Diagnosis and examination

You start your clinic to do clinical examination and to do proper diagnosis, you need to: 1- get information from the patient, 2clinical examination, 3- evaluates the diagnostic records. 1-Asking the patient or the parents, you need to start with: A) Chief complaint: what bothers the patient (if the patient is too young ask the parent) in their own words by asking direct questions. It is important to know the chief complaint; imagine you start with treatment without asking about chief complaint and you end and the patient still complaining about something you haven't addressed during your treatment and he still complains about same thing. B) Medical, dental and social history or any habit. C) Physical growth status and how much growth to come; by looking at the patient, when the patient come to your clinic, you assess the patient by eyeball, you assess physical and developmental status of the patient, if the patient is mature enough or there is too much growth to come ? The idea is to utilize the remaining growth and trying to modify the growth for the correction of the underlying problem. D) Motivations and expectations; if the patient is motivated it will help you in your treatment because you ask the patient to comply with your treatment, the patient will be motivated to do that. The motivation can be either: 1-internal (which is good) or 2-external (the patient forced to come to your clinic by parent, colleague, etc.)

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Expectations: what does the patient expect at the end of your treatment? Sometimes I can do simple ortho treatment only and sometimes I can do orthognathic surgery, and at this case his expectations should be at the level of orthodontic treatment only. So you should explain to your patient what you can do for him and what he will look like. 2) Clinical examinations: Intra oral and extra oral examinations are usually 3D: anterioposterior, vertical and transverse. A) Extra oral examination: (Eyeball the patient): starts when the patient enters the clinic, you see the profile, appearance of the face and also you assess the growth status. b) Intra oral examination: mainly soft and hard tissues.

A) extra oral examination :

*Transverse

dimension or frontal: symmetry of the

face; you should not expect to have 100% symmetry relative to mid facial axis (mid facial axis: imaginary line, axis divides the face into two equal halves).

# Mid -facial axis usually runs through the midpoint of

eyebrows tip of the nose philtrum the tip of the chin.

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The most accurate point to be use is philtrum; sometimes we have deviation in the nose or chin. Face can be divided into three thirds: From the frontal view you assess the symmetry of the face, then the vertical dimension ; (1st third: hair line to supraorbital ridge, 2nd third: supra-orbital ridge to base of the nose (sub nasale), and the lower third: sub nasale to the most inferior point of the chin (menton)), but the 1st third is not important to us; so From supra-orbital ridge to menton we call total facial hight so we divide to1) upper facial hight (UFH) =middle third= 45% , 2)lower facial hight (LFH)=lower third= 55% mostly in the normal population.

Lateral view: profile assessment

You need to assess the profile of the patient ;( convex, concave or straight), set the patient in upright position and ask him to look at distinct object; to achieve natural head position and then draw two lines:
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1) From bridge of nose to the base of the upper lip , 2) from the base of the upper lip to soft tissue of chin point (most prominent point of chin) . Nearly it should be straight line in average to slight convex and called profile angle (165 11) (154-176)

Slight convex.

* Skeletal examination: anterior posterior dimension.

Profile angle helps to know skeletal examination; sometime the soft tissue mask the underlying severe skeletal problem, so it doesnt look like what it should be; E.g.: patient with class 2 skeletal relationship with thick chin( soft tissue); so the profile look slight convex. Skeletal examination can be class 1,2,3 skeletal relationship. Sometimes clinical skeletal relationship assessments arent accurate.

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Its a relationship between maxilla and mandible; (A) point represent maxilla and (B) point represent mandible, {ANB angle}. A: the deepest point on premaxilla. N: Nasion B: the deepest point on contour on mandibular symphysis. We assess it clinically by using index and middle finger; by seat the patient in upright position and Frankfort plane almost parallel to floor and using index finger on (A) point and middle finger on (B) point and the line bisector between index finger and middle finger; if bisector parallel to the floor then class 1. (A) point should be slightly ahead of (B) point because in class 1 relationship the normal ANB angle is (2-4) and thats why we use index finger which is slightly shorter than middle finger. To assess the vertical relationship in lateral view: 1) Vertical dimension; we divide patient face into UFH and LFH (usually LFH 55% slightly more than UFH). If it's more => increased lower facial height. If it's less => decreased lower facial height. 2) Frankfort mandibular plane angle (FMPA) Between Frankfort plane and mandibular plane, can be assessed clinically. Frankfort plane: line between lower most anterior point of the orbit to prion (clinically tragus). Mandibular plane: tangent on lower border of the mandible.
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-The angle between them is (27 5) (22-32). -During clinical examination we need cephalometric measurements to support our findings. -Where those two planes match? 1) On the mastoid => angle is average. 2) In front of mastoid => angle is increased. 3) Behind mastoid => angle is decreased.

*Soft tissue analysis:

1) Lips competency; {competent, incompetent or potentially competent (in contact, fulling upper and lower lips together)}. 2) Naso-labial angle ; between tangent of upper lip with tangent of columella of the nose and its around 90-100 degree and in some references its from 90-130 degree.
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3) Antero-posterior = upper and lower relative to Rickets Eplane = its the line from the tip of the nose tip of the chin (pogonion) = aesthetic line, so this line can assess the anteroposterior position of upper and lower position, in average the lower lip should be touching the line 2mm, and the upper lip should be slightly behind the lower lip around 25%. If the lower lip is touching the E-line then the upper lip should be just behind the E-line. If the lower lip is 2 mm ahead the E-line then the upper lip should be touching the E-line.

