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Clinical examination and diagnosis

Dr. Issam Aljorani (BDS, MSc. Ortho.)

the term diagnosis is defined as the identification of a disease by careful

investigation of its symptoms and history. While not a true disease per se,
malocclusions are the "disease" processes of orthodontics and the central focus
of orthodontic diagnoses.
Successful orthodontic treatment begins with the correct diagnosis, which
involves patient interview, examination and the collection of appropriate records.
At the end of this process, the orthodontist should have assimilated a
comprehensive database for each patient, from which the appropriate treatment
plan can be formulated.
The clinical examination includes an extra- and intra oral analysis of morphology
and function. Often, the clinical examination has to be supplemented with further
analyses using extra- and intra oral photographs, study casts (model analysis) and
radiographs. The results from the interview, clinical examination and the
supplementary analyses will constitute a solid basis for a comprehensive
orthodontic diagnosis, which in turn forms a cornerstone for the treatment plan.

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"What is the patient's chief complaint?" This question is the basis of the
anamnesis. At a minimum, the treatment plan should aim to address this
important fundamental component of the patient's initial screening. The clinician
is responsible for accurately understanding and addressing the chief complaint.
Some patients will have very specific goals for treatment while others will
provide more generalized expectations. Clear communication is the key to
understanding a patient's objectives.
Medical history
As with all aspects of dentistry, oral problems cannot be treated in isolation of
the rest of the body. A clear understanding of a patient’s medical problems and
how this can affect potential orthodontic treatment is vital.
Medical Conditions to be Considered in Orthodontic Treatment
Allergies Allergic reaction
Asthma Root resorption
Coagulation disorders Bleeding risk
Diabetes Periodontal disease
epilepsy Gingival hypertrophy (medication)
Heart valve conditions Endocarditis
High blood presser patient taking calcium Gingival hyperplasia secondary to
habit breaker medications
HIV Periodontal disease, opportunistic
infections
Leukemia Mucositis, oral infections
Osteoporosis Bisphosphonate related ONJ
delayed tooth movement
Physical or mental handicap Gingivitis, relapse (muscle
Hyperactivity or hypooe1ivily)
Rheumatiod arthritis TMJ degeneration
Transplant patient Gingival hyperplasia related to
immunosuppressant drugs
Xerostomia Caries

Dental history
The patient should be asked about their previous dental experience. This will
provide an idea of their attitude towards dental health, what treatment they have
had experienced previously and how this may affect their compliance with
orthodontic treatment.
Extraoral examination
Assessment of the patient should begin with an examination of the facial features
because orthodontic treatment can impact on the soft tissues of the face. Although
a number of absolute measurements can be taken, a comprehensive facial
assessment involves looking at the balance and harmony between component

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parts of the face and noting any areas of disharmony
Natural head posture
Natural head posture (NHP) is the position that the patient naturally carries their
head and is therefore the most relevant for assessing skeletal relationships and
facial deformity. The patient is asked to sit upright and look straight ahead to a
point at eye level in the middle distance. This can be a point on the wall in front
of them, or a mirror so that they look into their own eyes.
Frontal view
The frontal view of the face should be assessed vertically and transversely, with
attention being paid to the presence of any asymmetry. In addition, the
relationship of the lips within the face is examined in detail.
Vertical relationship
Vertically the face is split into thirds, with these
dimensions being approximately equidistant. Any
discrepancy in this rule of thirds will give an
indication of disharmony within the facial proportions
and where this lies. Of particular relevance is an
increase or decrease in the lower face height. The
lower third of the face can be further subdivided into
thirds, with the upper lip falling into the upper third
and the lower lip into the lower two-thirds.

Lip relationship
The relationship of the lips should also be evaluated from the frontal view
• Competent lips are together at rest;
• Potentially competent lips are apart at rest, but this is due to a physical
obstruction, such as the lower lip resting behind the upper incisors; and
• Incompetent lips are apart at rest and require excessive muscular activity to
obtain a lip seal.
Lip incompetence is common in preadolescent children and competence
increases with age due to vertical growth of the soft tissues, especially in males.

