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1. INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2.
Diagnosis involves development of a
comprehensive & concise database of
pertinent information, sufficient to
understand the patients problem.
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7.
Chief complaint:
two main concerns:
-Impaired dentofacial esthetics
-Impaired function
-priorities
-desires/expectations
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8.
Past Medical history
-H/o of trauma to the orofacial region
-H/o allergies to medications or medical
products
-H/o past illness or treatment
-H/o past and present medications
-Chronic medical problems e.g. diabetes,
arthritis or osteoporosis
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9. Special concerns:
-H/o Condylar fractures
- H/o Long term medications
-H/o allergy to latex or nickel sensitivity
- H/o blood transfusions
-H/o heart problems
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10.
Past Dental history
- Caries
-Restorative treatment
-Extraction of deciduous / permanent
teeth
- Periodontal problems
- history of trauma to the teeth and jaws
- H/o pain or clicking in TMJ
- H/o bleeding gums
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11.
Pre-natal and Natal history
Placental transfer of drugs
Forceps injury,
Caeserian surgical complications
Congenital anomalies
Post-natal history
Milestones in development
Childhood diseases
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12.
Family history :
H/o malocclusion in parents or siblings
and type of malocclusion
H/o of previous familial orthodontic
treatment
Heriditary/Genetic influence on
malocclusion
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13. History of habits :
- Thumb sucking
-tongue thrusting
-lip and nail biting
-mouth breathing .
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14.
Physical Growth Evaluation
Growth Charts
Hand – wrist radiographs
Cervical vertebral development
Serial cephalometric radiographs
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15.
Social and Behavioral Evaluation
-Patient’s motivation for treatment
–Internal or External
- Expectations
- Co-operation: more of concern with
children:
-Benefits of T/t as seen by the child
-Degree of parental control
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18.
Body-build (physique)
Aesthetic-THIN: narrow dental arches.
Pletoric -OBESE: large square dental
arches
Athletic –NORMAL: normal sized dental
arches
•Sheldon's classification:
•Ectomorphic - tall and thin physique
•Mesomorphic - average physique
•Endomorphic- short and obese physique
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19.
Shape of the head
Mesocephalic: average shape of
head- normal dental arches.
Dolicocephalic: long and narrow
head- narrow dental arches.
Brachycephalic: broad and short
head- broad dental arches.
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20. Cephalic Index :
I= maximum skull
width/maximum skull
length
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27.
Vertical facial proportions:
The ideal face is divided into equal thirds
by horizontal lines adjacent to the
hairline ,the nasal base , the bottom of
the nose and menton .
The lower third of the face is further divided
into -upper one third comprise the upper
lip and the lower lip to the chin comprise
the lower two thirds.
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28.
“Rule of fifths”
› Middle fifth
› Medial two fifths
› Outer two fifths
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29.
Transverse facial proportions:
Describes the ideal transverse relationships
of the face.
The face is divided sagitally into five equal
fifths from helix to helix of the outer ears.
Each of the segment equals one eye
distance in width
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30.
The middle fifth of the face – delineated by
inner canthus of the eye.A line from the
inner canhus should be coincident with the
ala of the nose.
The medial two fifths of the face – A line
from the outer canthus of the eye should be
coincident with the gonial angle of the
mandible.
The outer two fifths of the face – measured
from the base of the ear to the helix of the
ear,which represents the width of the ears.
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32.
The profile is evaluated in the natural
head position which is determined by
the visual axis – the patient is asked to
look straight forwards.
Three soft tissue points are taken into
consideration – most prominent point on
the forehead,base of the upper lip and
pogonion.
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33.
Facial divergence
› Facial angle. i.e. angle
bw N- Pog line to FHplane.
Straight/ orthognathic
face :90
Anterior divergent
face: more than 90
Posterior divergence:
less than 90
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34.
Facial Divergence:
An anterior or posterior inclination of the
lower face relative to the forehead.
