ORTHODONTIC DIAGNOSISDR RITESH SHIWAKOTI

CASE HISTORY

Case history involves eliciting and recording of relevant information from the patient and parent to aid in overall diagnosis of the case

PERSONAL DETAILS:

NAME :the patient’s name should be recorded for the purpose of communication and identification.

BIRTHDATE : to assist growing age and for diagnosis and treatment planning.

AGE-the patients chronological age should be recorded. Age consideration helps in diagnosis as well as treatment planning.

growth modification procedures using functional and orthopaedic appliances are carried out during growth period.

SEX-patient’s sex should be recorded in case history.

This is important in planing treatment,as the timing of growth events such as growth spurts is different in males and females.

ADDRESS AND OCCUPATION-recording of address and occupation helps in evaluation of socio-economic status of the patient and the parents.

CHIEF COMPLIANT -the patient’s chief compliant should be recorded in his/ her on words.

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

GENERAL EVALUTATION

Height and weight-they provide clue to the physical growth and maturation of the patient.

Gait-(way a person walks) abnormalities of gait are usually associated with neuromuscular disorders that may have a dental correlation.

Posture-(way a person stands)abnormal postures can predispose to malocclusion due to alteration in maxillo-mandibular relationship.

FACIAL STRUCTURE

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

FACIAL PROFILE

The facial profile is examined by viewing the patient from the side. The facial profile helps in diagnosing the gross deviation of 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 part of the chin)

STRAIGHT PROFILE-the two lines form nearly straight line.

CONVEX PROFILE-the two lines form an angle with concavity facing the tissue.

This kind of profile occurs as a result of prognathic maxilla retrognathic mandible as seen in CLASS 11,DIVISON 1 MALOCCLUSION.

STRAIGHT PROFILE CONVEX PROFILE

COCAVE PROFILE-the two reference lines form an angle with convexity towards tissue.

This type of profile is associated with a prognathic mandible or retrognathic maxilla as in CLASS 111 MALOCCLUSION.

FUNCTIONAL ANALYSIS

TMJ

Clicking ,popping or crepitus.

Deviation or Deflection while opening.

Pain or tenderness over joint or masticatory muscles.

Maximal inter Incisal opening ( 40-45 mm)

Range of vertical & lateral movements.

PALPATION OF PRE TRAGUS AREA:

The examiner can be positioned either in front of or behind the patient.

Patient is asked to slowly open and close the mouth.Palpation with index finger,placed in the pre tragus depression is done.

 

INTRA AURICULAR PALPATION:

Performed by inserting small finger into the ear canal and pressing anteriorly.

While palpating with this methods check whether condyle moves symmetrically, with the rotation and translation phase.

INTER-OCCLUSAL CLEARANCE.

The postural rest position of the mandible at which the muscles that closes the jaw and those that open them are, in state of minimal contraction to maintain the posture of mandible.

At postural rest position, a space exists between the upper and lower jaws.

This space is known as FREEWAY SPACE.

FREEWAY SPACE is 3mm in canine region.

VERNIER CALIPERS CAN BE USED DIRECTLY IN THE PATIENT’S MOUTH IN THE CANINE OR INCISAL REGION TO MEASURE FREEWAY SPACE.

THIS IS DIRECT INTRA ORAL METHOD.

PATH OF CLOSURE

The path of closure is the movement of mandible from the rest position to habitual occlusion .

Forward path of closure: a forward path of closure occurs in patients with mild skeletal and prenormalcy or edge to edge incisor contact. In such patients ,the mandible is guided to a more forward position to allow the mandibular incisors to go labial to the upper incisors.

Backward path of closure: class 11 ,division 2 exhibit premature incisor contact due to retroclined maxillary incisors. Thus the mandible is guided posteriorly to establish occlusion

Lateral path of closure : lateral deviation of mandible to left or right side is associated with occlusal prematurities and a narrow maxillary arch

ASSESSMENT OF ANTERO-POSTERIOR JAW RELATIONSHIP

It can be assessed clinically.

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

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

In skeletal CLASS1 PATIENTS, the index finger is anterior to middle finger or the hand points upwards.

In a skeletal CLASS 11 patient, the middle finger is ahead of the forefinger or the hand points downwards.

In a patient with CLASS 111 skeletal pattern the hand is at an even level.

ASSESSMENT OF VERTICAL SKELETAL RELATIONSHIP

The vertical skeletal relationship assessed by studying the angle formed between the lower border of the mandible and the Frankfort horizontal plane(a line between the most superior point of external auditory meatus and inferior border of orbit)

Normally the two planes intersects at the occipital region.

In case the two planes meets beyond the occipital region, it indicates a low angle case or a horizontal growing face.

If two planes meet anterior to occipital region it indicates a high angle case or a vertical growing face.

Assessment of vertical facial height

EVALUATION OF FACIAL PROPORTIONS

A WELL PROPORTIONED FACE CAN BE DIVIDED INTO THREE EQUAL VERTICAL THIRDS USING FOUR HORIZONTAL PLANES AT THE LEVEL OF THE HAIRLINE,THE SUPRA ORBITAL RIDGE, THE BASE OF THE NOSE AND THE INFERIOR BORDER OF CHIN

WITHIN THE LOWER FACE, THE UPPER LIP OCCUPIES A THIRD OF THE DISTANCE WHILE CHIN OCCUPIES THE REST OF THE SPACE.

