Case History and

Clinical Examination

in orthodontics

Presented by :Dr. Rajesh Gyawali (rajeshgyawali@hotmail.com)Resident,Department of Orthodontics and Dentofacial OrthopaedicsFaculty of Dentistry,Institute of Medicine, Kathmandu

Guided by :Dr. Basant Kumar ShresthaAssociate Prof. and HeadDepartment of Orthodontics and Dentofacial OrthopaedicsFaculty of Dentistry, Institute of Medicine, Kathmandu

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Case History Case History is the information gathered from the patient or parent or guardian to

aid in overall diagnosis of the case. It includes personal details, chief complaint, past and present medical and dental history and any associated family history. The aim is to establish a rapport with the patient and to obtain information about individual’s complaint.

1. Personal details

A. Name The patient’s name should be recorded for the purpose of communication and identification. Addressing a patient by his or her name has a beneficial psychological effect. It makes the patient more comfortable and arouses a feeling of familiarity.

B. Age The age of the patient helps in diagnosis, treatment planning and growth prediction. There are certain transient conditions that occur during development are considered normal for that age. In addition, there are certain treatment modalities that are best carried out during growing age, like- growth modification using functional and orthopedic appliances. Surgical corrective procedures are best carried out after the cessation of the growth.

C. Sex The patient’s sex also helps in treatment planning. The timing of growth related events including growth spurts, eruption of teeth and onset of puberty are different in males and females. Psychological reaction of males and females may be different towards the same malocclusion. Females are more concerned about facial esthetics.

D. Address and contact number It helps in future correspondence and managing the appointments. Patients coming from far may require a different appliance therapy as they might not be able to visit the clinic frequently.

E. Occupation It helps in evaluation of the socio-economic status of the patient and helps in the selection of the appropriate appliance.

F. Religion G. Ethnic origin

2. Chief Complaint The patient’s chief complaint should be recorded in his or her own words. There are

three logical reasons for patient concern about the alignment and occlusion of the teeth: impaired dentofacial esthetics that can lead to psychosocial problems; impaired function; and a desire to improve dentofacial esthetics. It is important to establish their relative

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importance to the patient and their desires. The parents’ perception of the malocclusion should be noted.

A series of leading questions, beginning with, "Tell me what bothers you about your face or your teeth," may be necessary to clarify what is important to the patient. The orthodontist may or may not agree with the patient’s assessment – the judgement comes later. But, at this stage, it is necessary to find out what is important to the patient.

This will help in setting treatment objectives and satisfying the patient and or parents in general.

3. Medical History Knowledge of the patient’s general health is essential and should be obtained prior

to the examination. It is best obtained by questionnaire.In most of the cases, orthodontic treatment can be undertaken but precautions

should be taken prior to surgical procedures. Patients with rheumatic fever, cardiac anomalies, epilepsy, diabetes and blood dyscrasias may require special precautions.

The medical history should include information on drug usage. The use of certain drugs like aspirin (prostaglandin inhibitors) or bone resorption inhibiting agents may impede orthodontic tooth movement. Patients who are suffering from acute, debilitating conditions such as viral fever should be allowed to recover prior to initiating orthodontic treatment.

History of trauma should be noted. Trauma to the jaws or teeth is often overlooked in child with other trauma, so a jaw injury may not have been diagnosed at that time. This is significant as it affects the future development of jaws and teeth.

4. Dental History The patient’s dental history should include information on the age of eruption and

exfoliation of deciduous and permanent teeth, history of extraction, decay, restorations and trauma. The past dental history will also help in assessing the patients and parents’ attitude towards dental health.

5. History of Habits History of abnormal habits like finger, digit sucking, nail biting, lip biting grinding,

clenching, and mouth breathing should be taken as they influence the development of dentoalveolar structures.

6. Pre-natal History Pre-natal history should include information on the condition of the mother during

pregnancy and the type of delivery. Forceps deliveries have been associated with injury to the temporomandibular joint (TMJ) and may cause ankylosis and mandibular growth retardation. Nutrition status and infections during pregnancy should also be noted.

7. Post-natal History It should include information on type of feeding, presence of habits and milestones of

normal development.

8. Family History

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Many malocclusions like skeletal Class II and Class III, crowding, spacing overjet, high frenal attachments and congenital conditions like cleft lip and palate are inherited.

9. Physical Growth evaluation The parents should be questioned about the child’s growth status. (eg: Has your child

had any recent rapid growth ?). Rapid growth during the adolescent growth spurt facilitates tooth movement but growth modification may not be possible in a child who is beyond the peak of the growth spurt.

For children approaching puberty, questions about how rapidly the child has grown recently, whether clothes sizes have changed, whether there are signs of sexual maturation, and when sexual maturation occurred in older siblings usually provide the necessary information about where the child is on the growth curve.

In orthodontic clinic, measuring the height and weight regularly and calculation of bone age from vertebrae as seen in the cephalometric radiograph can be helpful. Serial cephalometric radiographs offer the most accurate way to determine whether growth has stopped or is continuing.

10. Social and Behavioral Evaluation It should explore – patient’s motivation for treatment, what he or she expects as a

result of treatment and how co-operative or unco-operative the patient is. Motivation can be external or internal. External motivation is that supplied by

pressure from another individual, like child brought for treatment by mother; older patient by his girlfriend. Internal motivation comes from within the individual and is based upon his or her own assessment of the situation and desire for the treatment.

What patient expects from the treatment should be explored carefully especially in case of patients with primarily cosmetic problems.

Clinical Examination

1. General Examination Each patient should be regarded as a whole person rather than as a 'pair of jaws'. The

examination, therefore, begins immediately the patient enters the clinic. If possible, both parents should be present at the examination; this affords an opportunity to observe any hereditary characters which may be present, and also an opportunity to discuss the medical history, diagnosis and treatment.

A. Height and weight It gives a clue to the physical growth and maturation of the patient. The

growth of the body in general is related to the growth of the jaws and face particularly.

B. Gait Gait is the way a person walks. Abnormalities of gait are usually associated with neuromuscular disorders.

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C. Built Sheldon classified body built into:

i. Ectomorphic : Tall and thin physiqueii. Mesomorphic : Average physiqueiii. Endomorphic : Short and obese physique

2. Extra-oral Examination

A. Shape of Head The shape of head can be evaluated based on the cephalic index which is

based on the anthropometric determination of the maximum width and maximum length of the head.It is given by Martin and Saller as: Maximum skull width Maximum skull length

Mesocephalic : I = 76.0 -80.9 Brchycephalic : I = 81.0- 85.4 Broad and short head Dolicocephalic : I < 75.9 Long and narrow head Hyperbrachycephalic : I > 85.5

B. Shape of the face

The shape of the face is assessed by morphologic facial index which was given by Martin and Saller(1957) as: Facial Index Morphologic facial height (Distance between nasion and gnathion) Bizygomatic width (Distance between the two zygoma points)

Hypereuryprosopic : I < 78.9 Euryprosopic : I = 79.0 – 83.0 – Broad and short facial form Mesoprosopic : I = 84.0 – 87.9 – Average or normal facial form Letoprosopic : I = 88.0 – 92.9 – Long and narrow facial form Hyperleptoprosopic : I > 93.0

C. Assessment of facial symmetry

A certain degree of asymmetry between right and left sides of the face is seen in most of the individuals. The face should be examined in the transverse and vertical planes to determine a greater degree of asymmetry than the normal.