Divergence of the face -coined by the
eminent orthodontist – anthropologist
Milo Hellman
The facial angle,which is the angle formed
by the nasion-pogonion sot tissue line
and the frankfurt horizontal line is used to
define the facial divergence.
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36.
Evaluated by measuring the Frankfurt
mandibular plane angle ( FMA) depending
upon the point where the two planes –
“Frankfurt horizontal plane and the
mandibular plane” meet to form the FMA
angle.
Average FMA angle cases – two planes
meet at the occipital region.
Low angle cases – two planes meet
beyond the occipital region.
High angle cases – the two planes meet in
the mastoid region in front of the ear.
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38.
Lip incompetence –
-excessive seperation of the lips at rest
-teeth protrude excessively
-the lips are prominent and everted
-lips separated at rest by more than 3
to 4 mm
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39.
Lip posture : evaluated by viewing the
profile with the lips relaxed. This is done
by relating the upper lip to a true vertical
line passing through the concavity at the
base of the upper lip (soft tissue point A)
and by relating the lower lip to a similar
true vertical line through the concavity
between the lower lip and chin( soft
tissue point B ).
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40.
Lip length: The length of the lips can
be examined by gently parting the
lips. Usually the upper lip covers the
entire labial surface of upper anteriors
except the incisal third or 2 to 3 mm
and the lower lip extends on to the
incisal one third of the upper anterior
teeth.
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41.
Texture and color:-usually both the lips are of same color.
-Less active or hypoactive upper lip is
chapped and lighter in
color.
Tonicity: Normal lip – minimal tonicity,
Hypertonic lip – tend to be firm and
redder, Hypotonic lip is flaccid.
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43.
affected by- lower incisor position,the
vertical height of the lower face & chin
projection
-Upright lower incisors tend to result in
a shallow mentolabial sulcus.
-Excessive lower incisor proclination
deepens the mentolabial sulcus.
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44.
Examination of nose
Radix-soft tissue nasion
Nasofrontal angle
Nasal dorsum
Nasal tip
Columella
Nasolabial angle-102
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45.
Nasal dorsum:
Bony dorsum- onethird to onehalf of
nasal dorsum formed by the confluence
of nasal bones
Cartilagenous/septal dorsum
On profile, the septal cartilage protrudes
infront of the pyriform aperture
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46.
Nasal tip: most anterior point of the nose
Supratip - just cephalic to the nasal tip
Supratip break- area just cephalic to
nasal tip where the lobule meets the
dorsal portion of the nose
On esthetic nose, a slight depression is
present on the Supratip – more
pronounced in females
Double break-angular formation of nasal
tip created by Supratip, tip and infratip
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48.
Naso-labial angle:
- the angle between the lower border of
the nose to the upper lip.
-Average - 90 to 120
-reduced in cases of proclined maxillary
anterior teeth, maxillary prognathism
-Increased in cases of maxillary
retrognathism, retroclined maxillary
anterior teeth
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49.
Fomon and Bell-three major categories of
nasal features according to racial
background.
1.
Leptorrhine – Usually found in whites and
characterized by a long, high, narrow nose
and nostrils.
2.
Mesorrhine – Usually found in Asians and
characterized by lack of dorsal height and
collumellar support.
3.
Platyrrhine – Usually found in blacks and
characterized by a flat broad nose and
wide nostrils.
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52.
Chin projection:
-two factors
1. the amount of anteroposterior bony
projection of the anterior inferior border
of the mandible
2. the amount of soft tissue that overlays
that bony projection
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53.
The amount of bone projecting past the
cephalometric NB line
NB-Pg: linear measurement
Normal- 2±2 mm
Retrusive/protrusive
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54.
Throat form:
Contour of the submental tissues
Lip chin throat angle:-The angle between the lower lip, chin
and R point ( the deepest point along the
chin neck contour) should be
approximately 90 degrees.
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56.
An obtuse Lip chin throat angle
which is unaesthetic reflects the
following:
•
Chin deficiency
•
Lower lip procumbency
•
Excessive sub-mental fat
•
Retropositioned mandible
•
Low hyoid bone position.
