Case History 93 Case History The first step in the assessment of orthodontic cases is the critical examination of the case history. The purpose of this is to understand the development of the malocclusion, so that by early elimination of the causative factors, correct therapy can be undertaken. Such an approach increases the likelihood of a more favorable prognosis and greater stability as compared to a purely symp- tomatic approach to orthodontic or dentofacial orthopedic treatment. As a rule, the case history is usually assessed with the help of a special questionnaire. Questions related to the case history are divided into two parts: © Family history © Patient history From the family history, one learns about certain malocclussions and other abnormalities (for instance, impaired nasal breathing) present in members of the same family. A relatively large number of dysgnathias are in- herited and transmitted through a dominant gene, whereas in cases of cleft lip and palate, it is mostly through a recessive gene. The patient's history is divided into three parts. First is the prenatal period, during which the following are of interest: Nutritional disorders, diseases and accidents to the mother during pregnancy. The best-known example of this is the relationship between viral infec- Hereditary malocclusions 229 Deep bite in the deciduous dentition Most hereditary dysgnathias are ‘akeady evident in the deciduous dertiton. Dominanty inherted fanomabes include mandibular rognathism, Class li, Divsion 2 some cases of distoclusion, letal open bite, and bimaxillay protrusion. ‘An excossive vertical dovelop- ‘ment of the anterio maxilary gum pads in the newborn (‘Schachtel- biss"; engl. "boxbite") is assessed as the early form of the congeni- tal deep bite. tion and cleft formation in the newborn. The questions which relate to the birth include time of birth, the fetal position at birth, and complications. The most detailed part of the patient’s own history isthe postnatal development. The manner of feeding, as well as nutritional disturbances are noted (mineralization defects of the teeth). Questions regarding the eruption of the first deciduous tooth, the child’s general develop- ment (initiation of talking, walking), and information concerning sucking and other “bad habits” are useful. Accidents in childhood, the state of the deciduous dentition, and the early loss of primary teeth should also be noted.94 Diagnostic Procedures Other more generalized diseases are of interest, in parti- cular conditions which affect the development of the jaws (for instance, rickets, dysostoses). This aspect would also include all diseases which are important in influencing the type of breathing (colds, pneumonias, otitis, allergies). Further evidence of disturbed respira- tion includes the type of breathing during sleep (open mouth, snoring) as well as previous adenoidectomy and/or tonsillectomy. After adenoidectomy, the possi- bility of homeostatic adaptation must be considered. 230 Bimaxillary protrusion The neredtary component of this dentoaiveolar abnormality is usu: ally localized in the neuromuscular system Because ct hereditary lip incom: petence, the muscular equilibaum Dbetwoen tongue and line ic dic turbed Tho labial inelinationottheanter. lor teeth results from a relative hhyperactivty ofthe tongue muscu- lature, Right: Weak onus ofthe orbicula: ‘isons muscle 231 Drug-induced enamel dysplasia Decaloification of six anterior teeth and first permanent molars ina 1 year-old patent Clinical situation ‘allowing tetracycline treatment ior meningitis at the age of 2 years Teen which had not yet calctied at the time of treatment for the meningiisarenotaffected (premo- lars and second molars) 232 Head and neck surgery Denial condition of a 10-year-old ical closure of & lip and paiate, in the rnewoorn and infant period. ‘Sear besve can further restrict sagfial and vertical maxillary growth, resulting in. mandibular rognatismn, ‘Specific questions should include medical conditions which may limit orthodontic treatment (for example, diabetes mellitus, epilepsy, blood dyscrasias, rheumatic disease, allergies to nickel and acrylic). Psychologie aspects of orthodontic treatment should be also discussed while taking the history and talking with the patient (motivation of the patient, also of parents in young patients, expectation with regard to treatment result). Such information is helpful to estimate future ‘cooperation during treatment.Interpretation of the Case History In many cases, the findings of the patient's history may give some clues regarding the cause of the malocclusion and help