Gross facial asymmetries may be seen in patients with- Hemifacial atropy/hypertrophy Congenital defects Unilateral condylar hyperplasia Unilateral Ankylosis

D. Facial profile

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Cephaic index =

The profile is examined from the side by making the patient view at a distant object, with the FH plane parallel to the floor. The profile is assessed by the two reference lines-

A line joining the forehead and the soft tissue point A (deepest point in the curvature of upper lip)

A line joining point A and the soft tissue pogonion (most anterior point of the chin)

Based on the relationship between these two lines, three types of profile exists-

Straight : The two lines form a nearly straight line Convex : The two lines form an angle with the concavity facing the tissue. It

occurs in cases of prognathic maxilla or retrognathic mandible as seen in Class II Div I.

Concave : The two reference lines form an angle with the convexity towards the tissue. This type of profile is seen in Class III patients.

E. Facial divergence It is defined as an anterior or posterior inclination of the lower face relative

to the forehead. Facial divergence is determined by a line drawn from forehead to the chin -

Anterior divergence : The line is inclined anteriorly . Posterior divergence : The line is inclined posteriorly. Straight or orthognathic : The line is perpendicular to the floor, no slanting.

F. Assessment of antero-posterior jaw relationship The antero-posterior jaw relationship between the upper and lower jaw can

be assessed to certain extent clinically by placing index and middle fingers at the approximate A and B points after lip retraction. Ideally the maxillary skeletal base is 2-3mm forward of the mandibular skeletal base when the teeth are in occlusion. In skeletal Class II patients, the index finger is anterior to the middle finger or the hands point upward. In skeletal Class III patients, the middle finger is anterior to the index finger or the hands points downwards. In skeletal Class I patients, the hand is at even level.

G. Assessment of vertical jaw relationship Normally, the distance between glabella to subnasale is equal to the distance

between the subnasale to the underside of the chin. Reduced lower facial height is associated with deep bite while the increased facial height is with anterior open bite.

The vertical skeletal relationship can also be assessed by studying the angle formed between the lower border of the mandible and the Frankfort horizontal plane. Normally, the two planes intersect at the occipital region. In case the two planes meet beyond the occipital region, it indicates a low angle case or horizontal growing face. If the two planes meet anterior to the occipital region it indicates a high angle case or a vertical growing face.

H. Evaluation of facial proportion

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A well proportioned face is divided into three equal vertical thirds using four horizontal planes- at the level of the hair line, the supraorbital ridge, the base of the nose and the inferior border of chin.

Within the lower face, the upper lip occupies one third of the distance.

I. Lips Normally, the upper lip covers the entire labial surface of upper anteriors

except the incisal 2-3mm. The lower lip covers the entire labial surface of the lower anteriors and 2-3 mm of the incisal edges of the upper anteriors.

Lips can be classified into- Competent: Slight contact of lip when the musculature is relaxed. Incompetent: Anatomically short lips which do not contact when musculature

is relaxed. Lip seal is achieved only be active contraction of the orbicularis oris and mentalis muscle.

Potentially competent: Normal lips which fail to form the lip seal due to proclined upper incisors.

Everted lips: Hypertropied lips with weak muscular tonicity.

J. Nose Size: Normally nose is one third of the total facial height. Contour: Shape can be straight, convex or crooked. Nostril: Normally they are oval and bilaterally symmetrical.

K. Nasolabial angle It is the angle formed between the lower border of the nose and a line joining

the subnasale with the tip of the upper lip (labrale superius). The angle is normally 110o. It is reduced in patients with proclined upper anteriors or prognathic maxilla.

L. Chin Chin position and prominence: Prominent chin is usually associated with

Class III malocclusion while recessive chins are common in Class II malocclusion.

Mentolabial sulcus: It is the concavity present below the lower lip. Deep sulcus is seen in class II cases where as shallow sulcus is seen in bimaxillary protrusion.

Mentalis activity: Normally, the mentalis muscle does not show any contraction at rest. Hyperactive mentalis activity is seen in some malocclusion such as Class II division 1 cases. It causes puckering of the chin.

3. Intra-oral Examination A. Tongue

Abnormalities of tongue can upset the muscle balance and equilibrium leading to malocclusion. Presence of excessively large tongue is indicated by the presence of imprints of teeth on the lateral margins of the tongue giving a scalloped appearance. Short lingual frenum called tongue tie leads to impaired tongue movement.

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B. PalatePalate is examined for the following findings-

i. Variations in palatal depth are associated with variation of facial form. Brachycephalic patients have broad and shallow palates where as dolicocephalic patients have deep palates.

ii. Presence of swelling indicates impacted tooth, cysts or bony pathology.iii. Mucosal ulceration and indentations are feature of traumatic deep bite.iv. Presence of cleftsv. The third rugae is usually in line with the canine. It helps to assess maxillary

anteriors proclination.

C. Gingiva

The gingiva should be examined for inflammation, recession, mucogingival lesions. Local gingival lesions may occur due to occlusal trauma, abnormal functional loadings or medications (eg: Dilantin, Phenytoin). In mouth breathers, open lip posture causes dryness of the mouth leading to anterior marginal gingivitis.

D. Frenal attachmentsThe maxillary labial frenum can be thick, fibrous and have low attachment.

Such attachments prevent the two maxillary central incisors from approximating each other leading to midline diastema. Mandibular labial frenum if has high attachment, may lead to recession of gingiva.

Abnormal frenum attachments can be diagnosed by blanch test( when the upper lip is stretched upwards and outwards, blanching in the region of the interdental papilla indicates abnormal frenum attachment).

E. Tonsils and AdenoidsThe size and inflammation of tonsil should be examined. Abnormally inflamed

tonsils cause alteration in tongue and jaw posture thereby upsetting the oro-facial balance leading to malocclusion.

F. Dentition

i. Status- the number of teeth present, unerupted or missing.ii. Presence of caries, restoration, malformation, hypoplasia, wear and

discoloration.iii. Molar relation.iv. Overjet, overbite.v. Midline of the face and its coincidence with the dental midline.

vi. Individual tooth irregularities like rotation, displacement, fracture.vii. Shape and symmetry of the upper and lower jaws.

4. Functional Examination

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Normal functioning of stomatognathic system promotes normal growth and development of oro-facial complex. Improper functioning can result in various malocclusions. Therefore, orthodontic diagnosis should not be restricted to static evaluation of teeth and their supporting structures but should include examination of the functional units of stomatognathic system.

It is important to note in the beginning whether the patient has normal coordination and movements. If not, as in an individual with cerebral palsy or other types of gross incoordination, normal adaptation to the changes in tooth position produced by orthodontics may not occur, and the equilibrium effects may lead to post-treatment relapse.

The functional examination should include-

A. Assessment of postural rest position and inter-occlusal clearanceThe postural rest position is the position of the mandible at which the

muscles that close the mandible and that open the mandible are in the state of minimal contraction. At rest position, a space exists between the upper and lower jaws which is called interocclusal clearance or freeway space which is normally 3mm in canine region.

The postural rest position should be determined with the patient relaxed and seated upright with back unsupported. The head is oriented by making the F_H plane parallel to the floor. Methods to record the postural head position are-

i. Phonetic method: The patient is told to pronounce some consonants like “M” or words like “Mississippi” repeatedly. The mandible returns to the postural rest position 1-2 seconds after the exercise.

ii. Command method: The patient is asked to perform selected functions like swallowing. The mandible then returns spontaneously to rest position.

iii. Non command method: The patient is observed as he speaks or swallows. The patient is not aware that he is being examined. While talking, the patient’s musculature is relaxed and the mandible reverts to the postural rest position.

