Orthodontic diagnosisIn an orthodontic context, it is important not to characterize the dental

occlusion while overlooking a jaw discrepancy, developmental syndrome, systemic

disease, periodontal problem, psychosocial problem or the cultural milieu in which the

patient is living.

For orthodontic purposes, the database may be thought of as derived from

three major sources: (1) questions of the patient (written and oral), (2) clinical

examination of the patient, and (3) evaluation of diagnostic records, including dental

casts, radiographs and photographs.

Personal details:

The clinical examination starts with asking the patient about his

name ,age ,address ,phone number ,and by whom he was referred . From this fist

contact with the patient we can discover any defect in the patients pronunciation and

to take a good impression about the mentality.

Name:

The patient’s name should be recorded for the purpose of communication

and identification. Addressing a patient by his or her name has a beneficial

psychological effect. It makes the patient more comfortable and arouses a feeling

of familiarity.

Age:

The age of the patient helps in diagnosis, treatment planning and growth

prediction.

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رؤوف. دطعمة

There are certain transient conditions that occur during development are

considered normal for that age.

A brief examination of the developing occlusion should be carried out around 7-8

years to check the presence of permanent teeth, their position, and to detect any

problem which may affect the normal eruption .

In addition ,there are certain treatment modalities that are best carried out during

growing age, like- growth modification using functional and orthopedic appliances.

Surgical corrective procedures are best carried out after the cessation of the

growth.

The patients age is the most important factor in orthodontic treatment planning :

1. If the patient age is one day

what type of dental or orthodontic treatment can be done?

In such age the patient may have either :

a cleft lip and palate which can be treated via the construction of feeding plate

to separate the nasal cavity from the oral cavity and to prevent the suffocation

during feeding process.

Or the patient may have a natal or neonatal teeth which is better to be left

without treatment unless it cause severe trauma to the mother during the

feeding process so in this case it is better to be trimmed or extracted at this age.

2. If the patient age is four years :

the most important treatment in this age is the interceptive treatment which

include filling of the carious teeth especially CLII carious lesions in order to

maintain the space available for the erupting permanent teeth.

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The presence of premature contact should be treated because it can lead to the

development of anterior or posterior cross-bite with a functional shift or a

mandibular displacement that should be corrected as soon as possible to

prevent the development of skeletal problems.

A skeletal CLIII with that can be observed by the presence of negative over-jet

or mandibular prognathism can be treated at this age by the use of chin cap to

retard and redirect the mandibular growth.

3. If the patient age is 8 years:

Interceptive treatment

Correction of cross-bite

Serial extraction which is started at the early mixed dentition to relief the

incisor crowding and facilitate the eruption of the canine

Skeletal CLII due to maxilla?

Skeletal CLIII due to maxilla or mandible?

Supernumerary teeth which can be checked by taking a radiograph (OPG or

peri-apical) and these teeth should be removed as it may interfere with the

eruption of incisors.

4. If the age is 15 years :

All the permanent teeth were erupted, except the third molar, in this period of

age, it is difficult I or not wise to use " the serial extraction " or " the functional

appliances " since the patient passed the maximum growth spurt , So ; The

question is : What we can do for this patient ???... Fixed orthodontic appliances

usually used in cases ' that require rotation of (90'')) , impaction , true intrusion ,

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extrusion , bodily movement , uprightening and tourqing, also removable

appliance can be used when the case require tipping movement , minor

rotation, anterior or posterior dental cross bite.

Race:

Also the race of the patient is very important ?

For a negroid pt. with bimaxillary dentoalveolar protrusion and competent lips

there will be no need for orthodontic treatment as this malocclusion is related to a

genetic factor and there will be little or no change in the pt. esthetic in addition to that

the case is susceptible to relapse.

Address and contact number:

It can affect the spring design for example if you have a patient living in a far

distance away from your clinic so the active components of the appliance should be

from the supported types like sleeved “supported” buccal canine retractor or

modified finger spring which need activation every 3-4 weeks rather than the simple

types which need activation every 2-3 weeks.

Social and Behavioral Evaluation(Referred by):

It should explore – patient’s motivation for treatment, what he or she expects

as a result of treatment and how co-operative or un co-operative the patient is.

Motivation can be external or internal.

External motivation is that’ supplied by pressure from another individual, like child

brought for treatment by mother; older patient by his girlfriend. Internal motivation

comes from within the individual and is based upon his or her own assessment of the

situation and desire for the treatment .

