Examination of the Patient

EXAMINATION OF THE PATIENT

For orthodontic purposes, the informations needed to find out thediagnosis are derived from three major sources:

1. questions of the patient (written and oral)
2. clinical examination of the patient
3. evaluation of diagnostic records, includingdental casts, radiographs and photographs.

Since all possible diagnostic records will not be obtained for all patients,one of the goals of clinical examination is to determine what additional information is required.

Questionnaire/Interview

The first step in the interview process should be to establish the patient's chief complaint (major reason for seekingconsultation and treatment), usually by a direct question to the patient or parent.

Further information should be sought in threemajor areas:

1. medical and dental history
2. physical growth status
3. motivation, expectations, and othersociobehavioral factors.

Chief Complaint

There are three major reasons for patient concern about the alignment and occlusion of the teeth:

• impaired dentofacialesthetics that can lead to psychosocial problems
• impaired function, and
• desire to enhance dentofacial esthetics andthereby the quality of life.

Although more than one of these reasons often may contribute to seeking orthodontic

treatment, it is important to establish their relative importance to the patient. At this stage the objective is to find out what is important to the patient.

Medical and Dental History

Orthodontic problems are almost always the culmination of a developmental process, not the result of a pathologicprocess. It is often difficult to be certain of the etiology, but it is important toestablish the cause of malocclusion if this can be done, and at least to rule out some of the possible causes.

A carefulmedical and dental history is needed for orthodontic patients both to provide a proper background for understandingthe patient's overall situation and to evaluate specific orthodontically related concerns.

A growth deficit related to an old condylar injury is the most probable cause of facial asymmetry. It has become apparent in recent years that early fractures of the condylar neck of the mandible occur morefrequently than was previously thought . A mandibular fracture in a child often is overlooked in theaftermath of an accident that caused other trauma, so a jaw injury may not have been diagnosed at the time.

Althoughold jaw fractures have particular significance, trauma to the teeth may also affect the development of the occlusionand should not be overlooked.

Second, it is important to note whether the patient is on long-term medication of any type, and if so, for what purpose.

This may reveal systemic disease or metabolic problems that the patient did not report in any other way. Chronicmedical problems in adults or children do not contraindicate orthodontic treatment if the medical problem is undercontrol, but special precautions may be necessary if orthodontic treatment is to be carried out. For example,orthodontic treatment would be possible in a patient with controlled diabetes but would require especially carefulmonitoring, since the periodontal breakdown that could accompany loss of control might be accentuated byorthodontic forces. In adults being treated for arthritis or osteoporosis, high doses of prostaglandininhibitors or resorption-inhibiting agents may impede orthodontic tooth movement.

Physical Growth Evaluation

A second major area that should be explored by questions to the patient or parents is the individual's physical growthstatus. This is important for a number of reasons, Rapid growth during the adolescent growth spurt facilitates tooth movement, but growth modificationmay not be possible in a child who is beyond the peak of the growth spurt.

On the other hand, the combined surgical – orthodontic treatment is planed in pacients after growth has stopped.

For normal youths who are approaching puberty, questions about how rapidly the child has grown recently, whetherclothes sizes have changed and whether there are signs of sexual maturation usually provide the necessary information about where the child is on the growth curve

Recording height and weight changes in the dental office provides important insight

into growth status.

Occasionally, a more precise assessment of whether a child has reached the adolescent growth spurt is needed, andcalculation of bone age from the vertebrae as seen in a cephalometric radiograph can be helpful. Hand-wrist radiographs are an alternative methodfor evaluating skeletal maturity,but these also are not an acceptably accurate way to determine when growth iscompleted.Serial cephalometric radiographs offer the most accurate way to determine whether growth has stoppedor is continuing.

Social and Behavioral Evaluation

Social and behavioral evaluation should explore several related areas:

• the patient's motivation for treatment
• what heor she expects as a result of treatment
• and how cooperative or uncooperative the patient is likely to be.

