‫بسم ال الرحمن الرحيم‬

Examination and diagnosis in

orthodontics

We have to collect information from the patient and this is done by

Patient questioning/ interview-1
Clinical examination-2
Evaluation of diagnostic records-3

When the patient enters the clinic we ask the patient the ordinary questions like the
chief complaint… age…. Name… medical history.. social history and dental history,
then we undertake the clinical examination by examining the patient extraorally and
intraorally , then if there is any need to take any diagnostic records like radiographs
(OPG, lateral cephalometric) , we request them then analyze them to meke the final
.diagnosis

SO three ways to get information from the patient by asking the patient, examining
..the patient and evaluating the records

 1-Patient questioning/ interview

Chief complaint (C.C) here is very important because you are going to address the
pt's C.C so that you treat him, but if you treat another thing than the CC then the pt
wont be happy.. so you need to know the CC by directing questions to the pt or the
parent (in case that your pt is a child that came to you due to their parents willing not
. (their own willing

So you can get the CC by asking the pt or the parent about it..and about medical,
dental history , social status and then assess the pt's physical growth status and how
much growth to come (i.e. I look to the pt's height, age, do they match with the
…physiological status of the pt
‫ سنه‬12 ‫ سنه او بالعكس بيجيك عمره‬12 ‫ سنين بس بتفكره انه عمره‬9 ‫ بكون عمره‬patient ‫يعني بيجيك مرات‬
‫ سنين‬9 ‫وبتفكر انه عمره‬
.So we have to assess the physical growth bcoz its important in orthodontics

Then we have to assess the pt's motivation and expectation of the treatment : if patient
or parent expects too much from orthodontics treatment , you have to inform them
about the limitations of it (trt) whether you can achieve what they desire or not, you
have to assess the motivation : if the pt wants to have orthodontic treatment or not, if
they are forced by their parents (in case of kids) or not, bcoz if they are forced then

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you will have a harder job in making him\her commit to the OHI that you give to
.him\her

.So motivation has to be internal (self motivation) and the pt has to be self motivated

2nd step to get information for the final diagnosis is the clinical examination of the
.patient

Clinical examination of the patient in orthodontics is divided into 2 parts

extra oral-1
intra oral-2

From the 1st moment that the pt enters your clinic you "eyeball" him\her, you assess
the growth bcoz further growth can be anticipated by sexual maturity, so you assess
the physical growth to know if the pt had undergone enough growth in order to
.determine if its suitable for him to come to you to have trt or not

Now we come to extra oral examination

:Extra oral examination should be three dimensional

transverse-1
lateral-2
vertical-3

Transverse plane examination is achieved in frontal view of the patient, you assess
the patient in the frontal view in which you can assess the symmetry of the face in
.relation to the mid facial axis

Look at this picture 

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The line here is the mid facial axis which is the line that divides the face into two
nearly equal halves, its very rare to have 100% symmetry between the two parts,
usually there is some degree of asymmetry which is acceptable (or should be
.( acceptable ..it shouldn't be pathological asymmetry
Mid facial axis is the line that passes along the mid point between the eye brows or
.the glabella (soft tissue glabella), nose, philtrum and the chin

But sometimes you have to pay attention that the nose might be deviated from the mid
facial axis, and the chin might be also deviated as a result of mandibular growth
.asymmetry

Again from the frontal examination you assess the symmetry then you assess vertical
……dimension
??How
You divide the face into three thirds
The 1st third is from the hair line to supra orbital ridge (soft tissue glabella), then the
2nd third which is from the supra orbital ridge to the base of the nose and this third is
called the upper facial height (UFH) , then the 3rd third which is from the base of the
nose to the most inferior point of the chin (or the menton) and this third is called the
. (lower facial height (LFH

The ideal or the average LFH is 55% of the TFH (total facial height which includes
the lower two thirds and doesn’t include the upper bcoz we are not interested in this
third in orthodontics especially if you have a bold patient , i.e TFH = UFH + LFH ),
..and the ideal or the average UFH is 45% of the TFH

Look at this picture 

This is a frontal view of the patient, the face is divided into three thirds as mentioned
.…above

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the second dimension of the extra oral examination is the profile analysis or the **
lateral view.. so you look at the patient from the side… in this regard you have to
position the patient in the right position which is the upright position or the natural
.head position
There are two ways to achieve the natural head position
manually; you move the pt's head with your hands till its in the upright position (the-1
.(Frankfort plane or the horizontal plane should be parallel to the floor
..Or
you ask the patient to look at the horizon.. and automatically his head will be in the -2
.upright head position