EXAMINATION OF LIPS

The upper lip covers the entire labial surface of upper anteriors except the incisal 2-3 mm during rest position.

The lower lip covers the entire labial surface of lower anteriors and 2-3 mm of incisal edge of upper anteriors during rest position.

CLASSIFICATION OF LIPS

COMPETENT LIP-THE LIPS ARE IN SLIGHT CONTACT WHEN MUSCULATURE IS RELAXED.

INCOMPETENT LIPS-they are morphologically short lips which do not form a lip seal in a relaxed state.

The lip seal can only be achieved by active contraction of perioral and mentalis muscle.

POTENTIALLY INCOMPETENT LIP-they are normal lips that fails to form a lip seal due to proclaimed upper incisor.

EVERTED LIP-they are hypertrophied lips with weak muscular tonicity.

Lip are seperated at rest by more than 3-4 mm .

Measured by vernier caliper

An imaginary line is drawn from the tip of the nose to the tip of the chin called as E line.

If the lip is significantly forward from this line it can be judged to be prominent, if the lip fall behind this line it is retrusive.

Lower lip to E line measures = -2 mm

Gingival display

Ideal = 2.3 mm tooth coverage

Maximum = 0.8 mm tooth coverage

Minimum = 4.5 mm tooth coverage

Incisal display at rest = 2-3 mm

Overjet  refers to the extent of horizontal (anterior-posterior) overlap of the maxillary central incisors over the mandibular central incisors

Normal 1mm – 2mm

Mild 3mm- 4mm

Moderate 5 – 6 mm

Severe - more than 7 mm

Overbite refers to the extent of vertical (superior-inferior) overlap of the maxillary central incisors over the mandibular central incisors, measured relative to the incisal ridges.

0-2 mm = normal

3-4 mm = slightly deep

5-7 mm = moderately deep

>7 mm = significantly deep

Abnormal occlusion in the transverse plane. It is a condition where one or more teeth may be abnormally malposed bucally or lingually or labially with reference to opposing tooth or teeth

Anterior crossbite

Single tooth

Segmental

Posterior crossbite

Unilateral

Bilateral

Upper and lower crowing: discrepancy between the tooth size and the arch width leads to crowding

0-1 mm = Normal

2-3 mm = Mild crowding

4-6 mm = Moderate crowing

>7 mm = Severe

Angle’s classification of malocclusion:

Canine relationship:

Class I relation: It means, mesial inclination of the cusp of the upper canine which overlaps the distal incline of the cusp of lower canine.

Class II relation: Distal incline of cusp of upper canine overlaps the mesial incline of the cusp of the lower canine.

Class III relation: lower canine is forwardly placed compared to upper canine.

Class I molar relation: Mesiobuccal cusp of the permanent maxillary first molar occludes in mesiobuccal groove of first permanent mandibular molar.

Class II relation: distobuccal cusp of the permanent maxillary first molar occlude in mesiobuccal groove of first permanent mandibular molar.

Division I : class II molar relation on either side with proclined maxillary anteriors.

Division II : class II molar relation with retroclined maxillary anterior.

Class III : mesiobuccal cusp of maxillary first permanent molar occludes interdentally between first and second mandibular molar.

End to End relation: the cusp of upper and lower first permanent molar are in same plane.

Flush terminal plane: A relationship between primary teeth in which the buccal(distal) surfaces of the opposing second molars are aligned when occlusion is centric.

Arch length :

Overall ratio = sum of mand 12* 100/sum of max 12

Overall ratio = 91.3%

If < 91.3 max excess

If > 91.3 mand excess

Curve of spee

Normal = 2-4 mm

Flat = 0-2 mm

Deep = >/= 2 mm

Palate contour:

High ( V shaped )

Normal ( U shaped )

Low ( Flat )

Arch width:

Wide : increase inter canine width and increased inter molar width

Narrow : decreased inter canine and inter molar width

Normal

Arch form:

Symmetrical

Asymmetrical

Caries :

High

Moderate

Low

Tongue

Normal : Tongue lies in the floor of the mouth with the tip forward & slightly below the incisal edges of the mandibular anterior teeth.

Large : The tongue is flattened &broadened but the tip is in a normal position.

Small :the tongue is retracted & depressed into the floor of the mouth ,with the tip curled upward, downward or assimilated into the body of tongue.•.

Lingual frenum.

Normal : lingual frenum is loosely attached to the floor of the mouth.

Short : lingual frenum is short and leads to tongue tie.

Broad : fan shaped.

Tonsils and adenoid

Enlarged

Inflamed

Moderate

Small

Not visible

Removed

Gingiva :

Healthy

Marginal irritation

Inflamed

Bleeding

Hypertrophic

Recessed

Hygiene :

Good

Fair

Poor

Habits:

None , thumb , finger

Cephalometric reading :

Study of area maxillary to cranial base and mandible to cranial base and maxillo-mandibular relationship gives us idea that malocclusion is of skeletal origin.

Vertical height is used to denote if a person has vertical or horizontal growing face.

Maxillary mandibular incisor position : denotes malocclusion is of dental origin

Normal soft tissue line = -2mm