Key topics

• General examination of the orthodontic patient
• Interview for the anamnesis
• Extra oral examination
• Intra oral examination
• Functional examination
• Examinations at different dental developmental stages/ages and of adults

Learning objectives

• To perform a comprehensive orthodontic examination for a basis to make an orthodontic diagnosis, which in turn forms a cornerstone for the treatment plan
• To know how to assess examinations at different dental stages/ages, including adults

Introduction

Usually, the first meeting between the clinician and a patient starts with an interview with the patient, discussing general and oral health status (past and present), any medication, the chief complaint, followed by the patient’s attitude towards an eventual orthodontic treatment. When it comes to child patients, it is important that one or, preferably, both parents are present during the interview and examination. After the interview is performed, the clinical examination is assessed. 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.

Examination of cleft-lip-palate children and children with syndromes and disabilities are not included in this chapter. These children have an individualised examination programme depending on the individual condition and are carefully examined during the first week after birth by specialist teams in which, for example, plastic surgeons, oral surgeons, speech therapists, child psychologists and orthodontists are included.

Interview and anamnesis

To provide the best conditions for an interview, it is important that the conversation takes place in an undisturbed environment, there is ample time and that the dentist actively listens to the patient and lets the patient express what has brought her/him to the clinic. It may also be helpful for the dentist to use a checklist in order to avoid losing important information (Figure 4.1).

In the interview with the patient, it is essential to consider the general health conditions, possible medication and whether the patient suffers from allergies. It is also relevant to include questions of family history since malocclusions, growth and development may be expressions of genetic patterns.

Questions on the general health, with special emphasis on diseases and medication are valuable, since diseases causing altered metabolism may affect growth and tissue reactions. Furthermore, medication with anti-inflammatory drugs can interact with bone turnover, which is important in orthodontic treatment. Allergies may affect the mode of breathing and respiratory capacity. It can also be noted that an orthodontic appliance may contain various metals and composites, which although rare, can cause contact allergies. For example, if the dentist is aware that the patient is allergic to nickel before the treatment begins, nickel-containing materials like stainless steel, which is a frequently used component in orthodontic appliance, can be replaced with other materials, to avoid the risk of allergic reactions.

It is also important to ask the patient about dental trauma and experience of headache. Frequency of headache can be rated on a 5-point scale: never, a few times per year, every month, every week and every day (List et al., 1999).

Considering child patients, the psychological development and previous experience of dental treatment has to be stressed, especially when deciding the start and mode of treatment. Many children have received very little dental care, and it can be a delicate task for the dentist to determine how well these patients can tolerate orthodontic treatment for 1.5 to 2.5 years. Furthermore, often there are situations where a child patient is very eager to start the treatment, but the assessment is that the child’s present psychological and social development makes it better to perform the treatment later.

Extra oral examination

The examination starts with the patient standing in order to study the body physiognomy (size and nutrition state). The body height can be measured in cases where the growth is regarded important for the treatment outcome.

The face is then observed in both frontal and lateral view to assess symmetry and harmony (van der Linden and Boersma, 1987). The best way to examine the face is to sit opposite the patient with the patient’s and dentist’s heads at the same level and the patient holding the head in a normal relaxed head position.

Examination of the frontal view can disclose asymmetry of eyes, nose and chin. The dental midlines of the maxilla and mandible are determined in relation to the facial midline. For determination of midline discrepancies between the jaws and the facial midline, it is recommended to have the patient lying down flat in the dental chair and the examiner sitting behind the patient’s head asking the patient to smile. The midline deviation has to be greater than 1 mm to be registered.

The lateral view of the face exposes the face profile and the profile can be characterised into straight, convex and concave profiles (Figure 4.2). Most patients have a straight to slightly convex profile. The prominence of the nose and chin in relation to the profile can also be noted, as well as the texture of the lips. When the patient is in a relaxed position, it is also important to observe whether the lips cover the incisors, i.e. competent lip closure or whether an incomplete lip closure is apparent (Figure 4.3). In an incomplete lip closure situation, there is an increased risk of trauma to the maxillary incisors (Dimberg et al., 2015; Petti, 2015).

In more specific cases, it can also be noteworthy to check the nasio-labial angle, since this angle often reflects the incisor positions, i.e. a large nasio-labial angle may imply retroclined maxillary incisors and small angle proclined incisors (Figure 4.4). In addition, if the mentolabial fold is marked (Figure 4.5), this should be noted because a marked mentolabial fold indicates high muscular strain on mandibular incisors.

The vertical dimension of the face may also be examined. Often the vertical height of the face is divided into three parts: the top part from the hairline to where the nose begins, the middle part is the vertical height of the nose, and the lowest part corresponds to the height of the upper and lower lips plus the chin height (Figure 4.6). Analysing the vertical dimension can give the dentist information about whether the patient represents a short or a long vertical face (Figure 4.7).