*Intra oral examination:

1- Evaluation of oral health: when you examine your patient you should aim for pathology free mouth and good oral hygiene to start with treatment otherwise you postpone your treatment. - OH -Gingival/periodontal diseases -Dental caries -Ulcerations
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-any other problems in general. 2) Evaluation of dental tissuesteeth - Count the present teeth (this is a very important point), always count the teeth because many patient come with a missing tooth & you don't notice it. - Palpate the un-erupted tooth for example if there is an unerupted maxillary canine, you need to palpate it if it's not palpable Then you need to take a radiograph because it might be impacted. -Evaluate upper & lower arch separately: you need now to look at the upper arch alone & the lower arch alone. You assess the upper arch alone; count the teeth, assess the crowding and spacing and shape of upper arch (U shape, V shape). You need to assess: *Arch form & arch width: (narrow, symmetrical). *Alignment of the teeth & presence of crowding "space deficiency". If we have space deficiency: *1-4 mm (mild) *5-8 mm(moderate) *>9 mm (severe) *Inclination of the incisors (proclined, average, retroclined) *Tooth morphology (macrodontia, microdontia, peg lateral, anomalies)

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*Tooth malposition & rotation (rotated, not rotated, and tilted mesially or distally) 3- Evaluation of teeth in occlusion (3 planes): ** AP (anterio-posterior) # Incisor relationship (class I, class II division 1or 2, class III) # Overjet: (increased or decreased) the horizontal distance between the tips of upper incisors & the labial surfaces of the lower incisors (average ~ 2-3 mm). # Canine relationship (class I , II , III). # Molar relationship (class I ,II, III). ** Vertical: We need to assess Overbite (vertical overlap between upper & lower incisors): # Average ~ incisal 1/3 # Increased > incisal 1/3; so if it is complete OB or incomplete OB and if it is complete then is it traumatic? # Decreased <1/3. # open. ** Transverse: # Centerlines (Anterior area): upper & lower should coincide with each other & with the mid-facial axis. # Cross-bite or scissor bite.

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Evaluation of functional occlusion:

a) Static occlusion: there is no teeth movement (incisor relationship, canine relationship, molar relationship). b) Dynamic occlusion: during mandibular function (when we make dentures and look at working side interferences or nonworking side interferences). So you have to assess: * Lateral excursion * Protrusion * Canine guidance or group function * Working side & non-working side interferences * Displacement of the mandible; crossbite with displacement or without displacement. And we assess patient at RCP (retrouded contact position) and ICP (intercuspal position); RCP is the origin thats why we use it in complete denture (centric relation). So if the patient is at RCP and we have a displacement then there is a point that elevate ICP and make interference and displacement for the mandible.
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3) Diagnostic records:
* We take the records after we do the examination for many reasons: -To document the starting point for treatment -Medico legal issues: you can use these records in the court if the patient wasn't satisfied about the results of the treatment. -To add to the information gathered in clinical examination.

What types of diagnostic records? 1) Photographs: extraoral & intraoral 2) Radiographs: OPG & lateral cephalogram 3) Dental casts (study models for U & L)

1) Photographs: We take 4 extraoral photographs:

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-At rest (frontal) -Smile: to assess the midline & the smile line -3/4: to assess the para-nasal area - Profile

We take 5 intra-oral photographs: -Frontal. -Right buccal &left buccal (to assess canine and molars). -Upper & lower occlusal.

2) Radiographs: - OPG: general scan for pathology, tooth number, tooth position, impacted teeth &root developmental stage.

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-Lateral cephalometric: it's important for *evaluation of facial proportions & aesthetics *evaluation of skeletal & dental relationships *growth assessment & predictions -Intra-oral radiographs to supplement assessments You may ask for radiographs for upper occlusal or periapical. 3) Dental casts with accurate wax-bite: In this station we need to make 2 models: 1) Study model: it's just as a record for the patient. 2) Working model: it's used if you need to do any appliance for the patient on the cast & because if we work on it, it will be damaged (we can't use it as a record) so therefore we need to make another model which is the study model *To assess: -Teeth in occlusion -Arches relationship (U shape, V shape). -Symmetry of arch form -Space analysis.

After that you will be able to give the Diagnosis:

To get the right diagnosis and to know the problems exist.

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Incisors relationship class 2 div 2, Canine relationship class 2 on the right, and primary canine on the left by taking OPG permanent canine is still unerupted. So you should give the diagnosis like this " class ll div 2 malocclusion based on mild class 2 skeletal base with average vertical proportion complicated by mild crowding in the U&L & impacted upper left maxillary canine & retaining primary canine & increased overbite deep bite & lower centerline shift to right. " - Skeletal examination for the same patient:

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Profile : class 1 LFH: average. FMPA (Frankfort mandibular plane angle): average.

The End Done by : Mai Alsoutari.

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