Incisor show at rest

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In adolescents and young adults, 3–4 mm of the maxillary incisor should be
displayed at rest. In general, females tend to show more upper
incisor than males, with the amount of incisor show reducing
with age in both sexes. An increased incisor show is usually
due to an increase in anterior maxillary dentoalveolar height
or vertical maxillary excess. Occasionally it is due to a short
upper lip. The average upper lip length is 22 mm in adult males
and 20 mm in females.
Incisor show on smiling
Ideally 75–100% of the maxillary incisor should be shown
when smiling but this also reduces with age. Some gingival
display is acceptable, although excessive show or a ‘gummy
smile’ is considered unattractive.

Smile aesthetics
Most patients seek orthodontic treatment to improve their smile, so it is important
to recognize the various components of a smile that will improve the aesthetics
A normal smile should show the following:
• The whole height of the upper incisors should be visible on full smiling, with
only the interproximal gingivae visible. This smile line is usually 1–2 mm higher
in females.
• The upper incisor edges should run parallel to the lower lip (smile arc)
• The upper incisors should be close to, but not touching, the lower lip
• The gingival margins of the anterior teeth are important if they are visible in the
smile. The margins of the central incisors and canines should be approximately
level, with the lateral incisors lying 1 mm more incisally than the canines and
central incisors
• The width of the smile should be such that buccal corridors should be visible,
but minimal. The buccal corridor is the space between the angle of the mouth and
the buccal surfaces of the most distal visible tooth.
• There should be a symmetrical dental arrangement
• The upper dental midline should be coincident to the middle of the face.

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Transverse relationship and symmetry
The transverse proportions of the face should divide
approximately into fifths. No face is truly
symmetrical; however, any significant facial
asymmetry and the level at which it occurs should be
noted. This can be done by assessing the patient from
the front and also from behind and above, looking
down the face. The relative position of each dental
midline to the relevant dental base should be recorded.
Asymmetries of the lower face are particularly
common in class III malocclusion with mandibular
prognathism.

Profile view
The facial profile should be assessed anteroposteriorly and vertically.
Anteroposterior relationship
an assessment should be made of the skeletal dental base
relationship between the upper and lower jaws in the
anteroposterior plane. This can be achieved by mentally
dropping a true vertical line down from the bridge of the
nose (often called the zero meridian). The upper lip should
rest on or slightly in front of this line and the chin slightly
behind.
Alternatively, the dental bases can be palpated labially.
• In a normal or skeletal class I relationship, the upper jaw
should be approximately 2–4 mm in front of the lower.
• In a skeletal class II relationship the lower jaw is greater
than 4 mm behind the upper;and
• In a skeletal class III relationship the lower jaw is less than 2 mm behind the
upper.
An assessment can also be made of the
angle between the middle and lower third of
the face, with the profile being described as:
• Normal or straight;
• Convex; or
• Concave

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Nasolabial angle and lip protrusion
The nasolabial angle is formed between the upper lip and base of the nose
(columella) and should be between 90° and 110°. It gives an indication of upper
lip drape in relation to the upper incisor position. A high or obtuse nasolabial
angle implies a retrusive upper lip, whilst a low or acute angle is associated with
lip protrusion.

Vertical relationship
The face can also be divided into thirds as described earlier and direct
measurements made of the facial heights
.

The angle of the lower border of the mandible to the cranium should also be
assessed. This can be done by placing an index finger along the lower border and
approximating where this line points. If it points to the base of the skull around
the occipital region, the angle is considered average. If it points below this, the
angle is reduced, whilst above it the angle is increased. This usually, but not
always, correlates with measurements
made of the anterior face height.