For the facial profile ; you drop two lines; the first one is from the bridge of the nose
to the base of the upper lip, and the second is from the base of the upper lip to the soft
..tissue chin point, the profile should ideally be straight to slightly convex

 in this picture

The lines here in the picture are approximate not accurate

Two lines are drawn the 1st is from the bridge of the nose to the sub nasale (base of
(the nose), the 2nd line is from the sub nasale to the soft tissue chin point (pogonion
They both give the facial profile.. and the angle b\w the two lines is called the profile
angle…if its acute or reduced then the profile is convex, if it is increased alittle then
the profile is nearly straight, if it increases more (>180 degrees) then the profile will
.be concave

So the profile could be straight, convex, concave, slightly convex, slightly concave,
.but the ideal or the average profile is straight to slightly convex

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Again from the profile analysis we assess the profile itself and the skeletal relation,
whether the pt has class I,II,III or mild class II, moderate class II, severe class II, or
mild, moderate and severe class III but the ideal skeletal relation is class I. and from
the profile analysis we said also you ca assess the vertical relation… two vertical
proportions can be assessed from the profile view which are
LFH \ TFH = 55%-1
.Frankfort\ mandibular plane angle that = 27 +5 degrees or 27 -5 degrees -2

?But why Frankfort \ mandibulat plane angle

Because it can be analyzed or assessed clinically, the other angle that corresponds to it
is the maxillary \ mandibular plane angle but this angle cant be assessed clinically but
it can be assessed from the lateral cephalogram… so the used one is the one that is
. measured in clinic which is Frankfort\ mandibular plane angle

Frankfort plane

Mandibular plane

(these lines are not accurate… I drew them on the pictures )

???What is the Frankfort plane

It’s the line that passes along the external auditory meatus (EAM) of the ear to the
.infra orbital border
The mandibular plane is the line that passes through or along the lower border of the
.mandible
The line b\w these two planes is not measured in the clinic by placing a
‫منقــله‬

But instead you determine the Frankfort plane and then the mandibular plane, the two
planes or lines should intersect (meet) at appoint around the mastoid process, if they
meet anterior to the mastoid then the angle b\w them increases and if the meeting is
.posterior to the mastoid then the angle is decreased

p.s… we can't determine the porion clinically and even on a radiograph it’s a little bit
.difficult to locate so we use the EAM instead of it
Lower border of the mandible may not be so accurate on the radiograph but it can be
.drawn.. but I have to palpate it clinically to determine the mandibular plane

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So far we did the extra oral analysis, frontal examination, lateral examination, vertical
examination, vertical relation ship, Frankfort mandibular angle, LFH, UFH, anterior
posterior skeletal relationship class I, II, III (skeletal assessment), symmetry which
could be combined between soft tissue and skeletal tissue, bcoz skeletal structures
could be symmetrical but the soft tissue may not be due to a scar (may be) that
.contracted so it will give us the look of asymmetry

Soft tissue analysis

In Soft tissue analysis we are interested in the areas around the lips (paraoral area),*
we look at the lips' competency; if they are competent (the upper and lower lips
contact each other at rest) , incompetent (upper and lower lips don’t touch neither at
rest nor at function when the pt tries to), potentially competent (the upper and lower
lips don’t contact at rest but they do at function i.e when the pt tries to bring them
..together) but here there will be stretching of the chin muscle bcoz its an effort

naso labial angle**

..Its ideally between 90 – 100 degrees

upper and lower lip assessment***

.If they are either prominent, retrusive or average

For the upper and lower lip assessment we draw a line that we call RICKETS E
.(PLANE (esthetic line

Pic nasiolabial angle Naso labial angle

E plane +

E PLANE

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This E PLANE is drawn from the tip of the nose to the soft tissue chin point, then we
assess the positioin of the lips in relation to it (E plane), ideally the lower lip should
be 1-2 mm behind it (-1 or -2), and the lower lip ideally shows 25% more of the
vermilion border than the upper lip (upper lip shows 25% less than the lower of the
vermilion border, so its less prominent), so both lips should be within this plane,
.ideally

INTRA ORAL EXAMINATION

When we look inside the pt's mouth we should assess the general oral health of the
.patient, oral hygiene, periodontal condition, soft tissue condition, caries, fillings
We need to assess all of these bcoz I have to achieve my aim (as orthodontist) before
orthodontic treatment, and the aim is : to achieve pathology free mouth and good oral
hygiene. i.e if I have caries or periodontal problem or poor oral hygiene, we should
wait and not to start the orthodontic treatment immediately, and refer my patient to a
.dentist or a periodontist or to a hygienist to restore oral health and stabilize it

*: (Then we come to the evaluation of dental tissues (upper and lower teeth
count the present teeth-1
.palpate the un erupted teeth-2