B. Evaluation of path of closureThe path of closure is the movement of mandible from rest position to

habitual occlusion. Abnormalities of path of closure are seen in some form of malocclusion.Forward path of closure: Many children and adults with a skeletal Class II relationship and an underlying skeletal Class II jaw relationship will position the mandible forward in a "Sunday bite," making the occlusion look better than it really is. Sometimes an apparent Class III relationship results from a forward shift to escape incisor interferences in what is really an end-to-end relationship. These patients are said to have pseudo- Class III malocclusion.

Backward path of closure: Class II division 2 cases exhibit premature incisor contact due to retroclined maxillary incisors. Thus the mandible is guided posteriorly to establish occlusion.

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Lateral path of closure: Lateral deviation of the mandible is associated with occlusal prematurities and a narrow maxillary arch.

C. Examination of TMJThe functional examination of TMJ should include auscultation and palpation

of the temporomandibular joint and the musculature associated with mandibular opening. The patient is examined for the symptoms of TMJ problems like clicking, crepitus, pain of the masticatory muscles, limitation of jaw movement, hyper mobility and morphological abnormalities.

The maximum mouth opening is determined by measuring the distance between the maxillary and mandibular incisor edge with the mouth wide open. The normal inter incisal distance is 40-45 mm.

D. Examination of oral functionsi. Respiration

Humans exhibit three types of breathing- nasal, oral and oro-nasaal.There are some tests which helps to diagnose the mode of respiration-

a. Mirror test: A double sided mirror is held between the nose and mouth. Fogging on the nasal side of the mirror indicates nasal breathing while fogging towards the oral side indicates oral breathing.

b. Cotton test: A butterfly shaped piece of cotton is placed over the upper lip below the nostrils. If the cotton flutters down it indicates nasal breathing. It helps to determine unilateral nasal blockage.

c. Water test: The patient is asked to fill the mouth with water and retain it for a while. Nasal breathers do it easily while mouth breathers feel difficult.

d. Observation: In nasal breathers, the external nares dilate during inspiration. In mouth breathers, there is either no change in the external nares or they may constrict during inspiration.

ii. Tongue thrustingiii. Speech

Speech problems can be related to malocclusion, but normal speech is possible in the presence of severe anatomic distortions. Speech difficulties in a child, therefore, are unlikely to be solved by orthodontic treatment. If a child has a speech problem and the type of malocclusion related to it, a combination of speech therapy and orthodontics may help. If the speech problem is not listed as related to malocclusion, orthodontic treatment may be valuable in its own right but is unlikely to have any impact on speech. Patients having tongue thrust habit tend to lisp while cleft palate patients may have a nasal tone.

Speech Difficulties Related to Malocclusion:

Speech Sound Problem Related malocclusion/s/, /z/ (sibilants) Lisp Anterior open bite,

large gap between incisors

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/t/, /d/ (linguoalveolar stops)

Difficulty in production Lingual position of maxillary incisors

/f/, /v/ (labiodentals fricatives)

Distortion Skeletal Class III

Th, sh, ch (linguodental fricatives [voiced or voiceless])

Distortion Anterior open bite

iv. SwallowingIn a new born, the tongue is relatively large and protrudes

between the gum pads and takes part in establishing the lip seal. This kind of swallow is called infantile swallow and is seen till 1.5 to 2 yrs of age. Infantile swallow is replaced by mature swallow as the buccal teeth erupt. The persistence of infantile swallow can be a cause of malocclusion. The persistence of infantile swallow is indicated by the presence of-

Protrusion of the tip of the tongue.Contraction of perioral muscles during swallowing.No contact at the molar region during swallowing.

v. Lips

5. Evaluation of Facial and Dental Appearance A systematic examination of facial and dental appearance should be done in three steps:

1. The face in all three planes of space (macro-esthetics)2. The smile framework (mini-esthetics)3. The teeth (micro-esthetics)

1. Facial Proportions: Macro Esthetics a. Assessment of Developmental Age:

The assessment of developmental age is particularly important for children around the age of puberty when most of the orthodontic treatment is carried out. The degree of physical development is much more important than chronological age in determining how much growth remains.

b. Facial Esthetics vs Facial proportionWhether a face is considered beautiful or not is determined by ethinc and cultural factors, a disproportionate face becomes a psychosocial problem. Distorted and asymmetric facial features are a major contributor to facial esthetic problems; where as proportionate features are acceptable if not always beautiful. So the goal of the facial examination is to detect the facial disproportion.

i. Frontal Examination A small degree of facial asymmetry exists in all normal individual. This normal symmetry should be distinguished from severe disproportion caused due to deviation of chin or nose to one side.Some of the measurements could be made on a cephalometric radiograph but many could not. It is better to make measurements

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clinically because soft tissue proportions as seen clinically determine facial proportion.The distance from the hair line to base of the nose, base of the nose to bottom of nose and bottom of nose to chin should be same. Similarly, an ideal proportional face can be divide into central, medial and lateral equal fifths. The separation of the eyes and the width of the eyes which should be equal, determine the central and medial fifths. The nose and chin should be centred within the central fifth, with width of the nose the same as or slightly wider than the central fifth. The interpupillary distance should be equal the width of the mouth.Low set eyes or ears that are unusually far apart (hypertelorism) may indicate either the presence of a syndrome or a microform of a craniofacial anomaly. If a syndrome is suspected, hands should be examined because there are a number of dental digital syndromes.

ii. Profile AnalysisProfile analysis gives the same information though in less detail for the underlying skeletal relationships, as obtained from the analysis of lateral cephalometric radiographs. So, the technique of facial profile analysis is also called “Poor man’s cephalometric analysis”.

1) Assessment of jaw position in antero-posterior plane of spaceIt is examined by placing the patient in physiologic natural head position (FH plane is parallel to the ground). The profile is assessed by the two reference lines-

line joining the forehead and the soft tissue point A. line joining point A and the soft tissue pogonion.

These two lines nearly form a straight line. A straight profile whether it is anteriorly or posteriorly diverging doesn’t indicate a problem where as concavity or convexity does.

2) Evaluation of lip posture and incisor prominence

3) Re-evaluation of vertical facial proportions, and evaluation of mandibular plane angle

The mandibular plane is visualized clinically by placing a finger or mirror handle along the lower border of the mandible. A steep mandibular plane angle indicates long anterior facial vertical dimension and a skeletal open bite tendency, while a flat mandibular plane angle often correlates with short anterior facial height and deep bite malocclusion.

2. Tooth –lip relationship: Mini Esthetics a. Tooth-lip relationshipsb. Smile Analysis

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i. Amount of incisor and gingival displayii. Transverse dimension of smile relative to upper arch

iii. The smile arciv.

3. Dental Appearance: Micro Esthetics a. Tooth proportions

i. Width relationships and “Golden Proportion”ii. Height- Width relationships

b. Gingival heights, shape and contourc. Connectors and Embrasuresd. Embrasures: Black Triangles?e. Tooth Shade and Color

Case History Case History is the information gathered from the patient or parent or guardian to

aid in overall diagnosis of the case. It includes personal details, chief complaint, past and present medical and dental history and any associated family history. The aim is to establish a rapport with the patient and to obtain information about individual’s complaint.

11. Personal details

H. Name The patient’s name should be recorded for the purpose of communication and identification. Addressing a patient by his or her name has a beneficial psychological effect. It makes the patient more comfortable and arouses a feeling of familiarity.

I. Age The age of the patient helps in diagnosis, treatment planning and growth prediction. There are certain transient conditions that occur during development are considered normal for that age. In addition, there are certain treatment modalities that are best carried out during growing age, like- growth modification using functional and orthopedic appliances. Surgical corrective procedures are best carried out after the cessation of the growth.

