allergies, especially latex or nickel sensitivity; history of blood transfusions; and heart problems such as mitral valve prolapse or rheumatic fever .

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.

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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.

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principal stages in craniofacial development :-

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

For e.g. The AAPD endorses the policy statement of the American Academy of Pediatrics (AAP) on breastfeeding and the use of human milk. The AAPstatement includes the acknowledgment that "breastfeeding ensures the best possible health as well as the best development and psychosocial outcomes for the infant." However, both organizations discourage extended or excessive frequency of feeding times (from the breast or bottle) and encourage appropriate oral hygiene measures for infants and toddlers.

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

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.

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CLINICAL EXAMINATION :-

GENERAL EXAMINATION :-a. Height and Weight – They provide a clue to the physical

growth and maturation of the patient.b. Gait – It is the manner of walking. Abnormalities of gait are usually

associated with neuro-muscular disorders.c. Posture – Posture refers to the way a person stands.

Abnormal postures can predispose to malocclusion due to alteration in maxillo-mandibular relationship.

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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. SHELDON has classified the

general body build into three types :-d. Ectomorphic – tall and thin physiquee. Mesomorphic – average physiquef. Endomorphic – short and obese physique

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EXTRA ORAL EXAMINAATION :- SHAPE OF HEAD –• Mesocephalic – average shape of the head.

They posses normal dental arches.• Dolicocephalic – long and narrow head.

They have narrow dental arches.• Brachycephalic – broad and short head.

They have broad dental arches.

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oFACIAL FORM :-• simple classification – round, oval or square.• scientific classification – a.Mesoprosopic – average or normal

face formb.Euryprosopic – broad and short

face formc.Leptoprosopic – long and narrow

face form

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ASSESMENT OF FACIAL SYMMETRY :-

The patient’s facial symmetry is examined to determine disproportions of the face in transverse and vertical planes.

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

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Composite photographs are the best way to indicate normal facial asymmetry. For this boy, whose mild asymmetry rarely would be noticed and is not a problem, 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. This technique dramatically illustrates the difference in the two sides. Although the normal asymmetry usually is less than in this boy, mild asymmetry is the rule rather than the exception. Usually, the right side of the face is a little larger than the left ,rather than the reverse as in this individual.

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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. The nose and chin should be cantered within the central fifth, with the width of the nose the same as or slightly wider than the central fifth. The inter – pupillary distance (dotted lines) should equal the width of the mouth.

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Vertical facial proportions in the frontal and lateral views are best evaluated in the context of the facial thirds, which the Renaissance artists noted were equal in height in well-proportioned faces. In modern Caucasians, the lower facial third often is slightly longer than the central third. The lower third has thirds : the mouth should be one-third of the way between the base of the nose and the chin.

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FACIAL PROFILE :-

The facial profile is examined by viewing the patient from the sides.

The facial profile helps in diagnosing gross deviations in the maxillo-mandibular relationship.

The profile is assessed by joining the following two reference lines:

1. A line joining the forehead and the soft tissue point A( deepest point in curvature of upper lip).

2. A line joining point A and the soft tissue pogonion (most anterior point of the chin).

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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. A convex facial profile( A) indicates a Class ll jaw relationship, which can result from either a maxilla that projects too far forward or a mandible too far back. A concave profile( C) indicates a Class lll relationship, which can result from either a maxilla that is too far back or a mandible that protrudes forward.

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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 :a. Anterior divergence : a line drawn

between the forehead and chin is inclined anteriorly towards the chin.

b. Posterior divergence : a line drawn between the forehead and chin slants posteriorly towards the chin.

c. Straight divergence : the line between the forehead and chin is straight or perpendicular to the floor.

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ASSESSMENT OF ANTERO – POSTERIOR JAW RELATION :-

Ideally the maxillary skeletal base is 2 – 3 mm forward of the mandibular skeletal base when the teeth are in occlusion.

Estimation is done by placement of the index and middle fingers at the soft tissue point A and point B respectively.

Class I skeletal patternThe hand is at an level

Class II skeletal patternThe hands points upwards.

Class III skeletal patternThe hand points downward

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ASSESSMENT OF VERTICAL SKELETAL RELATION :-

The vertical skeletal relationship can be assessed by studying the angle formed between the lower border of the mandible and the Frankfort horizontal plane.

A markedly reduced lower facial height is associated with deep bites while increased lower facial height is associated with anterior open bites.

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EXAMINATION OF LIPS :-

Normally the upper lips covers the entire labial surface of upper anterior except the incisal 2 – 3mm. The lower lip covers the entire labial surface of the lower anterior and 2-3 mm of the incisal edge of the upper anteriors.

Classification :- i. Competent lips ii. Incompetent lips iii. Potentially incompetent lipsiv. Everted lips

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Competent lips

Incompetent lips

Potentially incompetent lips

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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.

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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.

Deep mento labial sulcus and hyperactive mentalis activity in Class II div. 1

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oLIP STEP ACCORDING TO KORKHAUS :-

Positive lip step

Slightly negative lip step

Marked negative lip step

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oNASOLABIAL ANGLE :-•It is the angle formed between the lower border of the nose and a line connecting intersection of nose and upper lip with the tip of the lip (labrale superius).•This angle is normally 110◦ . •It reduces in patients having proclined upper anteriors or prognathic maxilla.•It increases in patients with retrognathic maxilla or retroclined maxillary anteriors.