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57.
Chin neck angle:
It is also termed cervicomental angle.
Vistness and Souther stressed that the normal
cervico mental angle is approximately 90
degrees.
Soft tissue sag due to ageing is one of the
contributors for less than ideal sub mental
form.
Weight gain also plays an important role.
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58.
Soft tissue examination
Oral hygiene status
Gingiva:
-size & shape
-texture & colour
-width of attached gingiva
-in young healthy patients 2 –3 mm of
attached gingiva is apparent.
-gingival recession
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61.
Frenal attachments:
-upper & lower labial and buccal freni
-In infant, upper labial frenum extends
from the upper lip to the incisive papilla.
-As the incisors erupt, the frenum usually
migrates and gets attached to the labial
surface of the alveolar process.
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62.
Occasionally, the frenum will persist and
this may be associated with midline
diastema. In these cases, the palatine
papilla will blanch, if the lip is pulled
forward.- Blanch test
Lower lingual frenum is examined for
tongue tie or ankyloglossia.
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69.
Palate:
-palatal contour
-depth and width of the palate
-other developmental abnormalities
like torus palatinus and clefts
-scar tissue formation
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73.
Hard tissue examination:
Examination of teeth:
-developmental status of dentition
-teeth present
-carious teeth
-endodontically treated teeth
-impacted/unerupted teeth
-supernumerary/ supplementory teeth
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74. -congenitally missing teeth
-variations in size of teeth
microdontia
macrodontia
-variations in shape of teeth
peg shaped lateral incisor
mulbery molars
-variations in no. of teeth
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75. -variations in normal eruption sequence
-restorations
-discoloured teeth
-hypoplastic teeth
-occlusal wear facets/bruxism
-traumatic/fractured teeth
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76.
Examination of arches:
-shape: ovoid/tapered/square
-symmetry
-alignment:
crowding/spacing/rotation
-curve of spee:
flat/average/exaggerated/reverse
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78.
Examination of occlusion:
A. antero-posterior relationship:
1.molar relation-Angle’s classification
2.canine relation
3.incisor relation
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79.
Overjet:
-Horizontal overlapping of upper and lower
teeth
-Normal- 2 to 3 mm.
Variations in overjet :
-decreased
- increased
-reverse overjet or anterior cross bite
-edge to edge bite.
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81.
B. Vertical relationship:
Over bite:
-vertical overlapping of anterior teeth
-Normal- 2 to 3 mm.
-Overbite percentage –
overbite/ clinical crown length x 100
Normal value – 33 %.
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82.
Variations in overbite:
Deep bite – overbite > 2 to 3 mm.
Complete deep bite – lower anteriors
contact either the cingulum of upper
anteriors or the palatal mucosa.
Closed bite –upper anteriors overlap the
lower anteriors completely – class II div 2
malocclusion.
Open bite – lack of vertical overlapping of
teeth.
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83. C. Transverse relationship:
-posterior cross bite
-buccal non-occlusion/ Scissors bite
-lingual non-occlusion
D. Midline
-upper and lower midline
-skeletal midline
-mid sagittal plane
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84.
Macro-esthetics -Face in all three
planes of space
-asymmetry
-excessive or deficient face height
-mandibular deficiency or excess
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86.
Micro-esthetics –the teeth
-tooth proportion in height and width
-gingival shape and contour
-connectors and embrasures
-black triangular holes
-tooth shade
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87.
Facial esthetics vs. Facial proportions
Frontal examination:
1.Bilateral Facial symmetry in the
fifths of face
2.Proportionality of width of
eyes/nose/mouth
-composite photographs-Rt/Lt
- Facial index: proportional relationship
of facial height to width
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88.
anthropometric measurements
Vertical facial proportions
-vertical facial thirds
-artists of the Renaissance period
da Vinci and Durer
-Farkas-modern Caucasians of
European descent-lower third is
slightly longer
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90.