J. Sex The patient’s sex also helps in treatment planning. The timing of growth related events including growth spurts, eruption of teeth and onset of puberty are different in males and females. Psychological reaction of males and females may be different towards the same malocclusion. Females are more concerned about facial esthetics.

K. Address and contact number

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It helps in future correspondence and managing the appointments. Patients coming from far may require a different appliance therapy as they might not be able to visit the clinic frequently.

L. Occupation It helps in evaluation of the socio-economic status of the patient and helps in the selection of the appropriate appliance.

M. Ethnic origin The ethnic differences should be considered during treatment. E.g. in American blacks, arch size is notably larger and arch form is squarer and less tapered compared to American whites.

12. Chief Complaint The patient’s chief complaint should be recorded in his or her own words. There are

three logical reasons for patient concern about the alignment and occlusion of the teeth: impaired dentofacial esthetics that can lead to psychosocial problems; impaired function; and a desire to improve dentofacial esthetics. It is important to establish their relative importance to the patient and their desires. The parents’ perception of the malocclusion should be noted.

A series of leading questions, beginning with, "Tell me what bothers you about your face or your teeth," may be necessary to clarify what is important to the patient. The orthodontist may or may not agree with the patient’s assessment – the judgement comes later. But, at this stage, it is necessary to find out what is important to the patient.

This will help in setting treatment objectives and satisfying the patient and or parents in general.

13. Medical History

Knowledge of the patient’s general health is essential and should be obtained prior to the examination. It is best obtained by questionnaire.

In most of the cases, orthodontic treatment can be undertaken but precautions should be taken prior to surgical procedures. Patients with rheumatic fever, cardiac anomalies, epilepsy, diabetes and blood dyscrasias may require special precautions.

The medical history should include information on drug usage. The use of certain drugs like aspirin (prostaglandin inhibitors) or bone resorption inhibiting agents may impede orthodontic tooth movement. Patients who are suffering from acute, debilitating conditions such as viral fever should be allowed to recover prior to initiating orthodontic treatment.

History of trauma should be noted. Trauma to the jaws or teeth is often overlooked in child with other trauma, so a jaw injury may not have been diagnosed at that time. This is significant as it affects the future development of jaws and teeth.

14. Dental History The patient’s dental history should include information on the age of eruption and

exfoliation of deciduous and permanent teeth, history of extraction, decay, restorations

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and trauma. The past dental history will also help in assessing the patients and parents’ attitude towards dental health.

15. History of Habits History of abnormal habits like finger, digit sucking, nail biting, lip biting grinding,

clenching, and mouth breathing should be taken as they influence the development of dentoalveolar structures.

16. Pre-natal History Pre-natal history should include information on the condition of the mother during

pregnancy and the type of delivery. Forceps deliveries have been associated with injury to the temporomandibular joint (TMJ) and may cause ankylosis and mandibular growth retardation. Nutrition status and infections during pregnancy should also be noted.

17. Post-natal History It should include information on type of feeding, presence of habits and milestones of

normal development.

18. Family History Many malocclusions like skeletal Class II and Class III, crowding, spacing overjet, high

frenal attachments and congenital conditions like cleft lip and palate are inherited.

19. Physical Growth evaluation The parents should be questioned about the child’s growth status. (e.g.: Has your child

had any recent rapid growth?). Rapid growth during the adolescent growth spurt facilitates tooth movement but growth modification may not be possible in a child who is beyond the peak of the growth spurt.

For children approaching puberty, questions about how rapidly the child has grown recently, whether clothes sizes have changed, whether there are signs of sexual maturation, and when sexual maturation occurred in older siblings usually provide the necessary information about where the child is on the growth curve.

In orthodontic clinic, measuring the height and weight regularly and calculation of bone age from vertebrae as seen in the cephalometric radiograph can be helpful. Serial cephalometric radiographs offer the most accurate way to determine whether growth has stopped or is continuing.

20. Social and Behavioral Evaluation It should explore – patient’s motivation for treatment, what he or she expects as a

result of treatment and how co-operative or uncooperative the patient is. Motivation can be external or internal. External motivation is that supplied by

pressure from another individual, like child brought for treatment by mother; older patient by his girlfriend. Internal motivation comes from within the individual and is based upon his or her own assessment of the situation and desire for the treatment.

What patient expects from the treatment should be explored carefully especially in case of patients with primarily cosmetic problems.

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Clinical Examination

6. General Examination Each patient should be regarded as a whole person rather than as a 'pair of jaws'. The

examination, therefore, begins immediately the patient enters the clinic. If possible, both parents should be present at the examination; this affords an opportunity to observe any hereditary characters which may be present, and also an opportunity to discuss the medical history, diagnosis and treatment.

D. Height and weight It gives a clue to the physical growth and maturation of the patient. The

growth of the body in general is related to the growth of the jaws and face particularly.

E. Gait Gait is the way a person walks. Abnormalities of gait are usually associated

with neuromuscular disorders.

F. Built Sheldon classified body built into:

j. Ectomorphic : Tall and thin physiqueii. Mesomorphic : Average physiqueiii. Endomorphic : Short and obese physique

7. Extra-oral Examination

M. Shape of Head The overall head shape is closely related to the bony structures of the skull and to

the shape of the underlying brain. Alterations in head shape can be the result of unusual brain growth, but they may also reflect a number of other factors such as premature synostosis of cranial sutures or unusual intrauterine mechanical forces. Abnormal planes of muscle pull, as in torticollis, can cause asymmetric skull growth.

Five major sutures are present in the calvaria. Coronal, lambdoidal, and squamosal are paired; and sagittal and metopic are single. Cranial growth normally proceeds in a direction perpendicular to each of the major sutures. Increased length of the skull in comparison to width (dolichocephaly or scaphocephaly) and the converse (brachycephaly) can be normal variants. However, both can also occur because of premature synostosis of cranial sutures, where skull growth at right angles to the fused suture is inhibited with compensatory expansion at other patent sutural sites. Head shape depends on which sutures are prematurely synostosed, the order in which they fuse, and the time at which they synostose.

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Fontanelles Sutures

Sutures and fontanelles

Dolichocephaly can occur with early closure of the sagittal suture, producing a long, narrow cranium.When both sides of the coronal suture are prematurely fused, the head is brachycephalic. Unilateral synostosis of the coronal suture results in asymmetry of head shape or plagiocephaly. The frontal eminence on the fused side is flattened and the glabella region is underdeveloped. The eyebrows and orbit on the affected side appear elevated. Premature closure of one lambdoid suture can similarly result in plagiocephaly. In trigonocephaly, premature synostosis of the metopic suture results in a triangular prominence of the frontal bone, usually in association with ocular hypotelorism. Metopic ridging may occur.

The shape of head can be evaluated based on the cephalic index which is based on the anthropometric determination of the maximum width and maximum length of the head.

It is given by Martin and Saller as: Maximum skull width Maximum skull length

Mesocephalic : I = 76.0 -80.9 Brchycephalic : I = 81.0- 85.4 Broad and short head Dolicocephalic : I < 75.9 Long and narrow head Hyperbrachycephalic : I > 85.5

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Cephaic index = ×100

Skull Length is the maximum dimension of the sagittal axis of the skull. It is measured as the distance between the glabella (the most prominent point on the frontal bone above the root of the nose, between the eyebrows) and the opisthocranion (the most prominent portion of the occiput, close to the midline on the posterior rim of the foramen magnum).

Skull width is measured between the most lateral points of the parietal bones (eurion) on each side of the head. The measurement is done with spreading calipers.