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For a patient with a thumb sucking habit it is better to use fixed habit breaker which

contain palatal cribs but if the patient was cooperative it is better to be use a

removable one which is easier to be constructed and cleaned.

What patient expects from the treatment should be explored carefully especially in

case of patients with primarily cosmetic problems.

Chief Complaint

The patient’s chief complaint should be recorded in his or her own words. There are

three logical reasons for patient concern about the alignment and occlusion of the

teeth:

1) psychosocial problems

2) impaired function.

3) esthetics.

It is important to establish their relative importance to the patient and their

desires. The parents’ perception of the malocclusion should be noted.

A series of leading questions, beginning with, "Tell me what bothers you about your

face or your teeth," may be necessary to clarify what is important to the patient. The

orthodontist may or may not agree with the patient’s assessment – the judgement

comes later. But, at this stage, it is necessary to find out what is important to the

patient. This will help in setting treatment objectives and satisfying the patient and or

parents in general.

Speech problems can be related to malocclusion, but normal speech is possible in the

presence of severe anatomic distortions. Speech difficulties in a child therefore are

unlikely to be solved by orthodontic treatment.

Sleep apnea may be related to mandibular deficiency, and occasionally this functional

problem is the reason for seeking orthodontic consultation. Both the diagnosis and

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management of sleep disorders requires an interdisciplinary team and should not be

attempted without assessment, documentation, and referral from a qualified

physician. Recent research suggests that oral appliances to advance the mandible can

be effective, but only in patients with mild forms of sleep apnea

Medical History

Patients with rheumatic fever, cardiac anomalies, epilepsy, diabetes and blood

dyscrasias may require special precautions.

The medical history should include information on drug usage. The use of certain

drugs like aspirin (prostaglandin inhibitors) or bone resorption inhibiting agents may

impede orthodontic tooth movement . acute, debilitating conditions such as viral

fever should be allowed to recover prior to initiating orthodontic treatment .

orthodontic treatment would be possible in a patient with controlled diabetes but

would require especially careful monitoring, since the periodontal breakdown that

could accompany loss of control might be accentuated by orthodontic forces. In adults

being treated for arthritis or osteoporosis and now increasingly also in children with

chronic disease treated with drugs (like glucocorticoids) that can be osteotoxic, high

doses of resorption-inhibiting agents, such as bisphosphonates, often are used. This

impedes orthodontic tooth movement and may increase the chance of complications

History of trauma should be noted. Trauma to the jaws or teeth is often overlooked in

child with other trauma, so a jaw injury may not have been diagnosed at that time.

This is significant as it affects the future development of jaws and teeth?

Dental History :

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The patient’s dental history should include information on the age of eruption and

exfoliation of deciduous and permanent teeth, history of extraction, decay,

restorations and trauma.

The past dental history will also help in assessing the patients and parents’ attitude

towards dental health.

History of Habits

History of abnormal habits like finger, digit sucking, nail biting, lip biting grinding,

clenching, and mouth breathing should be taken as they influence the development of

dento-alveolar structures.

Family History

Many malocclusions like skeletal Class II and Class III, crowding ,spacing over-jet , high

frenal attachments and congenital conditions like cleft lip and palate are inherited.

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Clinical examinationThe aim of clinical examination is to evaluate and document the skeletal, facial

and occlusal characteristics in three planes of space in addition to the function of the

teeth ,lips and the tongue.

The causative factor of malocclusion could be

1) Skeletal factor: jaw mal-relation to each other or to one or both of them to the

cranial base in any plane of space.

2) Soft tissue factor

3) Dental factor

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4) Combination of one or more of the above in one or more than one plane of

space

The most important factor of these is the skeletal factor and the orthodontic

treatment should focuses on which factor that cause the malocclusion?

If the cause was skeletal so the treatment would be either orthopedic treatment for

growing pt. or orthognathic surgery for adult pt. depending on the patients age.

Examination of the skeletal relationship:

The pt. should sit in upright position in a comfortable state because tilting the head

upward or downward may increase or decrease the prominence of the chin so the

Frankfort plane should be parallel to the floor and the teeth in maximum

interdigitation because if the pt. posture the mandible forward it will give a false

result. This skeletal examination should be done in three planes of space.

Assessment of Anteropsterior (sagittal) jaws relationship:

Or is it known as the skeletal pattern that can be assessed by one of these methods:

A. Facial profile

The profile is examined from the side by making the patient view at a distant

object, with the FH plane parallel to the floor. The profile is assessed by the angle

of convexity which is formed by the two reference lines:

A line joining the forehead and the soft tissue point A (deepest point in the

curvature of upper lip)

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A line joining point A and the soft tissue pogonion (most anterior point of the

chin) .