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oEXAMINATION OF TONGUE :-•Abnormalities of the tongue can upset the muscle balance and equilibrium leading to malocclusion.•Presence of excessively large tongue is indicated by scalloping on the lateral margins of the tongue.•The lingual frenum should be examined for tongue –tie as it alters the resting tongue position and impairs the tongue movement.

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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

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oEXAMINATION OF GINGIVA :-•The gingiva should be examined for inflammation, recession and other mucogingival lesions.•Presence of poor oral hygiene is usually associated with generalized marginal gingivitis.•Anterior marginal gingivitis can be seen in mouth breathers due to dryness of the mouth caused be the open lip posture.•Bleeding on probing indicates active disease, which must be brought under control before treatment is undertaken.

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oEXAMINATION OF FRENAL ATTACHMENTS :-•A heavy maxillary labial frenum may be cause of a midline diastema.•An abnormally high attachment of the mandibular labial frenum can cause recession of the gingiva in that area.•Abnormal frenal attachments are diagnosed by a blanch test where the upper lip is stretched upwards and outwards for a period of time.

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ASSESSMENT OF THE DENTITION :-

The dentition is examined and the following details are recorded :

Status of dentition i.e. erupted and missing teeth.

Presence of caries, restorations, malformations, hypoplasia, wear and discoloration.

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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)

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

Angle’s class III (mesioclusion)

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Over jet and overbite :

Transverse malrelations, like cross bite and shift of midline :

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Individual tooth irregularities such as rotations, displacements, intrusion and extrusion.

Rotation Transposition

Arch form and symmetry.

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FUNCTIONAL EXAMINATION :-

Improper functioning of the stomatognathic system can result in various malocclusions.

The functional examination should include :a. Assessment of postural rest position and

inter occlusal spaceb. Path of closurec. Assessment of respirationd. Examination of TMJe. Examination of swallowingf. Examination of speech

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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 the freeway space.

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

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

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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.

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ASSESSMENT OF RESPIRATION :-

Humans may exhibit 3 types of breathing : nasal, oral and oro-nasal.

Tests to diagnose the type of respiration :a. Mirror testb. Cotton testc. Water testd. observation

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EXAMINATION OF T.M.J. :-

The patient is examined for symptoms of temporo mandibular joint problems such as clicking, crepitus, pain in the masticatory muscles, limitation of jaw movement, hyper mobility and morphological abnormalities.

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.

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oSPEECH :-Certain malocclusions may cause defects in speech due to interference with movement of the tongue and lips.

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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.

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ORTHODONTIC STUDY MODEL :-

Orthodontic study models are accurate plaster reproduction of the teeth and their surrounding soft tissues.

Uses of the study models :-• They enable the study of the occlusion from

all aspects.• They enable accurate measurements to be

made in a dental arch.• They help in assessment of treatment

progress by the dentist as well as the patient.• They help in assessing the nature and

severity of malocclusion.• They help in motivation of the patient.• It makes it possible to simulate treatment

procedures on the cast.• Useful in transfer of records.

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ORTHODONTIC STUDY MODEL

Frontal view Side view

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DIAGNOSTIC SET UP :-

The diagnostic set up was first proposed by H. D. Kesling.

The diagnostic cast is made from an extra set of trimmed and polished study model.

Uses of diagnostic set up :-• It is 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.

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DIAGNOSTIC SET UP

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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.

Frontal view Profile view

Oblique view

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oThe intra oral photographs :-

Frontal view Right lateral view

Left lateral view

Maxillary occlusal view Mandibular occlusal view

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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

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.

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RADIOGRAPPHIC EXAMINATION :- A valuable tool in orthodontic diagnosis. Uses of radiographs in orthodontics – i. To assess general development of the dentition,

presence, absence and state of eruption of the teeth.ii. To establish the presence or absence of supernumerary

teeth.iii. To determine the extent of root resorption of deciduous

teeth.iv. To study the extent of root formation of the permanent

teeth.v. To confirm the presence and extant of pathological and

traumatic conditionsvi. To study the character of alveolar bone.vii. To confirm the axial inclination of the roots of teeth.viii. To assess morphologically abnormal teeth.

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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

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2. EXTRA ORAL RADIOGRAPHS :- a. Panoramic radiographs –

b. Cephalometric radiographs –

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3. Other radiographs :- Hand wrist radiographs

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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.• 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.

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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.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.

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4. TOMOGRAPHY :-•In some situations superimposition of objects interferes with an observer’s ability to clearly discover the objects of interest.•In these instances 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.

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.

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6. DIGITAL SUBTRACTION RADIOGRAPHY :-•Subtraction radiography addresses many of the limitations in the detection of radiographic changes by decreasing 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.

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.

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CONCLUSION :-

The problem-oriented approach to diagnosis and treatment planning has been widely advocated in medicine and dentistry as a way to overcome the tendency to concentrate on only one part of a patient's problem. 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.

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REFERENCES :-

Contemporary orthodontics 4th edition by proffit

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

Orthodontics – the art and science, 4th edition by S. I. Bhalajhi

Orthodontics - Current principles and technique (Graber) 2000

Dentistry for the child – Mc Donald

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