Transcript lecture 8
Diagnosis in Orthodontics Dr. Zuber Ahamed Naqvi Objectives • • • • Introduction Diagnostic aids Case history Clinical examination Introduction • Diagnosis in orthodontics is based on collection of adequate database of information about the patient. Case history (questions of the patient written and/ or oral) Clinical examination Diagnostic aids DIAGNOSIS INTERVIEW CLINICAL EXAMINATION ANALYSIS OF DIAGNOSTIC RECORDS PATHOLOGY( CARIES, PERIO) CONTROL BEFORE ORTHO TREATMENT OPTIMAL TREATMENT PLAN INTERACTION COMPROMISE COST-RISK / BENEFIT DATA BASE CLASSIFCATION PROBLEM LIST ORTHODONTIC PROBLEMS ( IN PRIORITY ORDER) AND THE POSSIBLE SOLUTIONS TO INDIVIDUAL PROBLEMS MECHANOTHERAPY 4 Diagnostic aids Essential • • • • Case history Clinical examination Study models Radiographs periapical Bitewing panoramic • Facial photographs Supplemental • • • • • • • • • Specialized radiographsCephalometric radiographs Occlusal intraoral radiograph Cone shift technique Electromyography Hand wrist radiograph Endocrine test Estimation of BMR Diagnostic set up Occlusogram CT-Computerized tomography CBCT- cone beam computerized tomography Case history • • • • • • Personal details Name Age Sex Address Occupation Patient's chief complaint (major reason for seeking consultation and treatment) . There are three major reasons for patient concern about the alignment and occlusion of the teeth: 1. impaired dentofacial esthetics that can lead to psychosocial problems 2. impaired function, and 3. desire to enhance dentofacial esthetics and thereby the quality of life Case history Information should be sought in three major areas: 1. 2. 3. Medical and dental history Physical growth status Motivation, expectations, and other sociobehavioral factors A careful medical and dental history is needed for orthodontic patients both: - provide a proper background for understanding the patient's overall situation -to evaluate specific orthodontically related concerns early fractures of the condylar neck of the mandible trauma to the teeth long-term medication Osteoporosis , uncontrolled diabetes contraindicates orthoodntic treatment Physical Growth Evaluation This is important for a number of reasons: • Growth spurt – growth modification • Signs of sexual maturation • Recording height and weight • Calculation of skeletal age ( skeletal maturity) from the vertebrae hand-wrist radiographs serial cephalometric radiographs Mesomorphic Endomorphic Ectomorphic Social and Behavioral Evaluation Social and behavioral evaluation should explore several related areas • The patient's motivation for treatment • What he or she expects as a result of treatment • How cooperative or uncooperative the patient is likely to be. • External motivation. • Internal motivation. Clinical Evaluation There are two goals of the orthodontic clinical examination: 1. to evaluate and document oral health, jaw function,facial proportions and smile characteristics; and 2. to decide which diagnostic records are required. The clinical examination can be devided to: – Morphological (extraoral and intraoral) – Functional Extraoral examination • Facial Proportions: Macro-Esthetics • Assessment of Developmental Age • Facial Esthetics versus Facial Proportions Whether a face is considered beautiful is greatly affected by cultural and ethnic factors, but whatever the culture, a disproportionate face becomes a psychosocial problem. Distorted and asymmetric facial features – not esthetic Proportionate features are acceptable if not always beautiful. Frontal Examination Frontal view- one looks for bilateral symmetry and for proportionality of the widths of the eyes/nose/mouth Low set ears, or hypertelorism ---syndrome or a microform of a craniofacial anomaly. If a syndrome is suspected, the patient's hands should be examined for syndactyly. Facial index The proportional relationship of facial height to width (the facial index). Index Measurements Male Female Facial n-gn/zy-zy 88.5 (5.1) 86.2 (4.6) • Mesoprosopic- average • Euryprosopic - broad and short • Leptoprosopic – long and narrow vertical facial thirds • Distance from • the hairline to the base of the nose, • base of nose to bottom of nose, • and nose to chin should be the same. Profile Analysis Goals of facial profile analysis: 1. Establishing whether the jaws are proportionately positioned in the anteroposterior plane of space. 2. Evaluation of lip posture and incisor prominence 3. Re-evaluation of vertical facial proportions and evaluation of mandibular plane angle. Evaluation of lip posture and incisor prominence The teeth protrude excessively (1) the lips are prominent and everted, and (2) the lips are separated at rest by more than 3 to 4mm (lip incompetence) Intraoral examination • Evaluation of Oral Health The health of oral hard and soft tissues must be assessed for potential orthodontic patients as for any other. It includes: • medical problems- osteoporosis, uncontrolled diabetes. • dental caries or pulpal pathology • periodontal disease • • Permanent dentition- count the number of teeth In mixed dentition the orthopantomogram is necesary . Periodontal evaluation -indications of active periodontal disease and potential or actual mucogingival problems Aggressive juvenile periodontitis Attached gingiva around crowded incisors Insertion of the frenulum The evaluation of the malocclusion : • Angle´s classification • malposition of individual teeth • overjet • ovebite • examination of symmetry Evaluation of Jaw and Occlusal Function Three aspects of function require evaluation: 1. Mastication (including but not limited to swallowing), 2. Speech, and 3. the presence or absence of temporomandibular (TM) joint problems. Patients with severe malocclusion often have difficulty in normal mastication, not so much in being able to chew their food (though this may take extra effort) but in being able to do so in a socially acceptable manner. Speech problems Can be related to malocclusion Speech difficulties in a child If a child has a speech problem and the type of malocclusion related to it, a combination of speech therapy and orthodontics may help. Evaluation of the TM joints Restricted movement - indicates a functional problem. The most important single indicator of joint function is the amount of maximum opening. Palpating the muscles of mastication and TM joints Note any signs of TM joint problems such as joint pain, noise, or limitation of opening. The path of closure- the final part must be examined and any occlusal interferences with functional mandibular movements recorded. Orthodontic diagnostic records Orthodontic diagnostic records are taken for two purposes: • to document the starting point for treatment • and to add to the information gathered on clinical examination Orthodontic records fall into three major categories. Those for evaluation of the: 1. health of the teeth and oral structures 2. alignment and occlusal relationships of the teeth 3. facial and jaw proportions Radiographs A panoramic radiograph The panoramic image has two significant advantages over a series of intraoral radiographs: • broader view - to show any pathologic lesions and supernumerary or impacted teeth and • the radiation exposure is much lower • view of the mandibular condyles,. • periapical and bitewing radiographs only when greater detail is required. • Occlusal radiographs Cephalometric radiograph It is important in evaluation of the skeletal and dental relationship. Radiographs of the temporomandibular joint should be reserved for patients who have symptoms of dysfunction . Evaluation of the occlusion requires impressions for dental casts and a record of the occlusion. The rutine examination involves also the intraoral and extraoral photographs.