Based on the relationship between these two lines, three types of profile exists-

Straight : The two lines form a nearly straight line

Convex : The two lines form an angle with the concavity facing the tissue. It

occurs in cases of prognathic maxilla or retrognathic mandible as seen in Class II

Div I.

Concave : The two reference lines form an angle with the convexity towards the

tissue. This type of profile is seen in Class III patients.

Facial divergence:

It is defined as an anterior or posterior inclination of the lower face relative to the

forehead. Facial divergence is determined by a line drawn from forehead to the

chin -

Anterior divergence : The line is inclined anteriorly .

Posterior divergence : The line is inclined posteriorly.

Straight or orthognathic : The line is perpendicular to the floor ,no slanting.

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B. Palpation method:

by placing index and middle fingers at the approximate A and B points after lip

retraction or directly on the soft tissue A and B. Ideally the maxillary skeletal

base is 2-3mm forward of the mandibular skeletal base when the teeth are in

occlusion.

In skeletal Class II patients, the index finger is anterior to the middle finger

or the hands point upward.

In skeletal Class III patients, the middle finger is anterior to the index finger or

the hands points downwards.

In skeletal Class I patients, the hand is at even level.

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This method does not indicate where is the cause of malocclusion (in maxilla or in

the mandible) , it relates the jaws to each other not to the cranial base.

This method can be done intra-orally or extra-orally but the intra-oral method is

better?

C. Cephlometric analysis:

The skeletal pattern can be assessed by measuring the ANB angle from a lateral

cephalometric radiograph as follow:

If ANB is =2-4 the skeletal pattern is CLI

If ANB is >4 the skeletal pattern is CLII

If ANB is <2 the skeletal pattern is CLIII

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Assessment of vertical jaw relationship:

1. Normally, the distance between glabella to subnasale is equal to the distance

between the subnasale to the underside of the chin (lower facial height).

Reduced lower facial height is associated with deep bite while the

increased facial height is with anterior open bite.

2. The vertical skeletal relationship can also be assessed by studying the angle

formed between the lower border of the mandible and the Frankfort

horizontal plane either:

clinically by placing a ruler at the lower border of the mandible and another

one at the Frankort plane(from external auditory meatus to the lowest point

of the infra-orbital margin)if the angle between the above lines ranged

between 28-30 so it is normal

or radiographical by measuring the angle formed between two lines the

Frankfort plane which extend from the porion to orbitale and the mandibular

plane which extend from gonoin to menton .

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Assessment of transverse jaw relationship :

A certain degree of asymmetry between right and left sides of the face is seen in most

of the individuals. The face should be examined in the transverse and vertical planes

to determine a greater degree of asymmetry than the normal. Gross facial

asymmetries may be seen in patients with-

• Hemifacial atropy/hypertrophy

• Congenital defects

• Unilateral condylar hyperplasia

• Unilateral Ankylosis

There are many ways to assess the facial asymmetry

a) Bird look :by looking to the patient from above

b) Composite Photograph

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c) Tongue spatula

d) Radiographically(OPG or PA)

The most significant jaw mal-relation in transverse plane include the presence of

posterior cross-bite and whether this cross-bite is skeletal or dental in origin.

-*+

Lips:

Normally, the upper lip covers the entire labial surface of upper anteriors

except the incisal 2-3mm. The lower lip covers the entire labial surface of the lower

anteriors and 2-3 mm of the incisal edges of the upper anteriors.

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Lips can be classified into:

Competent: Slight contact of lip when the musculature is relaxed.

Potentially competent: Anatomically short lips which do not contact when

musculature is relaxed. Lip seal is achieved only by active contraction of the

orbicularis oris and mentalis muscle.

In competent: Normal lips which fail to form the lip seal due to proclined upper

incisors.

Everted lips: Hypertropied lips with weak muscular tonicity

Teeth are protruded excessively when two conditions are met:

1. The lips are prominent and everted

2. Lips are separated at rest by more than 3-4 mm(incompetent)

So there is protruded incisors that’s revealed by prominent and separated lips

when they are relaxed. so for such a patient retracting the teeth tend to improve the

esthetic and function.

But if the lips are prominent and closed over the teeth without strain so in this

case the lip position is independent on the tooth position and the retraction of the

incisors will have a little if no change in lip function and position and esthetic as in

negroid patient in addition to the high possibility of relapse.