Motivation can be classified as external or internal. External motivation is that supplied bypressure from another individual, as with a child who is being brought for orthodontic treatment by mother or an older patient who is seeking alignment of incisor teeth because her boyfriend (or hisgirlfriend) wants the teeth to look better. Internal motivation, on the other hand, comes from within the individual and isbased on his or her own assessment of the situation and desire for treatment. Self-motivation for treatment often develops at adolescence. Nevertheless, even in a child it is important for

a patient to have a component of internal motivation. Cooperation is likely to be much better if the child genuinelywants treatment for himself or herself, rather than just putting up with it to please a parent.

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 examinationcan be devided to:

• Morphological (extraoral and intraoral)
• Functional

EXTRAORAL EXAMINATION

Facial Proportions: Macro-Esthetics

The first step in evaluating facial proportions is to take a good look at the patient, examining him or her fordevelopmental characteristics and a general impression

Assessment of Developmental Age

The degree of physical development is much more important than chronologic age in determining how much growth remains.

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 andasymmetric facial features are a major contributor to facial esthetic problems, whereas proportionate features areacceptable if not always beautiful. An appropriate goal for the facial examination therefore is to detect disproportions

Frontal Examination

The first step in analyzing facial proportions is to examine the face in frontal view. Low set ears, or eyes that are unusually far apart (hypertelorism) may indicate either the presence of a syndrome or a microform of a craniofacialanomaly. If a syndrome is suspected, the patient's hands should be examined for syndactyly, since there are a

number of dental-digital syndromes.

In the frontal view, one looks for bilateral symmetryand forproportionality of the widths of the eyes/nose/mouth. A small degree of bilateral facial asymmetry exists in essentially all normal individuals. This can be seen mostreadily by comparing the real full face photograph with composites consisting of two right or two left sides.

This "normal asymmetry," which usually results from a small size difference between the two sides, should be distinguished from a chin or nose that deviates to one side, which can produce severe disproportion and estheticproblems.

The proportional relationship of facial height to width (the facial index), more than the absolute value of either, establishes the overall facial type.

Finally, the face in frontal view should be examined from the perspective of the vertical facial thirds: the distance from the hairline to the base of thenose, base of nose to bottom of nose, and nose to chin should be the same.

Profile Analysis

There are three goals of facial profile analysis, approached in three clear and distinct steps. These are:

1. Establishing whether the jaws are proportionately positioned in the anteroposterior plane of space.

Thisstep requires placing the patient in the physiologic natural head position. With the head in this position, note the relationship between twolines, one dropped from the bridge of the nose to the base of the upper lip, and a second one extending from that

point downward to the chin. These line segments should form a nearly straight line. An angle betweenthem indicates either profile convexity (upper jaw prominent relative to chin) or profile concavity (upper jaw behindchin). A convex profile therefore indicates a skeletal Class II jaw relationship, whereas a concave profile indicates askeletal Class III jaw relationship.

2. Evaluation of lip posture and incisor prominence.

Determining how much incisor prominence is too much can be difficult but is simplified by understanding the relationship between lip posture and the position of the incisors. The teeth protrude excessively if (and only if) two conditions are met:

• the lips are prominent and everted, and
• the lips are separated at rest by more than 3 to 4mm (which is sometimes termed lip incompetence).

3. Re-evaluation of vertical facial proportions

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. Thegeneral guideline is that any problems of disease or pathology must be under control before orthodontic treatment ofdevelopmental problems begins. This includes medical problems, dental caries or pulpal pathology, and periodontaldisease.

It sounds trivial to say that the dentist should not overlook the number of teeth that are present or forming-and yetalmost every dentist, concentrating on details rather than the big picture, has done just that on some occasion. It isparticularly easy to fail to notice a missing or supernumerary lower incisor. At some point in the evaluation, count the

teeth to be sure they are all there.

In mixed dentition the orthopantomogram is necesary to see if all permanent teeth are present, their position, stage of development and order of eruption.

