The main purpose of seeking the medical and dental history of the orthodontic patients is to establish the causes of malocclusion, if possible. Although it is sometimes difficult to be certain of etiologic processes, it is still important to conduct a thorough examination and prepare good records. This will clarify problems and allow the best treatment planning. The orthodontist must base the design of the treatment strategy on the nature of the problem and the findings obtained from recorded data.
The patient’s medical history consists of two parts, the family’s history and the patient’s history.
Family’s medical history
The most important points in the evaluation of family medical history are:
• Genetic background
• General health of the parents and siblings
• Facial and dental resemblances between the parents and the patient
• History of orthodontic treatment for the parents or siblings
• Dental health of the parents
• Condition of the mother during pregnancy (diseases, medications, accidents) as well as length of term and type of delivery
The family and genetic history can be evaluated by finding resemblances between the facial characteristics and dental occlusions of the parents and the patient.
Previous orthodontic treatment of family members and the nature of these issues should also be considered.
The parents’ general and dental health is a good indicator of the patient’s susceptibility to periodontal disease and caries. The mother’s general health during pregnancy can have a direct effect on the patient’s health and dental occlusion. Some medications or diseases (eg, viral infections and endocrine disease) and accidents during pregnancy are examples of history items that should be assessed. Reports indicate that length of term and premature birth can also affect development of occlusion by disturbing normal jaw growth or dental structures.2,3 The use of forceps in difficult deliveries can affect the temporomandibular joint (TMJ), and long-term
effects could detrimentally influence growth and development of the jaws.4 Patient’s medical history
As discussed in chapter 2, the exact contribution of genetic and environmental factors associated with specific types of malocclusion is not always easy to verify.
Therefore, the orthodontist or assistant must ask several important questions to aid assessment.
When the patient’s health is evaluated prior to treatment, it is important to note whether the patient has previously taken or is currently taking any long-term medication and for what purpose. This information can help to determine if the patient has any systemic or metabolic disease that may contraindicate orthodontic treatment or postpone the time of treatment. For example, orthodontic treatment for children with diabetes, even under medical control, requires special and careful monitoring, because these individuals are susceptible to periodontal breakdown following application of orthodontic forces. In children with mitral valve prolapse or heart problems caused by rheumatic fever, premedication and antibiotic prophylaxis might be required prior to invasive procedures such as banding.
Another area to assess when gathering the patient’s history is any previous occurrences of accidents or trauma to the dentition, jaws, and joints. Early fractures of the condylar neck should not be overlooked, because they can cause significant developmental defects at older ages. For example, childhood condylar jaw fracture is the most likely cause of asymmetric mandibular deficiency in children.5,6
Other destructive processes in the TMJ that can cause mandibular problems include rheumatoid arthritis and congenital absence of tissue, as is seen in patients with hemifacial microsomia.
Considering the phenomenon of “form related to function” and the possibility that one might affect the other, any imbalance in muscle function and any disturbed physiologic functions such as respiration, deglutition, mastication, and speech must be carefully evaluated. Assessment of a previous or present history of mouth breathing in growing children is important. This condition can have profound effects, including enlarged tonsils or adenoids, oronasal obstruction, and allergies.
Eliciting information regarding allergies is also important because many patients are allergic to clinical and orthodontic materials such as latex or have sensitivity to nickel, which can be a component of wires and brackets.
Any history of blood transfusions must be considered because of the risk of
immunodeficiency after exposure to viruses such as hepatitis and human immunodeficiency virus (HIV).
The important areas to ask about prior to orthodontic treatment can be summarized as follows:
• History of long-term medication use
• Last visit to a physician and dentist
• Hospitalizations: when and why
• Allergies, especially latex or nickel sensitivity
• History of blood transfusion (to assess the chance of hepatitis or HIV infection)
• Heart problems, such as mitral valve prolapse or problems associated with rheumatic fever (to assess need for antibiotic prophylaxis)
• Accidents or any traumatic injuries to the teeth or jaws (the effects of previous trauma to teeth and apical involvement without any clinical signs may be intensified by orthodontic force and tooth movement)
Clinical Examinations
The orthodontic clinical examination is a thorough evaluation of orofacial structure, both in stasis and in function. The health of oral and perioral hard and soft tissue structures must be carefully assessed before any orthodontic treatment. Pathologic problems such as dental caries, periodontal disease, inadequate attached gingiva, and apical involvement must be treated first. After the problem is under control, bonding and tooth movement can be started.
Clinical examinations involve a series of tests that can be performed by visual observation, digital inspection, and functional analysis of all of the extraoral and intraoral structures. It is important not to concentrate so closely on one aspect of the patient’s overall condition that other significant problems are overlooked.
Extraoral Examination
The extraoral clinical examination includes evaluation of facial esthetics and morphology, including structures, proportion, typing, and symmetry. The facial form, in both the frontal and lateral views, is now a major determinant of orthodontic
diagnosis and treatment planning. Facial and dental appearances are of major concern to almost all patients seeking orthodontic treatment. Evaluation of esthetics is an important part of the clinical examination. Graber and Vanarsdall7 pointed out that malocclusion is a disability with a potential to affect physical and mental health, not a disease, and that appropriate treatment can improve the well-being of the patient.
Assessment of dentoskeletal hard tissue relationships alone without a thorough knowledge of the condition and changes of soft tissue that take place during growth and orthodontic treatment is entirely inadequate. Facial esthetics is an extremely complex issue that must be carefully assessed in the extraoral examination.
Gugino and Dus8 stated that the human face as a whole is anatomically and functionally one of the most complex regions of the human body. A sound understanding of embryology and physiology of the occlusal system and the stomatognathic system is required to understand and recognize the problem of malocclusion in order to provide the best orthodontic treatment for each patient’s occlusion.
Many factors, including eyes, hair, skin, lips, teeth, nose, chin, and jaws, play an important role in the composition of an esthetic face. These components impact our perception of the face and must be carefully evaluated during diagnosis and treatment planning for orthodontic treatment.
Esthetic evaluation of the patient’s frontal and lateral appearances and detection of any deformity before treatment, prediction of future growth changes in early orthodontic treatment, and design of a treatment plan that takes these elements into consideration are majors goal of the extraoral examination.
Esthetic evaluation of the patient’s frontal and lateral appearances deserves special attention, especially in early-age orthodontic treatment. This evaluation is important at the time of examination, and all potential growth changes during and after treatment must be considered.
The extraoral examination should include assessment of the following important features (see Fig 3-1):
• Vertical and transverse frontal facial morphology (dolichocephalic, mesocephalic, or brachycephalic)
• Facial profile (straight, convex, or concave), to identify any adverse sagittal (anteroposterior) growth patterns and occlusal disharmonies
• Facial proportions, that is, the upper and lower facial dimensions, to identify any
adverse vertical growth patterns
• Upper lip–lower lip height ratio
• Facial symmetry, to identify any adverse transverse growth patterns including asymmetries of maxillary and mandibular bones
• Development, tonicity, and form of facial muscles and soft tissue
• Nose size and proportion and symmetry to the rest of the facial structures
• Chin size, shape, symmetry, and position related to other facial structures
• Lip size, tonicity, and position related to profile and incisors, at rest and in function
• Nasolabial angle
• Mentolabial sulcus
• Patient’s posture