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Intraoral examination
The intraoral examination is concerned primarily with the teeth in each dental
arch, in both isolation and occlusion.
Dental health
The teeth present clinically should be noted and an assessment made of the
general dental condition, including the presence of untreated caries, existing
restorations and the standard of oral hygiene.
Excellent oral hygiene is essential for orthodontic treatment otherwise there is
a high risk of decalcification. Treatment should not begin until a patient can
demonstrate they can consistently maintain high levels of oral hygiene.
We are particularly interested in detecting:
• caries
• areas of hypomineralisation
• effects of previous trauma
• tooth wear
• teeth of abnormal size or shape
• existing restorations which may change the way we bond to the tooth, as well
determine our choice of extractions if space is required
Dental arches
• Presence of crowding or spacing in the labial and buccal segments, Crowding
represents a discrepancy between the size of the dental arch and the size of the
teeth. It is important that the degree of crowding is assessed as accurately as
possible as this will in part determine the anchorage requirement and need for
extraction.
In general, crowding is usually described as mild (0–4 mm), moderate (5–8
mm) or severe (greater than 9 mm).

• Tooth rotations, described in relation to the most displaced aspect of the

coronal edge and the line of the dental arch;
• Tooth displacement in a labial or lingual direction in relation to the line of the

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arch;
• Position and inclination of the labial segment relative to the dental base. These
are described as being average, proclined or retroclined.
• Presence and position of the maxillary canines, which should be palpable
buccally from the age of 10 years;
• Angulation of erupted canines, which should be recorded as mesial, upright or
distal and
Incisor relationship
The incisor relationship is described using the British Standards Classification,
but also needs to be supplemented with a description of the overjet and
overbite.
Buccal segments
The buccal segment relationship is described using the Angle classification. The
molar and canine relationships should also be noted.
Overjet
The overjet should be measured from the labial surface of the most prominent
maxillary incisor to the labial surface of the mandibular incisors. The normal
range is 2–4 mm. If there is a reverse overjet, as can occur in a class III incisor
relationship, this is also measured and given a negative value.
Overbite
The normal range is for the maxillary incisors to overlap the mandibular by 2–4
mm vertically, or one-third to one-half of their crown height.
Overbite is described as:
• Increased if the maxillary incisors overlap the mandibular incisor crowns
vertically by greater than one-half of the lower incisor crown height;
• Decreased if the maxillary incisors overlap the mandibular incisors by less than
one third of the lower incisor crown height. If there is no vertical overlap
between the anterior teeth, this is described as an anterior open bite and a
measurement should be made of the incisor separation;
• Complete if there is contact between incisors, or the incisors and opposing
mucosa; and
• Incomplete if there is no contact between incisors, or the incisors and opposing
mucosa.

Anterior crossbite
Teeth in anterior crossbite should be noted along with the presence and size of

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any displacement of the mandible that may occur when closing from the
retruded contact position into the intercuspal position. An anterior crossbite
with displacement can cause labial gingival recession and mobility of the lower
incisors in traumatic occlusion, which if present, should be recorded.
Posterior crossbite
The transverse relationship of the dental arches is described in occlusion.
Crossbites are described in relation to the arch or teeth that are displaced most
from their ideal position, whether they are localized or affect the whole segment
of the dentition and if they occur unilaterally or bilaterally:
• A mandibular buccal crossbite exists when the buccal cusps of the mandibular
dentition occlude buccally to the buccal cusps of the maxillary dentition. If it is
primarily due to a narrow maxillary arch it should be described as a maxillary
lingual crossbite;
• A mandibular lingual crossbite exists when the buccal cusps of the mandibular
dentition occlude lingually to the palatal cusps of the maxillary dentition (this
can also be referred to as a scissors bite). If is primarily due to wide maxillary
arch, it should be described as a maxillary buccal crossbite.
• A unilateral crossbite affects one side of the dental arch; and
• A bilateral crossbite affects both sides of the dental arch.
Centrelines
Maxillary and mandibular dental centrelines are
assessed in relation to the facial midline and to each
other. Displacement of a centreline can be due to:
• Asymmetric dental crowding;
• Buccal crossbite with a mandibular displacement
on closing; and
• Skeletal asymmetry of the jaws.