If you have a ten years old patient and you notice that his upper permanent canine has
not erupted yet and you see his upper C in its place, then palpate the buccal sulcus and
.the palate, if you feel a bulge then this indicates that this canine is superficial
If the C is mobile then this indicates that physiological root resorption is taking place
.(and the permanent tooth is about to erupt (shedding process
If the C is firm and there is no palpable bulge in the buccal sulcus, then you should
order a radiograph (OPG, occlusal, periapical), just to make sure that the canine is
there, if not, then its congenitally missing. and this also applicable to the lower 2nd
.premolars which are commonly missing too

then evaluate the lower arch and the upper arch separately (you can start with the**
.(upper or the lower
.then evaluate the arch form and width ***

If the arch is symmetrical its good, but if the arch isn’t symmetrical then there is an
underlying skeletal asymmetry, if teeth are crowded then the arch is asymmetrical
.((but here its due to dental causes not skeletal

We have to look to the arch line , teeth that are outside the arch line they are
.considered as crowding teeth
If most of the teeth (premolars, molars) are located inside (in relation to the arch line)
.then we will have a cross bite and this indicates an underlying skeletal asymmetry

So we assess the arch form, width, teeth alignment, spacing and crowding…and as a
rule for crowding if it was from 1-4 mm then its mild, 5-8 mm is moderate, >=9 mm
.is severe crowding

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Crowding is due to lack of space for teeth between contact points and to measure the
;probability of crowding

We measure the mesiodistal width available for the teeth that we think that they are
crowded and then measure the mesiodistal width of each tooth and then sum the MD
width of the teeth, then subtract the MD width of the teeth from the available if the
result is negative then there is crowing and if its positive then there will be spacing
.but if the two widths are equal then there is no spacing or crowding

For ex. From the distal surface of the lower right canine to the distal surface of the
lower left canine the available space is 15 mm (this is just an example and its not
definite), and if we measure MD width for each tooth and then sum it and it was 20
mm, the difference is -5, i.e I need 5 mm to align teeth into the line of arch, and here
.in our case we have mild crowding

Also, in each arch we have to assess

the inclination of incisors (proclined, average, retroclined), if the upper are *
proclined and the lower are retroclined then this is class II dev I occlusion and this
(might be the dental relation (skeletal relation is class I
This is mostly seen in thumb suckling patients bcoz it makes upper incisors proclined
…and the lower incisors retroclined and the pt is class I skeletal relation
..So we have to assess the dental relation alone and the bone relation alone too

assess tooth morphology (we may have peg shape lateral incisors or small conical),**
.tooth malposition and tooth rotation

: Intra oral examination is three dimensional

anterioposterior-1
vertical-2
transverse-3

You examine the patient in 3 dimensions unlike a radiograph which is two

.dimensional

anterioposterior *
.(Incisal relation ship (class I, II dev I or dev II, III-
Overjet assessment ( the horizontal distance between the tips of the upper incisors-
.(and the labial surface of the lower incisors
Canine relation ship (class I ; upper canine tip is between lower canine and 1st-
premolar, class II ; upper canine tip is between lower canine and lateral incisor, class
III ; upper canine tip is between lower 1st and 2nd premolars) and this is in full units,
but if in class II the upper canine cusp was on lower canine cusp then its half unit
class II, if upper canine in cusp to cusp position with lower 1st premolar then its half
.unit class III
molar relation (class I ; upper 6 MB cusp in lower 6 buccal groove, class II ; if upper-
6 MB cusp is anterior to buccal groove of lower 6, class III ; upper 6 MB cusp is
.(posterior to lower 6 buccal groove

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 vertical**
Overbite : the vertical distance (overlap) between upper and lower incisors, it could be
.average, increased or decreased, could be complete, incomplete or traumatic
Complete ; when there is contact between lower incisors and upper teeth or upper soft
tissue, i.e lower incisors may occlude on upper teeth with contact and this is called
complete to a tooth, if the lower incisors occlude on the palate with contact this is
.called complete to a tissue

Incomplete; lower teeth don’t contact neither upper teeth nor upper soft tissue
.((palate

Traumatic; contact between lower incisors the palate, when you look at the palate you
.can see indentations due to trauma

transverse***
Cross bite or scissor bite, could be localized (upper 4 + lower 4 cross bite), unilateral,
.bilateral

Cross bite  as a result of crowding (localized cross bite), or due to underlying

skeletal deficiency (maxilla is narrower than the mandible), if unilateral see if there is
???any displacement of the mandible… why
If the maxilla is narrower and symmetrical , there will be cusp to cusp relation ship on
the right and the left side, and this is convenient to the patient so he will shift his
mandible either to the right or the left to achieve maximum inter cuspation (which is
more convenient) , so there will be unilateral cross bite on one side and good
.occlusion on the other side and this is called FUNCTIONAL CROSS BITE
P.s.. examine the patient in the RCP (retruded contact position) to see if it coincides
.(with the ICP (inter cuspal position