Measuring skull length and skull width

N. Shape of the face The shape of the face is assessed by morphologic facial index which was given

by Martin and Saller(1957) as: Morphologic facial height Bizygomatic width

Hypereuryprosopic : I < 78.9 Euryprosopic : I = 79.0 – 83.0 – Broad and short facial form Mesoprosopic : I = 84.0 – 87.9 – Average or normal facial form Letoprosopic : I = 88.0 – 92.9 – Long and narrow facial form Hyperleptoprosopic : I > 93.0

Facial height is the distance from the root of the nose (nasion) to the lowest median landmark on the lower border of the mandible (menton or gnathion). The measurement is done with spreading calipers. A tape-measure can be used but should be held parallel to the sagittal axis of the face, in front of the tip of the nose.

Bizygomatic width is the maximal distance between the most lateral points on the

zygomatic arches (zygion), localized by palpation.

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×100Facial index (I) =

Measuring bizygomatic width and the facial height

O. Assessment of facial symmetry A certain degree of asymmetry between right and left sides of the face is

seen in most of the individuals. The face should be examined in the transverse and vertical planes to determine a greater degree of asymmetry than the normal.

Gross facial asymmetries may be seen in patients with- Hemifacial atropy/hypertrophy Congenital defects Unilateral condylar hyperplasia Unilateral Ankylosis

P. Facial profile The profile is examined from the side by making the patient view at a distant

object, with the FH plane parallel to the floor. The profile is assessed by the two reference lines-

A line joining the forehead and the soft tissue point A (deepest point in the curvature of upper lip)

A line joining point A and the soft tissue pogonion (most anterior point of the chin)

Based on the relationship between these two lines, three types of profile exists-

Straight : The two lines form a nearly straight line Convex : The two lines form an angle with the concavity facing the tissue. It

occurs in cases of prognathic maxilla or retrognathic mandible as seen in Class II Div I.

Concave : The two reference lines form an angle with the convexity towards the tissue. This type of profile is seen in Class III patients.

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Convex Straight Concave

Q. Facial divergence It is defined as an anterior or posterior inclination of the lower face relative

to the forehead. Facial divergence is determined by a line drawn from forehead to the chin -

Anterior divergence : The line is inclined anteriorly. Posterior divergence : The line is inclined posteriorly. Straight or orthognathic : The line is perpendicular to the floor, no slanting.

Straight Posteriorly Anteiorly Diverging diverging

R. Assessment of antero-posterior jaw relationship The antero-posterior jaw relationship between the upper and lower jaw can

be assessed to certain extent clinically by placing index and middle fingers at the approximate A and B points after lip retraction. Ideally the maxillary skeletal base is 2-3mm forward of the mandibular skeletal base when the teeth are in occlusion. In skeletal Class II patients, the index finger is anterior to the middle finger or the hands point upward. In skeletal Class III patients, the middle finger is anterior to the index finger or the hands points downwards. In skeletal Class I patients, the hand is at even level.

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S. Assessment of vertical jaw relationship Normally, the distance between glabella to subnasale is equal to the distance

between the subnasale to the underside of the chin. Reduced lower facial height is associated with deep bite while the increased facial height is with anterior open bite.

The vertical skeletal relationship can also be assessed by studying the angle formed between the lower border of the mandible and the Frankfort horizontal plane. Normally, the two planes intersect at the occipital region. In case the two planes meet beyond the occipital region, it indicates a low angle case or horizontal growing face. If the two planes meet anterior to the occipital region it indicates a high angle case or a vertical growing face.

T. Evaluation of facial proportion A well proportioned face is divided into three equal vertical thirds using four

horizontal planes- at the level of the hair line, the supraorbital ridge, the base of the nose and the inferior border of chin.

Within the lower face, the upper lip occupies one third of the distance.

U. Lips

In the ideal lip form, the vertical dimension is such that, with the lip muscles in their position of resting posture, the lips meet together. In this condition of rest, there is minimal muscle contraction to maintain the position of the lips. Considerable variation occurs in the resting lip form.

Competent: Slight contact of lip when the musculature is relaxed. Incompetent: Anatomically short lips which do not contact when musculature

is relaxed. Lip seal is achieved only by active contraction of the orbicularis oris and mentalis muscle.

Potentially competent: Normal lips which fail to form the lip seal due to proclined upper incisors.

Everted lips: Hypertropied lips with weak muscular tonicity.

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If they are of sufficient size to be together at rest then lip closure will not place extra forces on the teeth. If the lips at rest are apart, then muscular contraction will be required to bring them together during swallowing and speech, and such contraction will impose extra forces on the erupting teeth. Furthermore, some people, whose lips do not meet at rest, maintain a conscious lip closure for much of the time, again imposing muscular forces on the teeth. The effect of these forces on the erupting teeth depends to a large extent on the sagittal relationship of the lips.

The sagittal relationship of the lips is almost entirely determined by the relationship of the basal bone of the jaws, to which they are attached. The lower lip tends to be further back than the upper lip in a skeletal Class 2 relationship, and further forward in a skeletal Class 3 relationship. This not only increases the difficulty of putting the lips together, but also may cause the lower lip to modify the eruptive path of the upper incisors. Such modification may alter the primary effect of the skeletal relationship on the occlusal relationship of the teeth, either increasing or reducing the effect of any skeletal discrepancy.

For example, with a skeletal Class 2 relationship the lower lip may function completely or partly behind the upper incisors. If the skeletal discrepancy is not severe, the lip may procline the upper incisors so that the occlusal relationship is more severely Class 2 than the skeletal relationship (fig a). If the skeletal discrepancy is severe, the lower lip may function behind the upper incisors without causing them to be proclined (fig b). In other instances, with skeletal Class 2, the lower lip functions entirely in front of the upper incisors, causing them to be retroclined into the Class 2 Division 2 incisor relationship.

It is equally possible for lip activity to produce Class 2 or Class 3 occlusal relationships on a Class I skeletal relationship by altering the inclination of the incisor teeth during eruption.

The level at which the lips meet together in normal function is usually called the 'lip-line'. The position of the lip-line in relation to the incisor teeth plays a part in governing the position of those teeth. The ideal level of the lip-line is approximately at the centre of the crowns of the upper incisor teeth, with the lower lip in front of the upper incisors.

The lip-line may be low, in which case part of the lower lip may function behind the upper incisors, causing proclination. If the lower lip functions completely behind the upper incisors the definition of lip-line is not strictly applicable. The lip-line may be high, as is

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Fig a Fig b

common in Class 2 Division 2 occlusal relationship. This is usually brought about by the fact that retroclination of the incisors results in the incisors not meeting correctly, with consequent continued development of upper and lower incisors and related alveolar bone in the vertical dimension. The upper incisors are thus too far down in relation to the lips, and the lip-line is high

a b c d

(a) The ideal level, the lower lip controlling the upper incisors, (b) A low lip-line, the lower lip functioning partly behind the upper incisors, (c) The lower lip functioning completely behind the upper incisors, (d) A high lip-line, the lower lip exerting extra control over the upper incisors, which are retroclined.

The Ricketts‘ E-line, the reference line connecting the tip of the nose with the soft tissue pogonion, passes about 4 mm in front of the upper lip and 2 mm in front of the lower lip.

V. Nose The nose, with its central position, plays a major role in facial aesthetics and the

parameters that one must consider in clinical nasal analysis are impressive.

Size: Normally nose is one third of the total facial height. Contour: Shape can be straight, convex or crooked. Nostril: Normally they are oval and bilaterally symmetrical. Asymmetry may

indicate nasal obstruction.

W. Nasolabial angle

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It is the angle formed between the lower border of the nose and a line joining the subnasale with the tip of the upper lip (labrale superius). The angle is normally 110o. It is reduced in patients with proclined upper anteriors or prognathic maxilla.