Saggital facial proportions
-Rule of fifths
-seperation of the eyes-equal the width of
the eyes
-nose & chin- centred within central fifth
-width of the nose-same as or slightly wider
than the central fifth
-interpupillary distance-equal the width of
mouth
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92.
Profile analysis
Poorman’s cephalometric analysis
3 goals:
Evaluation of Proportionality of jaws in
the A-P plane
Evaluation of lip posture and incisor
prominence
Re-evaluation of vertical facial
proportions and Evaluation MPA
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101. -Relationship of the dentition to the face
1.Examination of symmetry
-relationship of dental midline of each
arch to the skeletal midline
2.Vertical relationship of the teeth to the
lips-at rest and on smile
-amount of incisor display
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102.
Excessive incisor display1.long lower third of the face
2.short upper lip
-lip height at philtrum and the comissures
Transverse cant of occlusal plane
-transverse roll of the esthetic line of
dentition
-up-down transverse rotation of the
dentition on smiling or when the lips are
seperated at rest
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106.
Extent of the smile is outlined by
Curvature of the upper & lower lip
Position of the angle of mouth
Degree of exposure of both anterior &
posterior teeth, gingiva
width of the buccal corridor.
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108. Three points
1.Amount of icisor and gingival display
2.Transverse dimensions of the smile
relative to the upper arch
-buccal corridor
3.The smile arc
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109.
Amount of incisor and gingival
display:
-elevation of the upper lip on smile should
stop at or near gingival margin
-<100% incisor display-less attractive smile
-decrease in amount incisor display over
time
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111.
Buccal corridors:
-distance between the maxillary posterior
teeth and inside of the cheek
-excessively wide buccal corridors i.e.
negative space- unesthetic
-widening of the upper arch
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113.
Smile arc:
-contour of the incisal edges of the
maxillary anterior teeth relative to the
curvature of the lower lip during a social
smile
-consonant smile arc
-flattened smile arc
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115.
Tooth proportions:
-tooth widths in relation to each other
-height-width proportions of individual
teeth
-width relationship & the “Golden
proportion”
-the ratio of recurring 62% from central
incisor to posterior teeth
i.e.1.0:0.62:0.38:0.24 etc
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117.
Height-width relationships:
-width of the tooth should be about 80% of
its height- 8:10
-disproportions in height-width ratio:
1.Incomplete eruption
2.Loss of crown height from attrition
3.Excessive gingival height
4.Inherent distortion in crown form
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121. Gingival shape:
-curvature of gingiva at the margins of
tooth
-Max. Lateral Incisorsymmetrical half-oval/half circle
-Max. Central Incisor & Caninemore elliptical
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122. Gingival zenith:
-most apical point of the gingival tissue
- Max. Central Incisor & CanineDistal to long axis of the tooth
- Max. Lateral IncisorCoincide with the long axis
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124.
Connectors and embrasures:
Connectors:
-area where adjacent teeth appears to
touch
-extends apically or occlusally from the
actual contact point
-Normal connector height –greatest
between CI
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126. -diminishes from CI to posterior teeth
-moves apically in progression from CI to
PMs & Ms
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127.
Embrasures:
-triangular spaces incisal or gingival to the
contact area
Black triangles:
-open gingival embrasures above the
connectors
-causes:
1.Loss of gingival tissue
2.Orthodontic correction of crowded and
rotated maxillary incisors
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129.
Tooth shade & color:
-Max. Central Incisor -brightest in smile
-Max. Lateral Incisor- less than CI
-Max. Canine- least bright
-First & second PMs-lighter and brighter
than canine
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130.
Assessment of Postural rest position and
interocclusal space
Evaluation of path of closure
Examination of TMJ
Examination of muscles of mastication
Examination of muscles of neck and
head support
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131.
-
Examination of orofacial Dysfunctions
Respiration
Deglutition/Swallowing
Speech
Peri-oral muscle tone
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132.
Postural rest position and
interocclusal space:
-the position of mandible when the
muscles which elevates and depress
the jaw are in a state of minimum
tonic contraction to maintain the
posture of mandible
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135.
