7 examination

8/13/2019 7 Examination

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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, 2-

clinical 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; bylooking 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: anterio-posterior, 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.

:extra oral examinationA)

*Transverse dimension or frontal: symmetry of the

face; you should not expect to have 100% symmetry relative tomid 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 supra-

orbital 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; soFrom 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 convexand 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 profilelook 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 E-

plane = its theline from the tip of the nose tip of the chin

(pogonion) = aesthetic line, so this line can assess the antero-

posterior position of upper and lower position, in average thelower 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 yourtreatment.

- 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 toothfor example if there is an un-

erupted 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


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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 non-

working 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.

Radiographs:2)

- 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:

Study model: it's just as a record for the patient.1)

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 overbitedeep 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.

7 examination

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