Orthodontic records
Clinical orthodontic records are used primarily for diagnosis, monitoring of
growth and development, and are a medico-legal requirement. They provide an
accurate representation of the patient prior to orthodontic treatment,
demonstrate treatment progress and allow communication between
orthodontists, other healthcare professionals and the patient. Records also play
an important role in research and clinical audit. It is essential that accurate
clinical records are taken before commencing orthodontic treatment.

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Study models
Impressions showing all the erupted teeth, full depth of the palate and good soft
tissue extension are needed. These can be taken in
alginate for study models and poured in dental
stone. Orthodontic models should be trimmed with
the occlusal plane parallel to the bases, so the teeth
are in occlusion when the models are placed on their
back. The bases are also trimmed symmetrically so
the arch form can be assessed and they are neat
enough to be used for demonstration to the patient.
Accurate digital study casts are also now available,
which have the advantages of occupying no physical
storage space and having no deterioration over time, enabling indefinite
storage.

Clinical photographs
Good clinical photographs form an essential part of the clinical record. They
provide a baseline record of the presenting malocclusion, and are important in
treatment planning especially in relation to facial and dental aesthetics, allow
monitoring of treatment progress and are useful for teaching. The following
views should be taken:
• Intraoral, taken with the occlusal plane horizontal:
• Frontal occlusion;

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• Buccal occlusion (left and right);
• Maxillary dentition; and
• Mandibular dentition.
• Extraoral, taken against neutral background in natural head posture:
• Full facial frontal;
• Full facial frontal smiling;
• Facial three-quarters; and
• Facial profile.

Radiographs
Radiographs are usually required prior to orthodontic treatment to assess:
• Presence or absence of permanent teeth;
• Root morphology of permanent teeth;
• Presence and extent of dental disease;
• Presence of supernumerary teeth;
• Position of ectopic teeth; and
• Relationship of the dentition to the dental bases and their relationship to the
cranial base.
Routine radiographs used in orthodontic assessment
A number of radiographic views are routinely used by the orthodontist.

Occlusal radiographs
Occlusal radiographs are taken with the film
placed on the occlusal plane and can offer greater
detail in the labial segments. They are particularly
useful in the maxillary arch, for assessing root
form of the incisors, the presence of midline
supernumerary teeth and canine position, either
alone or in combination with additional views
using parallax.

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Dental panoramic tomograph (orthopantograph OPG)
Panoramic radiography or, more specifically, the dental panoramic tomograph
provides a useful screen for the presence or absence, position and general health
of the teeth and their supporting structures with a relatively low-radiation dose.
Because these radiographs are sectional in nature, they can be unclear in some
regions, particularly the labial segments where variations in the depth of the
anterior focal trough for different patients can influence clarity of the incisors.

Cephalometric lateral skull radiograph

Cone-beam computed tomography (CBCT)
it is three-dimensional diagnostic tool and particularly useful for the diagnosis
of impacted and ectopic teeth, allowing their accurate localization and the
visualization of any associated resorption.

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Optical laser scanning and stereo photogrammetry
Other less invasive techniques for generating three-dimensional images of the
facial soft tissues have also been developed. Optical laser scanning utilizes a
laser beam, which is captured by a video camera at a set distance from the laser
and produces a three dimensional image.
More recently, stereo photogrammetry has been developed, which involves
taking multiple pictures of the facial region simultaneously. This allows the
creation of a three-dimensional model image. These techniques are now being
used to study facial growth and soft tissue changes in normal populations and
investigate the effects of orthodontic and surgical treatment.

Optical laser scanning

You can download this lecture from E-MOODLE website

http://elearn.uobabylon.edu.iq


references
An introduction to orthodontics, Laura Mitchell, fourth edition, 2014
Essential orthodontics, Birgit Thilander, first edition, 2018
Handbook of orthodontics, Martyn and Andrew, second edition, 2016.

Dr. Issam M. Abdullah Aljorani

BDS, MSc. Ortho.
University of Babylon, college of dentistry
asd.issam@gmail.com
2017

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