MS2 - Orthodontic Referrals Flashcards
Learning Objectives
- what type of problems warrant a referral
- what age a pt should be referred
- what might be appropriate to manage in general practice
In general, what should be conducted in the patient’s history taking and examination?
History
- CC
- med hx, dental hx, family hx, social hx
Examination
- I/O, E/O, functional, TMj, special tests
What are some aspect of the medical history to look for which may warrant orthodontic referral? (3)
- Syndromes affecting craniofacial development
- Allergies
- Chronic upper airway obstruction (affects facial development)
- Previous facial trauma (can affect growth of Md / Mx e.g. # condyle at young age)
What is an example of medication tx’s which may be significant in alerting ortho tx (2) Why? (2)
- high dose prostaglandin inhibitors (e.g. high dose of ibuprofen, naproxen)
- bone resorption inhibitors
(both often seen in tx of RA or osteo)
→ may impede ortho tooth movement & try to exclude exos in ortho when possible
What habits would you look for in children which may cause AOBs?
- thumb sucking
- forward resting tongue position
How may you assess facial symmetry in practice?
- can accurately assess with clinical photographs etc, but you can start as soon as the patient walks through the door
- minor asymmetries may be picked up with photographic assessment, but in real life they may be clinically insignificant if not picked up through visual assessment
How to assess a pt’s vertical facial proportions and why are they important?
- divide face into thirds → should be fairly equal
- the lower third can be divided into thirds as well → ⅓ subnasale to lip, ⅔ lip to chin
→can identify brachy, meso and dolichofacial proportions and ortho may be required for abnormalities
What 3 things to assess in frontal examination
- symmetry - facial midline
- vertical (= ⅓s, lower ⅓ divided into upper ⅓ and lower ⅔) and transverse (width of eye = distance b/w, facial proportions
- tooth display
How to assess a pt’s vertical facial proportions and why are they important?
- divide face into thirds → should be fairly equal
- the lower third can be divided into thirds as well → ⅓ subnasale to upper lip, ⅔ lower lip to chin
→can identify brachy, meso and dolichofacial proportions and ortho may be required for abnormalities
How much anterior tooth display and gingival display is considered an ideal social smile? Why is this important?
100% incisal display, up to 2mm gingival display (for adolescents)
-tx planning should aim to achieve this
is there anything wrong with his smile?
how would this be corrected?
- Vertical maxillary excess (VME) on posterior RHS (due to posterior maxilla tipping downward)
- needs orthognathic surgery to fix this -would be for aesthetic concerns, not occlusal issues
what is the minimum incisal display considered acceptable for facial aesthetics and why?
75% incisal display is the minimum for acceptable facial aesthetics → less is seen as a sign of ageing
How do you achieve an aesthetic smile arch?
Have the curvature of their smile follow the curvature of the lower lip
What is a gummy smile called?
Vertical Maxillary Excess (VME)
Is there anything wrong with this smile?
- contour of teeth don’t follow the contour of the lower lip well
- some VME on posterior LHS
What are buccal corridors, and how are they made more aesthetic?
- the space between the buccal surfaces of the maxillary teeth and the corners of the mouth during smiling
- small buccal corridors are more aesthetic
How to examine facial profile and what should you evaluate?
- visually evaluate whether the jaws are positioned correctly in the AP plane
- evaluate the mandibular plane angle, lip posture and incisor prominence as well as the facial proportions
How to assess dental midline
when smiling the upper dental midline should coincide w facial midline
small deviation <2mm usually not noticeable
what will facial convexities tell us about the patient’s skeletal relationship
whether there is a skeletal discrepancy or not
What appearance can retruded lips give to a pt?
appearance of a much larger nose
How do you assess whether a pt has incompetent lips?
- if lips don’t meet at rest, they are incompetent
- if the lips are incompetent, as the pt to bring their lips together → assess whether there is activation of the circumoral muscles
What is the typical age an orthodontist will aim tx for in children and why?
approx. 11-13 - adolescent growth spurt
but refer sooner rather than later
What is a limitation in Angle’s Classification?
Only describes molar relationship, irrespective of other occlusal relationships present
would describe this picture as class III molar relationship, class II div 1 incisor relationship
how to classify incisor relationships according to the British Standards Institution?
same as angle’s classifications but for incisors only
How do you assess whether a patient has a true crossbite or a functional shift?
assess both Intercuspal position and Retruded Contact Position
(i.e. centric occlusal and centric relation)
What may happen to gingival margins in pts with anterior tooth Wear?
teeth will over-erupt to try and maintain contact, causing the gingival margin to come down with the CEJ
This pt presents to you saying his 11 was avulsed due to a skateboard injury 1 year ago and wants you to restore his 11 and his smile.
What issues are present and what tx would you recomend?
Issues
- midline shift due to missing 11
- LHS posterior crossbite (edge-edge molars)
- lateral open bites (in PM region)
- Class II div 1
Treatment recommendation:
- space issues present and some orthodontic issues present
- need to make space in 11 area to restore, and fix the other orthodontic issues → refer for specialist tx
What information should be included in a Referral letter to the orthodontist?
- pt details and practice/dentist details
- Medical history
- any social considerations (eg. living in separate homes, moving cities in some time, etc)
- Any issues with dental tx? (eg. phobic, doesn’t want radiographs, etc)
- radiographs
- Your treatment plan and end goal
Facial proportions