In the periodontal evaluation, there are two major points of interest:

• indications of active periodontal disease and
• potential or actual mucogingival problems

Any orthodontic examination should include gentle probing through thegingival sulci, not to establish pocket depths but to detect any areas of bleeding. Bleeding on probing indicates activedisease, which must be brought under control before other treatment is undertaken. Fortunately, aggressive juvenileperiodontitis occurs rarely, but if it is present, it is critically important to note this before orthodontictreatment begins. Inadequate attached gingiva around crowded incisors indicates the possibility of tissue dehiscencedeveloping when the teeth are aligned, especially with nonextraction (arch expansion) treatment.

Insertion of the frenulum labii sup. and inferior should be evaluated.

The next step is evaluation of the malocclusion ( Angle´s classification, malposition of individual teeth, overjet, ovebite), examination of symmetry, in which it is particularly important to note the relationship of the dental midline of each arch to the skeletal midline of that jaw

Evaluation of Jaw and Occlusal Function

Three aspects of function require evaluation:

1. mastication (including but not limited to swallowing),
2. speech, and
3. thepresence 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 theirfood (though this may take extra effort) but in being able to do so in a socially acceptable manner. These individualsoften have learned to avoid certain foods that are hard to incise and chew, and may have problems with cheek and lipbiting during mastication. Unfortunately, there are almost no reasonable diagnostic tests to evaluate masticatoryefficiency, so it is difficult to quantify the degree of masticatory handicap and difficult to document functionalimprovement.

It has been suggested that lip and tonguelip incompetence - lips that are separated when they are relaxed, so that the patient must strain to bring the lips together overthe protruding teethmay indicate problems in normal swallowing, but there is no evidence to support this contention. In the case of anterior open bite or big overjet the adaptive type of swalloving may be present.

Speech problems can be related to malocclusion, but normal speech is possible in the presence of severe anatomicdistortions. Speech difficulties in a child, therefore, are unlikely to be solved by orthodontic treatment. If a child has a speech problem and the type of malocclusion related to it, acombination of speech therapy and orthodontics may help. If the speech problem is not listed as related tomalocclusion, orthodontic treatment may be valuable in its own right but is unlikely to have any impact on speech

Jaw function is more than TM joint function, but evaluation of the TM joints is an important aspect of the diagnosticworkup. As a generalguideline, if the mandible moves normally, its function is not severely impaired, and by the same token, restricted

movement usually indicates a functional problem.For that reason, the most important single indicator of joint functionis the amount of maximum opening. Palpating the muscles of mastication and TM joints should be a routine part ofany dental examination, and it is important to note any signs of TM joint problems such as joint pain, noise, orlimitation of opening.

The path of closure, espetialy the final part must be examined and any occlusal interferences with functional mandibular movements recorded.

Orthodontic diagnostic records are taken for two purposes:

• to document the starting point for treatment
• and to add to the information gathered on clinicalexamination.

It is important to remember that the records are supplements to, not replacements for, the mostimportant source of information for clinical diagnoses, the clinical examination.

Orthodontic records fall into three major categories: those for evaluation of the:

• health of the teeth and oral structures
• alignment and occlusal relationships of the teeth
• facial and jaw proportions

A panoramic radiograph is valuable for orthodontic evaluation at most ages. The panoramic image has two significantadvantages over a series of intraoral radiographs:

• it yields a broader view and thus is more likely to show anypathologic lesions and supernumerary or impacted teeth and
• the radiation exposure is much lower.

It also gives aview of the mandibular condyles, which can be helpful as a screening image to determine ifother TM joint radiographs are needed. The panoramic radiograph should be supplemented with periapical and bitewing radiographs only when greater detailis required.

A cephalometric radiograph 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 of that joint that may be related to internal joint pathology.

Evaluation of the occlusion requires impressions for dental casts and a record of the occlusion so that the casts or images can be related to each other.

The rutine examination involves also the intraoral and extraoral photographs.