Interocclusal clearance/space:
-distance between the occlusal or incisal
surfaces of the maxillary and mandibular
teeth when the mandible is in the
physiologic rest position
-freeway space
-normal- 3mm in bicuspid region
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137.
Evaluation of path of closure:
-movement of mandible from rest position
to habitual occlusion
1.Forward path of closure:
-skeletal prenormalcy
-edge-to edge incisor contact
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138. 2.Backward path of closure:
-class II div 2
3.Lateral path of closure:
-occlusal prematurities
-narrow maxillary arch
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139.
Early symptoms of TMJ problems include:
•
Clicking and crepitus
•
Sensitivity in the condylar region and
masticatory muscles
•
Functional disturbances
•
Radiographic evidence of morphologic
and positional abnormalities.
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140. 1.Jaw movements, path of closure and
joint sounds:
-range of motion:
a)Maximum opening-40 mm
b)Right and left lateral excursion
c)Protrusion
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141. -path of closure:
-amount, direction, timing of any deviation
-clicks:
-disclose a loss of intimacy of condyle and
meniscus relationship
-crepitus:
-early arthritic symptoms
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145. Muscles of mastication
Morphologic Examination:
Palpation of each jaw muscle at rest
and in function - useful to reveal
asymmetries of muscle size and
placement.
Functional Examination:
Functional analysis of the jaw
musculature is best carried out with
each particular synchronized function
in mind.
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147. Muscles of neck and head
support
Pain and tenderness:Myalgia of the neck muscles may be
associated with
tempero mandibular dysfunction
spondylitis
other functional disorders of the
region.
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149.
Assessment of Respiration:
-breathing- three types
a)Nasal
b)Oral
c)Oro-nasal
-alteration in the posture of head, tongue
and mandible
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150. Methods of examination:
1.Study the patients breathing unobserved:
2.Ask the patient to take a deep breath
3.Ask the patient to close the lips and take
a deep breath through the nose
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151. Nasal breathers:
-lips touch lightly at rest
-good reflex control of the alar muscles
-dilate the external nares on inspiration
Mouth breathers:
-lips are parted
-maintain the size and shape of external
nares or contract the nasal orifices
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152.
1.
2.
3.
Other tests to diagnose the mode of
respiration:
Mirror test
Cotton test
Water test
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156. Normal infantile swallow:
-tongue lies between gum pads
-mandible is stabilized by contraction of
facial muscles
-strong buccinator muscle
-disappears with eruption of buccal teeth
in primary dentition
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158. Normal mature swallow:
-very little lip and cheek activity
-contraction of mandibular elevators
bringing the teeth into occlusion
Simple tongue thrust swallow:
-contraction of lips, mentalis and
mandibular elevators
-teeth in occlusion
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159. Complex tongue thrust swallow:
-tongue thrust with teeth apart swallow
-combined contraction of lips, facial
muscles and mentalis
-lack of contraction of mandibular
elevators
-mouth breathers and chronic
nasorespiratory disease
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160. Retained infantile swallow:
-persistence of the infantile swallowing
reflex after the arrival of permanent
teeth
-contraction of buccinator muscle
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161.
Assessment of Speech:
1.Lisping with sibilant sound(S,Z):
-large gap between incisors
-missing incisors or open bite
-tongue thrust habit
2.Difficulty in production of linguo-alveolar
stops(t,d):
-irregular incisors
-lingually positioned maxillary incisors
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162. 3.Distortion of labio-dental fricatives(t,v):
-excessive protrusion of mandible
4.Distortion of linguo-dental
fricatives(th,sh,ch):
-anterior open bite or missing incisors
5.Cleft palate- nasal tone
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164.
Two purposes:
- to document the patient’s initial
condition
- to supplement information obtained
from interview and clinical
examination
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165.
Three major categories:
-for evaluation of-
A. The health of the teeth and oral
structures
1.
2.
3.
4.
5.
Intraoral photographs
Panoramic radiographs
TMJ radiographs
Periapical & bitewings
Occlusal radiographs
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166. B. The alignment & occlusal relationship
of the teeth
1.