X. Chin Chin position and prominence: Prominent chin is usually associated with

Class III malocclusion while recessive chins are common in Class II malocclusion.

Mentolabial sulcus: It is the concavity present below the lower lip. Deep sulcus is seen in class II cases where as shallow sulcus is seen in bimaxillary protrusion.

Mentalis activity: Normally, the mentalis muscle does not show any contraction at rest. Hyperactive mentalis activity is seen in some malocclusion such as Class II division 1 cases. It causes puckering of the chin.

8. Intra-oral Examination G. Tongue

Abnormalities of tongue can upset the muscle balance and equilibrium leading to malocclusion because it counteracts the action of buccinator. Short lingual frenum called tongue tie leads to impaired tongue movement.

Presence of excessively large tongue is indicated by the presence of imprints of teeth on the lateral margins of the tongue giving a scalloped appearance. Large tongue(macroglossia) can be because of the absolute increase in size or because of the narrow arch. Individuals who appear to have a large tongue almost always have a well-developed mandible, but it is very difficult to establish tongue size. Only in extreme cases, as with a patient with early-onset thyroid deficiency, is it possible to be reasonably sure that an enlarged tongue contributed to excessive growth of the mandible. This is unlikely to be a major cause of mandibular prognathism.

H. PalatePalate is examined for the following findings-

vi. Variations in palatal depth are associated with variation of facial form. Brachycephalic patients have broad and shallow palates where as dolicocephalic patients have deep palates.

vii. Presence of swelling indicates impacted tooth, cysts or bony pathology.viii. Mucosal ulceration and indentations is feature of traumatic deep bite,

especially in case of Class II malocclusion.ix. The third rugae is usually in line with the canine. It helps to assess maxillary

anteriors proclination.x. Presence of clefts.

I. GingivaThe gingiva should be examined for inflammation, recession, mucogingival

lesions. Local gingival lesions may occur due to occlusal trauma, abnormal functional

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loadings or medications (eg: Dilantin, Phenytoin). In mouth breathers, open lip posture causes dryness of the mouth leading to anterior marginal gingivitis.

J. Frenal attachmentsThe maxillary labial frenum can be thick, fibrous and have low attachment.

Such attachments prevent the two maxillary central incisors from approximating each other leading to midline diastema. Mandibular labial frenum if with high attachment, may lead to recession of gingiva.

Abnormal frenum attachments can be diagnosed by blanch test (when the upper lip is stretched upwards and outwards, blanching in the region of the interdental papilla indicates abnormal frenum attachment).

K. Tonsils and AdenoidsThe size and inflammation of tonsil should be examined. Abnormally inflamed

tonsils cause alteration in tongue and jaw posture thereby upsetting the oro-facial balance leading to malocclusion.

L. Dentition and dental arch

i. StatusThe numbers of teeth present, deciduous or permanent; missing or unerupted teeth; extracted due to some reasons must be recorded.

ii. Presence of caries, restoration, malformation, hypoplasia, wear and discoloration.

iii. Molar relationMolar relation is defined as the relation betweeen maxillary and

mandibular first molars. It can be of - Class I: Mesio-buccal cusp of maxillary first molar occludes in the buccal

groove of the mandibular first molar.

Class II: Mesio-buccal cusp of maxillary first molar occludes in the groove between mandibular 2nd premolar and 1st molar.

o Div 1: With proclined maxillary incisors. o Div 2: Lingually inclined maxillary central incisors with labially tipped

lateral incisors overlapping the centrals. Lingual inclination of central and lateral incisors with canines labially tipped can also occur.

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Class III: Mesio-buccal cusp of maxillary first molar occludes in the groove between mandibular 1st and 2nd molar.

When there is Class II molar relation on one side, and Class I on other side, it is called Class II subdivision.

When there is Class III molar relation on one side and Class I on other side, it is called Class III subdivision.

When there is Class II molar relation on one side and Class II on other side, it is called Class IV relation.

When mesiobuccal cusp of maxillary first molar occludes with the mesiobuccal cusp of mandibular first molar, it is called end-on molar relation.

When mesiobuccal cusp relation is between Class I and Class III, it is called Super Class I relation.

Dewey’s modification of Angle’s Class I malocclusion-TYPE 1:-Angle’s class I with crowded maxillary anterior teeth.

TYPE 2:- Angle’s class I with maxillary incisor in labio-version (proclined).

TYPE 3:- Angle’s class I with maxillary incisor teeth on linguo-version to mandibular incisor teeth (anterior in cross bite)

TYPE 4:- Molar and/or premolars are in bucco or linguo-version,but incsors & canines are in normal alignment (posterior in crossbite) .

TYPE 5:- Molars are in mesioversion due to early loss of teeth mesial to them (Early loss of deciduous molars or second premolar) .

Dewey’s modification of Angle’s Class III malocclusion-TYPE 1:- Individual arches when viewed individually are in normal alignment, but when in occlusion the anterior are in edge to edge bite.

TYPE 2:- The mandibular incisors are crowed & lingual to the maxillary incisors.

TYPE 3:- Maxillary arch is underdeveloped, in cross bite with maxillary incisors crowded & the mandibular arch is well developed & well aligned.

Lischer’s modification of Angle’s classification-

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Lischer in 1933 further modified angle’s classification by substitute names for Angle’s Class I, II & III malocclusion he also proposed terms to designate individual tooth malpositions 1) Neutroocclusion 2) Distoocclusion 3) Mesioocclusion

iv. Incisor relationBritish standards Institute Classification of incisor relationship-

Class I : Lower incisor edges occludes with or lie immediately below the cingulum plateau of upper central incisors.

Class II : Lower incisor edges lie posterior to cingulum plateau. Two subdivisions of this category are –

o Div 1 – The upper central incisors are proclined or of average inclination and there is an increase in overjet.

o Div 2 – The upper central incisors are retroclined. Overjet is usually minimal or may be increased.

Class III : The lower incisor edges lie anterior to cingulum plateau. The overjet may be reduced or reversed.

v. Canine relation Class I : The mesial incline of upper canine overlaps the distal

slopes of the lower canine. Class II : Distal slope of maxillary canine occludes or contact the

mesial slope of lower canine.

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Class I Class III

Class II Div 1 Class II Div 2

Class III : Lower canine is displaced anteriorly to the upper canine with no overlapping of upper and lower canine.

vi. OverjetIt is defined as the horizontal overlap between the maxillary and

mandibular incisors. Normal overjet: The incisal edges of maxillary incisors are 2-3mm

ahead of mandibular incisors. Increased ovejet: Horizontal overlap more than normal. Decreased overjet: Horizontal overlap less than normal. No overjet (Edge to edge): The incisal edges of maxillary and

mandibular incisors are in same vertical plane. Reverse overjet (Cross bite): Mandibular incisors edges are

forwardly placed than the maxillary incisors edges.

vii. Overbite.It is defined as the vertical overlap between maxillary and mandibular

incisors. Normal overbite: The upper incisors cover the incisal third of the

lower incisors. Increased overbite (Deep bite): Lower incisors converage more

than normal.o Complete deep bite: There is a contact between the lower

incisal edge and tooth or soft tissue of the palate.o Incomplete deep bite: There is no contact between the

lower incisor edge and tooth or soft tissue of the palate. Decreased overbite: The vertical overlap of the mandibular

incisors is less than normal. Edge to edge bite: The incisal edges of upper and lower incisors

are in contact. No overbite (open bite): No vertical overlap.

o Anterior open bite: No overlap of incisors.o Posterior open bite: No overlap of posterior teeth.

viii. Midline of the face and its coincidence with the dental midline.The midline of the face should coincide with the midline of the face.