The sagittal relationship of the lips is almost entirely determined by the

relationship of the basal bone of the jaws, to which they are attached. The lower lip

tends to be further back than the upper lip in a skeletal Class II relationship, and

further forward in a skeletal Class III relationship.

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This not only increases the difficulty of putting the lips together, but also may

cause the lower lip to modify the eruptive path of the upper incisors? For example,

with a skeletal Class II relationship the lower lip may function completely or partly

behind the upper incisors. If the skeletal discrepancy is not severe, the lip is

functioning partly behind the upper incisors and may procline the upper incisors so

that the occlusal relationship is more severely Class II than the skeletal

relationship(low lip line as in CLII division 1 (b) . If the skeletal discrepancy is severe,

the lower lip may function completely behind the upper incisors without causing them

to be proclined(c) . In other instances, with skeletal Class II, the lower lip functions

entirely in front of the upper incisors ,causing them to be retroclined into the Class II

Division 2 incisor relationship (d) . Ideally the upper and lower lip shuold meet at the

center of upper cenrals crown which is called the lip line (a).

The Ricketts‘ E-line, the reference line connecting the tip of the nose with the soft

tissue pogonion, passes about 4 mm in front of the upper lip and 2 mm in front of the

lower lip.

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Nasolabial angle :

It is the angle formed between the lower border of the nose and a line joining

the subnasale with the tip of the upper lip (labiale superius). The angle is normally 110

.

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It is reduced in patients with proclined upper anteriors or prognathic maxilla.

Intra-oral Examination:

Tongue:

Abnormalities of tongue can upset the muscle balance and equilibrium leading

to malocclusion. Presence of excessively large tongue is indicated by the presence of

imprints of teeth on the lateral margins of the tongue giving a scalloped appearance.

Short lingual frenum called tongue tie leads to impaired tongue movement.

Frenal attachments :

The maxillary labial frenum can be thick, fibrous and have low attachment. Such

attachments prevent the two maxillary central incisors from approximating each other

leading to midline diastema .Mandibular labial frenum if with high attachment, may

lead to recession of gingiva .Abnormal frenum attachments can be diagnosed by

blanch test (when the upper lip is stretched upwards and outwards ,blanching in the

region of the interdental papilla indicates abnormal frenum attachment).

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Dentition and dental arch

i. Status The numbers of teeth present, deciduous or permanent ,missing ,

unerupted , extracted

ii. Presence of caries, restoration, malformation, hypoplasia ,wear and

discoloration.

iii. Molar relation :Molar relation is defined as the relation between maxillary

and mandibular first molars.

Molar relation (Angle classification)

Class I: Mesio-buccal cusp of maxillary first molar occludes in the buccal groove

of the mandibular first molar.

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Class II: Mesio-buccal cusp of maxillary first molar occludes in the groove

between mandibular 2nd premolar and 1st molar. (or half or more cusp width

mesial to the buccal groove according to Angle).it has two subdivisions:

○Div 1: With proclined maxillary incisors.

○Div 2: this also can be classified into:

Typical: Lingually inclined maxillary central incisors with labially tipped lateral

incisors .

Atypical: Lingual inclination of central and lateral incisors with canines labially tipped .

Class III: Mesio-buccal cusp of maxillary first molar occludes in the groove

between mandibular 1st and 2nd molar. (or half or more cusp width distal to the

buccal groove according to Angle).

When there is Class II molar relation on one side, and Class I on other side, it is

called Class II subdivision.

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When there is Class III molar relation on one side and Class I on other side, it is

called Class III subdivision.

Incisor relation : ( According to the British standards )

Class I : Lower incisor edges occludes with or lie immediately below the

cingulum plateau of upper central incisors.

Class II : Lower incisor edges lie posterior to cingulum plateau. Two subdivisions

of this category are –

Div 1 – The upper central incisors are proclined or of average inclination

and there is an increase in over-jet.

Div 2 – The upper central incisors are retroclined .Over-jet is usually

minimal or may be increased.

Class III : The lower incisor edges lie anterior to cingulum plateau. The over-jet

may be reduced or reversed.

Canine relation:

Class I : The mesial incline of upper canine overlaps the distal slopes of the lower

canine.

Class II : Distal slope of maxillary canine occludes or contact the mesial slope of lower

canine.

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Class III : Lower canine is displaced anteriorly to the upper canine with no overlapping

of upper and lower canine.

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