in planning the necessary therapy. Together with the interpretation of the case history, one has to bear in mind that a single etiologic factor does not exist A combination of different endogenous and exogenous factorsis responsible for the individual abnormality at a Case History ‘95 particular time. An inherited tendency may be present as well as the acquired malocclusion. The effect of a sucking habit is significantly less favorable in a vertical as compared with a horizontal growth tendency (see page 192). The course of orthodontic therapy, and the stability of treatment results, may be affected if causative factors of the malocclusion have not been recognized 233 Interpretation of the Cause of malocclusions patient's history Endogenous Exogenous Therapy © In the late mixed dentition © Symptomatic © Causal @ Inthe early mixed dentition (possibly in the deciduous dentition) ‘Therapy ‘Acquired malocclusions and predispositions 234 Lip dysfunction in neutroclusion Morpnc skeletal gical relationship in a Clase | case with ip oye Right: The dyskinesia in results in onlya slight overiet. efth 235. Lip dysfunction in distoctusion Morphological relationship in Clase Il case with concomitant lip dyskine Right: Compared with Fig, 234 The functional sof-tssue distur: bance leads to 4 greeter overetin the case of distoclusion96 Case History Questionnaire - Case History 1) Family history I Father | Mother | __ Siblings Relatives | Rickets (A), colds (6) [Adenoids (A), mouth breathing (M) | Adenoidectomy (AT), tonsillectomy (T) | Glet lip (U, jaw (), oF palate (P) L |__Supernumerary teeth (S), missing teeth (MT) |__Protrusion (P), Class Il, Division 2 (0), Class ill (M) Open-bite (0), deep bite (D) Dental crowding (Orthodontic treatment Miscellaneous: 2) Patient history Prenatal | (course of pregnancy) Diseases: Nutritional disorders: yes/no Psychological problems: yes/no Medication: yes/no Accidents: yes/no When: Type: Birth Premature - normal-—late: Course of labor: Normal Forceps Cesarian section ‘Suction cup Weight: Length: Incubator: yes/no Postnatal Developmental state at birth: Normal/ underdeveloped / hospitalization Infant feeding: Breastied up to month bottlefed up to year spoon-fed after the month fed solid foods affer the month _iven the folowing additional foods after the month: Vitamin O: Fluoride preparations: upto: First tooth: month Learned to walk during the month Leamed to speak during the month Premature loss of deciduous teeth: yes/no Which teeth: ‘Sucking: Which finger right/lelt, pacifier, comer of the blanket From, to years NUK nipple: yes/no From to years Nail biting, clenching, bruxism Position: Mouth opened /closed Snoring: yes/no Rickels—colds - pneumonia - otitis - asthma -allergies ‘Systemic diseases: Allergies: ‘Adenoidectomy tonsillectomy: Atage of: Accidents: Age: Type: ‘Teeth involved: yes/no Treatment: Operations in the head /neck region:Clinical Examination of Clinical Examination The clinical findings are the basis of diagnostic procedures. The aim of the investigation is the recognition of the orthodontic problem from the patient’s point of view as well as the examiner's, and todetermine the need for treatment. Clinical findings are the prerequisite for the correct assessment and interpretation of the quantitative analyses, i. the overall generaland the specific clinical findings, which serve as the foundation of treatment decisions. General State Examination of the constitution and physique of the Anevaluation of the somatogram providesan indica- patient, height and weight in relationship to the chrono- tion of the general growth tendency. Further factors logic age and development of the facial skeleton. include the nutritional situation, assessment of mental development, and the dental and skeletal age. 236 Somatogram Left: Reaistration of chronologic 22] ago, hoight (incn),woight (kg) at the time of examination, 334 Comparison of the data to aver- age values. Thetabies are ciflerent xed [Or boys and ails. Boys Gis BEB EEE BS Right: Data are underlined in ther seq respective colurnns. Physical de 424 velopmentistaken asnormalwhen lines are appraximately honzartal P40] ap wal Li eq Near night: 1 pathologic ditter- 11 ences trom the norm ofthe order of +2 standard devations relating to ihe patients chronologic age, sss PeIGh, and weight exst, asoccurs 309 in dwarfism, gigantsm, obesty, of anoteria, a medical examination is required (Kunze and Murken, Un versity of Munich, 1974), io] sa} (iar ara] ffuza| BEBE lag less] Bases) eae ae | 12 RESEERBESSERESESERTESRECSSCRERRSESRREZE har ve SR BEEBREREE SS ESSE REESBRB BER ERE weseaz aaa SERS se