Deviations can be seen in crowding, rotation of the dental arch around the vertical axis.

ix. Individual tooth irregularities like rotation, displacement, fracture.Lischer classified individual tooth irregularity as-

Buccoocclusion: Buccal placement Linguoocclusion: Lingual placement Supraocclusion: Eruption beyond the normal level Infraocclusion: Not erupted to the normal level Mesioversion: Mesial to normal position Distoversion: Distal to normal position

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Transversion: Transposition of two teeth Axiversion: Abnormal axial inclination of a tooth Torsiversion: Rotation of tooth around its long axis.

x. Shape and symmetry of the upper and lower jaws. Arch can be bilaterally symmetric or asymmetric. Asymmetry within

the dental arch, but with symmetric arch form, also can occur. It usually results either from lateral drift of incisors or from drift of posterior teeth unilaterally. Tansparent ruled grid placed over the upper dental arch and oriented to the midpalatal raphe can make it easier to see a distortion of arch form.

The arch form can be classified as (Thompson’s Classification):

Elliptical Round

U- Shaped V- Shaped

9. Functional Examination Normal functioning of stomatognathic system promotes normal growth and

development of oro-facial complex. Improper functioning can result in various malocclusions. Therefore, orthodontic diagnosis should not be restricted to static evaluation of teeth and their supporting structures but should include examination of the functional units of stomatognathic system.

It is important to note in the beginning whether the patient has normal coordination and movements. If not, as in an individual with cerebral palsy or other types of gross incoordination, normal adaptation to the changes in tooth position produced by orthodontics may not occur, and the equilibrium effects may lead to post-treatment relapse.

The functional examination should include-

E. Assessment of postural rest position and inter-occlusal clearance

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The postural rest position is the position of the mandible at which the muscles that close the mandible and that open the mandible are in the state of minimal contraction. At rest position, a space exists between the upper and lower jaw which is called interocclusal clearance or freeway space which is normally 3mm in canine region.

The postural rest position should be determined with the patient relaxed and seated upright with back unsupported. The head is oriented by making the FH plane parallel to the floor. Methods to assess postural rest position are-

i. Phonetic method: The patient is told to pronounce some consonants like “M” or words like “Mississippi” repeatedly. The mandible returns to the postural rest position 1-2 seconds after the exercise.

ii. Command method: The patient is asked to perform selected functions like swallowing. The mandible then returns spontaneously to rest position.

iii. Non command method: The patient is observed as he speaks or swallows. The patient is not aware that he is being examined. While talking, the patient’s musculature is relaxed and the mandible reverts to the postural rest position.

F. Evaluation of path of closureThe path of closure is the movement of mandible from rest position to

habitual occlusion. Abnormalities of path of closure are seen in some form of malocclusion.

Forward path of closure: Many children and adults with a skeletal Class II relationship and an underlying skeletal Class II jaw relationship will position the mandible forward in a "Sunday bite," making the occlusion look better than it really is. Sometimes an apparent Class III relationship results from a forward shift to escape incisor interferences in what is really an end-to-end relationship. These patients are said to have pseudo- Class III malocclusion.

Backward path of closure: Class II division 2 cases exhibit premature incisor contact due to retroclined maxillary incisors. Thus the mandible is guided posteriorly to establish occlusion.

Lateral path of closure: Lateral deviation of the mandible is associated with occlusal prematurities and a narrow maxillary arch.

G. Examination of TMJThe functional examination of TMJ should include auscultation and palpation

of the temporomandibular joint and the musculature associated with mandibular opening. The patient is examined for the symptoms of TMJ problems like clicking,

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crepitus, pain of the masticatory muscles, limitation of jaw movement, hyper mobility and morphological abnormalities.

The maximum mouth opening is determined by measuring the distance between the maxillary and mandibular incisor edge with the mouth wide open. The normal inter incisal distance is 40-45 mm.

H. Examination of oral functionsi. Respiration

Humans exhibit three types of breathing- nasal, oral and oro-nasal.There are some tests which help to diagnose the mode of respiration-

a. Mirror test: A double sided mirror is held between the nose and mouth. Fogging on the nasal side of the mirror indicates nasal breathing while fogging towards the oral side indicates oral breathing.

b. Cotton test: A butterfly shaped piece of cotton is placed over the upper lip below the nostrils. If the cotton flutters down it indicates nasal breathing. It helps to determine unilateral nasal blockage.

c. Water test: The patient is asked to fill the mouth with water and retain it for a while. Nasal breathers do it easily while mouth breathers feel difficult.

d. Observation: In nasal breathers, the external nares dilate during inspiration. In mouth breathers, there is either no change in the external nares or they may constrict during inspiration.

ii. SpeechSpeech problems can be related to malocclusion, but normal speech is

possible in the presence of severe anatomic distortions. Speech difficulties in a child, therefore, are unlikely to be solved by orthodontic treatment. If a child has a speech problem and the type of malocclusion related to it, a combination of speech therapy and orthodontics may help. If the speech problem is not listed as related to malocclusion, orthodontic treatment may be valuable in its own right but is unlikely to have any impact on speech. Patients having tongue thrust habit tend to lisp while cleft palate patients may have a nasal tone.

Speech Difficulties Related to Malocclusion:

Speech Sound Problem Related malocclusion/s/, /z/ (sibilants) Lisp Anterior open bite,

large gap between incisors

/t/, /d/ (linguoalveolar stops)

Difficulty in production Lingual position of maxillary incisors

/f/, /v/ (labiodentals fricatives)

Distortion Skeletal Class III

Th, sh, ch (linguodental fricatives [voiced or

Distortion Anterior open bite

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voiceless])

iii. SwallowingIn a new born, the tongue is relatively large and protrudes between

the gum pads and takes part in establishing the lip seal. This kind of swallow is called infantile swallow and is seen till 1.5 to 2 yrs of age. Infantile swallow is replaced by mature swallow as the buccal teeth erupt. The persistence of infantile swallow can be a cause of malocclusion. The persistence of infantile swallow is indicated by the presence of-

Protrusion of tip of the tongue.Contraction of perioral muscles during swallowing.No contact at the molar region during swallowing.

10.Evaluation of Facial and Dental Appearance A systematic examination of facial and dental appearance should be done in three steps:

4. The face in all three planes of space (macro-esthetics)5. The smile framework (mini-esthetics)6. The teeth (micro-esthetics)

4. Facial Proportions: Macro Esthetics a. Assessment of Developmental Age:

The assessment of developmental age is particularly important for children around the age of puberty when most of the orthodontic treatment is carried out. The degree of physical development is much more important than chronological age in determining how much growth remains.

b. Facial Esthetics vs Facial proportionWhether a face is considered beautiful or not is determined by ethnic

and cultural factors, a disproportionate face becomes a psychosocial problem. Distorted and asymmetric facial features are a major contributor to facial esthetic problems; whereas proportionate features are acceptable if not always beautiful. So the goal of the facial examination is to detect the facial disproportion.

i. Frontal Examination A small degree of facial asymmetry exists in all normal

individual. This normal symmetry should be distinguished from severe disproportion caused due to deviation of chin or nose to one side.

Some of the measurements could be made on a cephalometric radiograph but many could not. It is better to make measurements clinically because soft tissue proportions as seen clinically determine facial proportion.

The distance from the hair line to base of the nose, base of the nose to bottom of nose and bottom of nose to chin should be same.