So (as a revision ) cross bite could be localized due to crowding or unilateral due to
skeletal deficiency (maxilla is narrower but symmetrical functional cross bite and
displacement of the mandible) or due to skeletal asymmetry ( if the maxilla in one
side is ok and in the other side is narrower then  unilateral cross bite but with no
.(displacement of the mandible bcoz the ICP is achieved on the side that is OK

If the maxilla is symmetrical and narrow enough then there will be a bilateral cross
bite.. bilateral cross bite could be due to transverse deficiency of the maxilla or
??anterioposterior discrepancy… how
If the patient has class III skeletal relation ship so the maxilla will occlude in the most
posterior part of the mandible (which is the wider part), so there will be a bilateral
..(cross bite.(maxilla here is not small but the mandible is prognathic

Upper and lower center lines should coincide with each other and with the mid facial
.(axis as in the picture below (this patient was the DR's patient in Britain 

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CENTER LINES

-Evaluation of functional occlusion

We have to assess (during function) the functional occlusion, Lateral

excursion, Protrusion, Canine guidance or group function, Working side
and non working side interferences, Displacement of the mandible on
closure and presence of any premature contact (due to premature contact,
pt will try to achieve ICP bcoz its more convenient so pt will displace the
mandible), RCP & ICP(they coincide in average patients,in 99% of pts the
. (discrepancy b\w RCP, ICP is around 1 mm only

Diagnostic Records
After we complete our extra oral, intra oral examination, we need to take records for
: two reasons
To document the starting point for treatment -1
i.e… if im treating a patient and im now in the mid treatment stage I need to have the
..records so that I can if im on the right path to achieve my orthodontic goal

To add to the information gathered on clinical examination -2

e.g .. I assess the patient, examine him, I have non erupted canine, no palpable bulge
detected neither in the buccal sulcus nor in the palate.. so I need to take a radiograph

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to know where is my canine or if its missing (this information couldn’t be gathered in
.(the clinical examination so a radiograph was needed

Diagnostic Records Types

Photographs -1
Radiographs -2
Dental casts -3

(Photographs :extra oral (4 in number

.(one at rest (frontal-

one tosee the smile of the patient to see if the upper center line in relation to the mid-
.facial line, also to see the level of the smile

photo ; to assess the para nasal area ( the para nasal area sometimes due to 3/4-
maxillary deficiency it will be alittle inside…an orthodontic surgery is needed to
.(make the maxilla forward

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profile photograph (lateral): vertical dimension, frankfort mandibular plane, soft-
.tissue from lateral view

Intra oral photographs

frontal-

frontal

.right, left buccal-

Right buccal

Left buccal

(occlusal (upper and lower-

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Upper occlusal

Lower occlusal

If we encounter any mid treatment problems, they can be solved if we have these
.records

Radiographs
.for orthodontic treatment we order OPG, lateral cephalometric
OPG: general scan for pathology, tooth number, tooth position* 
.and root developmental stage
* :Lateral cephalometric
.Evaluation of facial proportions and aesthetics
Evaluation of skeletal and dental relationships( to see if upper
.(incisors are proclined in relation to maxillary plane
.Growth assessment and prediction

I might need to supplement the diagnosis and the examination by

taking other types of radiographs like ; periapical, standard
..maxillary occlusal

:Dental casts with accurate wax-bite

Study models (models are casted and a base is done, trimming of the base-
.(in accordance to the bite
Working models (the model on which the appliance is fabricated whether-
removable or fixed such as ; trans palatal arch, rapid maxiallry expansion,
.(quad helix or others

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P.s for the fixed appliances we take another set of models as working
models, so that there are additional models incase of failure of work (we
.(still have the study models

Diagnostic casts are important to

To assess teeth in occlusion ; if the patient cant occlude well during examination-
especially in the molar area or the posterior area then you can take a look at the
..cast
(Arches relationship (classes I, II, III -
(Symmetry of arch form (look at each cast alone -
If symmetrical or not, look at the arch form, arch width (inter molar width) , inter
.(canine width (in the upper
Space analysis -
MD width of teeth, MD width available… we don’t measure these widths by a
.ruler and its better to measure them in the patients mouth not on the cast

Final diagnosis after history taking, intra oral , extra oral examination, taking
radiographs and its Based upon the examination and the assessment of the
.diagnostic records

??WHAT IS THE DIAGNOSIS OF THIS PATIENT

the patient of the intra oral pictures above) )

Class II division 2 malocclusion on mild class 2 skeletal base with average

vertical proportion complicated by: impacted UL3, mild upper and lower arches
.crowding, deep O.B and lower centre line shift to R

Thank you

:Done by

RaZaN M. AlShEhAb

Teethos

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