2.
Study casts
Occlusal records
C. The face & jaw proportions
1.
2.
a.
b.
Facial photographs
Cephalometric radiographs
lateral ceph
P-A ceph
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167.
Intraoral photographs:
-to document the initial condition of hard
and soft tissues
-five standard views
1. Frontal/anterior
2. Right lateral
3. Left lateral
4. Maxillary occlusal
5. Mandibular occlusal
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170.
Panoramic radiographs:
-advantages:
1. Yields a broader view
2. Pathological lesions and supernumerary
or impacted teeth
3. Much lower radiation exposure
4. Views of mandibular condyles
5. Screening image to determine if other
TMJ radiographs are needed
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172.
Periapical & bitewing radiographs:
-supplemental to OPG when greater detail
is required
-children & adolescent-root resorption or
aggressive periodontal disease
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173.
Occlusal radiographs:
-to locate impacted teeth in combination
with periapical radiograph
Cone-beam computed tomography:
-to evaluate position of impacted tooth
and extent of damage to roots of other
teeth
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174.
CT or MRI scans:
-screening for TMJ internal joint pathology
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175.
Frontal :
-natural head position
-four views:
a) Frontal at rest:
-lip incompetence-lips in repose and
mandible in rest position
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176. b) Frontal with teeth in maximal
intercuspation:
-lips closed
-lip strain and its esthetic effect
-lip incompetence-lips together picture
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177. c) Frontal dynamic(smile):
-the amount of incisor display
-excessive gingival display
d) Close-up view of the posed smile:
-analysis of smile relationships
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179. 2. oblique(three-quarter; 45 degree):
-three views:
a) Oblique at rest:
-examination of midface
-midfacial deformities
-nasal deformity
-chin neck area
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180. -prominence of gonial angle
-length and definition of the border of
mandible
-lip fullness and vermilion display
-facial asymmetry-oblique views of both
sides
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181. b) Oblique on smile:
-anteroposterior cant of OP
c) Oblique close-up smile:
-more precise evaluation of lip relationships
to the teeth and jaws
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183. 3. Profile:
-orientation of the head to the visual axis
-inferior border: slight above the scapula,
at the base of the neck
-superior border: slight above the top of
head
-right border: slight ahead of the nasal tip
-left border: stops just behind the ear/ full
head shot
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188. Study casts are
oriented in
3 planes:
-Midpalatal raphe
-Tuberosity plane
-Occlusal plane
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189.
Cast analysis:
-Symmetry and space
1.Symmetry:
-trasparent ruled grid
-oriented to midpalatine raphe
-asymmetry within the dental arch
Lateral drift of incisors
Drift of posterior teeth on one side
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190. 2.Alignment (crowding): space analysis
-to quantify the amount of crowding within
the dental arches
-comparison between the amount of
space available for alignment of the
teeth and the amount of space required
to align them properly
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191. Mixed Dentition Analysis:
-Estimation of the size of unerupted
permanent teeth
-three basic approaches
1. Radiographic method:
-true width of primary molar/apparent
width of primary molar = true width of
unerupted premolar/apparent width of
unerupted premolar
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193. -Radiographic cephalometry
-1934 by Hofrath in Germany & Broadbent
in United States
Uses:
Research on growth patterns in the
craniofacial complex
To evaluate dentofacial proportions and
clarify the anatomic basis for
malocclusion
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194. Recognizing and evaluating changes
brought about by orthodontic treatment
by superimposition of serial radiographs
Screening of pathology:
-anomalies in the cervical spine
-degenerative changes in the cervical
vertebrae
-other pathological changes in the skull,
jaws or cranial base
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197.
Case history and clinical examination
are the two important tools in the
process of diagnosis which can be
supplemented with other diagnostic
records such as radiographs and study
casts to obtain proper diagnosis
A comprehensive diagnosis is necessory
for proper treatment planning and the
success of orthodontic treatment
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198. Thank you
For more details please visit
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