Similarly, an ideal proportional face can be divided into central, medial and lateral equal fifths. The separation of the eyes and

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the width of the eyes which should be equal, determine the central and medial fifths. The nose and chin should be centred within the central fifth, with width of the nose the same as or slightly wider than the central fifth. The interpupillary distance should be equal the width of the mouth.

Low set eyes or ears that are unusually far apart (hypertelorism) may indicate either the presence of a syndrome or a microform of a craniofacial anomaly. If a syndrome is suspected, hands should be examined because there are a number of dental digital syndromes.

ii. Profile AnalysisProfile analysis gives the same information though in less

detail for the underlying skeletal relationships, as obtained from the analysis of lateral cephalometric radiographs. So, the technique of facial profile analysis is also called “Poor man’s cephalometric analysis”.

1) Assessment of jaw position in antero-posterior plane of spaceIt is examined by placing the patient in physiologic natural head position (FH plane is parallel to the ground). The profile is assessed by the two reference lines-

line joining the forehead and the soft tissue point A. line joining point A and the soft tissue pogonion.

These two lines nearly form a straight line. A straight profile whether it is anteriorly or posteriorly diverging doesn’t indicate a problem where as concavity or convexity does.

2) Evaluation of lip posture and incisor prominenceDetection of excessive incisor protrusion or retrusion is

important because of the effect on space within the dental arches. If incisors protrude, they align themselves on the arc of a larger circle as they lean forward.

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The teeth protrude excessively if – (i) the lips are prominent and everted, and (ii). The lips are separated at rest by more than 3-4mm.

In other words, excessive protrusion of the incisors is revealed by prominent lips that are separated when they are relaxed, so that the patient must strain to bring the lips together over the protruding teeth. For such patients, retracting the teeth tends to improve both lip function and facial esthetics. On the other hand, if lips are prominent but close over the teeth without strain, the lip posture is largely independent of tooth position. For that individual, retracting the incisor teeth would have little effect on lip function or prominence.

Lip posture and incisor prominence should be evaluated by viewing the profile with the patient’s lips relaxed. This is done by observing the distance that each lip projects forward from a true vertical line through the depth of the concavity at its base (soft tissue points A and B). Lip prominence of more than 2 to 3 mm in presence of lip incompetence indicates dentoalveolar protrusion.

3) Re-evaluation of vertical facial proportions, and evaluation of mandibular plane angle

The mandibular plane is visualized clinically by placing a finger or mirror handle along the lower border of the mandible. A steep mandibular plane angle indicates long anterior facial vertical dimension and a skeletal open bite tendency, while a flat mandibular plane angle often correlates with short anterior facial height and deep bite malocclusion.

5. Tooth –lip relationship: Mini Esthetics a. Tooth-lip relationships

It is important to evaluate the relationship of dentition to the face. The relationship of the dental midline of each arch to the skeletal midline of that arch should be noted (the lower incisor midline related to the midline of the mandible and the upper incisor midline related to the midline of the maxilla).

The vertical relationship of teeth i.e. the amount of incisor display to the lips at rest and on smile is noted.

Finally, it is important to note whether an up-down transverse rotation of the dentition is revealed when the patient smiles or the lips are separated at rest. It is often called a transverse cant of the occlusal plane or transverse roll of the esthetic line of the dentition.

b. Smile AnalysisFacial attractiveness is defined more by the smile than by soft tissue

relationship at rest. There are mainly two types of smile- posed or social smile; and emotional smile. The social smile is reproducible and is the one

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that is presented to the world routinely. The emotional smile varies with the emotion being displayed. The social smile is the focus of orthodontic diagnosis.

In smile analysis, oblique ¾th view as well as the frontal and profile views is important. The three things need to be considered.

i. Amount of incisor and gingival displayThe elevation of the upper lip on smile should stop at or near

the gingival margin so that the entire upper incisor is seen. Some display of gingiva is acceptable and can be both esthetic and youthful appearing. Lip elevation that doesn’t reach 100% display of the incisor crown is less attractive.

It is important to remember that the vertical relationship of the lip to the incisor will change over time with the amount of incisor exposure decreases with age.

ii. Transverse dimension of smile relative to upper archDepending upon the facial index, a wide smile may be more

attractive than a narrow one. Wide dental arch and narrow buccal corridor width (the distance between maxillary posterior teeth- especially premolars and the inside of the cheek) is preferred.

iii. The smile arcThe smile arc is defined as the contour of the incisal edges of

maxillary anterior teeth relative to the curvature of the lower lip during a social smile. For best appearance, the contour of the teeth should match that of the lower lip.

A flattened smile arc decreases the attractiveness and makes look older.

6. Dental Appearance: Micro Esthetics a. Tooth proportions

i. Width relationships and “Golden Proportion”The apparent width of the maxillary anterior teeth on smile

and their actual mesio-distal width differ because of the curvature of the dental arch. For best appearance, the appearance, the apparent width of the lateral incisor should be 62% of the width of the central incisor, the apparent width of the canine should be 62% the width of the lateral incisor, same for the premolar. This is called “Golden Proportion”.

ii. Height- Width relationshipsThe width of the tooth should be 80% of its height. If the

height is insufficient, there may be several cause: incomplete eruption in a child, loss of crown height from attrition in older person, excessive gingival height etc. The disproportion and its probable cause should be noted.

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b. Gingival heights, shape and contourGenerally the central incisor has the highest gingival level, the lateral

incisor is approximately 1.5mm lower and the canine gingival margin is at the level of the central incisor.

For best appearance, the gingival shape of the maxillary lateral incisor should be symmetrical half-oval or half-circle. The maxillary centrals and canines should exhibit a gingival shape that is more elliptical and oriented distally to the long axis of the tooth. The gingival zenith (the most apical point of the gingival tissue) should be located distal to the longitudinal axis of the maxillary centrals and canines, while the gingival zenith of the maxillary laterals should coincide with their longitudinal axis.

c. Connectors and EmbrasuresThe connector (also referred to as the interdental contact area) is

where adjacent teeth appear to touch, and may extend apically or occlusally from the actual contact point. In other words, the actual contact point is very small area and the connector includes the contact point and the area above and below that are so close together they look as if they are touching.

The normal connector height is greatest between the central incisors and diminishes from the centrals to the posterior teeth. The embrasures (triangular spaces incisal and gingival to the contact area) are larger in size than the connectors and the gingival embrasures are filled with interdental papillae.

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d. Embrasures: Black Triangles?

Short interdenal papilla leave an open gingival embrasure above the connectors and these “black triangles” can detract significantly from the appearance of the teeth on smile.

In adult, black triangles are formed from loss of gingival tissue related to periodontal disease. But when crowded and rotated maxillary incisors are corrected orthodontically in adults, the connector moves incisally and black triangles may appear. So, both actual and potential black triangles should be noted during the orthodontic examination and the patient should be prepared for reshaping of the teeth to minimize this esthetic problem.

e. Tooth Shade and ColorThe teeth appear lighter and brighter at a younger age, darker and

dull as age progresses. A normal progression of shade change from the midline posteriorly is important contributor to an attractive and natural appearing smile. The maxillary central incisors tend to be the brightest in the smile, the lateral incisor less so, and the canines least bright. The first and second premolars are lighter and brighter than the canines more closely matched to the lateral incisors.

References: • Contemporary Orthodontics,, Proffit, Fields, Sarver, FourthEdition• Orthodontics: Principles and practice; Graber, Vananrsdall, Vig, Fourth Edition• Textbook of Orthodontics, Basic Principles and Practices, Sridhar Premkumar, 4th

edition• Textbook of Orthodontics : Gurkeerat Singh, 2nd Edition• Orthodontics, The Art and Science: S.I. Bhalajhi , 3rd Edition

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