Clinical examination of Orthodontic Patient

By-HIMSHIKHA
PG 2nd year
CONTENTS
• Introduction
• Diagnostic process
• Chief complaint
• Medical history
• Dental history
• Family history
• Clinical evaluation
Introduction
• Diagnosis is the recognition and systematic designation of
anomalies; practical synthesis of the findings, permitting therapy
to be planned and indications to be determined, thereby
enabling doctor to act.
• Diagnosis in orthodontics, as in other disciplines of dentistry
and medicine, requires the collection of an adequate database
of information about the patient and the distillation from that
database of a comprehensive but clearly stated list of the
patient’s problems.
 Recognizing
the problem

Formulating the
problem
Carrying out the
necessary
examinations
Interpretation
of results

Diagnosis
• In the development of a diagnostic database and formulation of a
problem list, the goal is truth—the facts about the patient’s
situation and problems.
• On the other hand, the goal of treatment planning is not scientific
truth, but wisdom—the plan that a wise and prudent clinician
would follow to maximize benefit for the patient.
• Diagnosis must be made scientifically; treatment planning cannot
involve science alone, because judgment by the clinician is
required as problems are prioritized and as alternative treatment
possibilities are evaluated.
Comprehensive diagnosis
• Diagnosis must be comprehensive and not focused on only a
single aspect of what in many instances can be a complex
situation.
• Orthodontic diagnosis requires a broad overview of the patient’s
situation and must take into consideration both objective and
subjective findings.
• It is important not to characterize the dental occlusion while
overlooking a jaw discrepancy, developmental syndrome,
systemic disease, periodontal problem, psychosocial problem,
or the cultural milieu in which the patient is living.
Patient
History

CASE
HISTORY
Family
history
• The first step in the assessment of orthodontic cases is the critical
examination of case history.
• The purpose of this is to understand the development of the
malocclusion, so that by early elimination of causative factors,
correct therapy can be undertaken.
• Such an approach increases the likelihood of a more favorable
prognosis and greater stability as compared to purely
symptomatic approach to orthodontic treatment.
• As a rule, the case history is usually assessed with the help of
questionnaire.
Chief complaint
• After the patient makes his or her first visit to the office, the
classic elicitation of the chief complaint follows, with emphasis
on whether the patient is seeking functional or esthetic
improvement or both.
• This process is most often a structured oral interview, although
questionnaires may be used to probe for what patients may feel
but are unable to verbalize very well.
Medical history
• Prenatal period-
• Nutritional disorder, diseases and accidents to the mother
during pregnancy.
• Eg. Viral infection and cleft formation in newborn.
• During Birth-
• Time of birth, the fetal position at birth and complications.
• Eg. Forcep delivery and TMJ Ankylosis.
Post-natal history
• Manner of feeding, nutritional disturbances, child’s general
development and information regarding habits, accidents during
childhood.
• Generalized diseases which can effect development of jaws,
eg. Ricketts, dysostosis.
• Medical condition which may limit orthodontic
treatment( diabetes mellitus, epilepsy, osteoporosis, arthritis)
• Diseases influencing type of breathing, eg. Cold, pneumonias,
otitis, allergies.
• Evidence of disturbed respiration- type of breathing and
previous history of adenoidectomy/ tonsillectomy.
• Hospitalization, medications, allergies eg latex allergy or nickel
allergy and history blood transfusion (increased chances of
Hepatitis B or HIV exposure.
• Heart problems such as mitral valve prolapse or rheumatic fever
(antibiotic prophylaxis is required for invasive procedures such as
banding in the presence of these conditions).
• Cancer chemotherapy and radiation therapy aimed at head and
neck tissues can result in morphologic impacts such as short
roots or missing teeth.
• Patients on Glucocorticosteroids (toxic to bone) and
bisphosphonates (resorption-inhibiting agents)  Impede
orthodontic tooth movement.
Dental history
• BLEEDING GUMS: Orthodontic treatment during periodontal
disease, either acute or chronic, is contraindicated until the
disease stage is either controlled or reversed.

• OPENING/CLOSING MOUTH: A previous history of

temporomandibular joint (TMJ) problems or treatment merits
pretreatment investigation. Limitations or problems with
opening, closing, or translation can indicate TMJ problems.
• INJURY TO TEETH? Dental trauma may have implications
during tooth movement because of the increased possibility of
pulpal necrosis and root resorption.
• Orthodontic treatment can exacerbate periapical symptoms that
are already present (although marginal) because of trauma.
• PACIFIER/THUMB or FINGER SUCKING: Habits may explain
some aspects of the malocclusion.
- History of dental treatment.
Family history

• A family history can begin with an inquiry as to whether any

siblings of the patient have required orthodontic treatment and a
discussion about the nature of their problems.
• Inquiries should also be made as to whether either or both
parents received orthodontic treatment.
• If the answer is yes, the orthodontist needs to know the reasons
for their treatment.
• It is not unusual to have a patient or parent respond that a close
relative had a significant malocclusion that required surgery.
Physical growth status
• An experienced orthodontist knows that the best clinical results
are achieved in good growers and the poorest results occur in
poor growers.
• In many instances, height–weight records and the child’s progress
on growth charts can be obtained from the pediatrician.
• Another approach is to get an estimate of how much mandibular
growth remains (a child with a skeletal Class II problem who
would benefit from orthodontic treatment to modify growth if that is
possible), by determining mandibular growth timing from the
vertebrae as seen in a cephalometric radiograph.
• The stage of dental development should not be used to
estimate the stage of jaw growth.
• Hand–wrist radiographs are an alternative method for
evaluating skeletal maturity, but these also are not an accurate
way to determine when growth is completed.
• Serial cephalometric radiographs offer the most accurate way to
determine whether facial growth has stopped or is continuing,
because you are not inferring future facial growth changes, but
measuring them.
Social and behavioral evaluation
• How cooperative or uncooperative the patient
is likely to be.
• The patient’s motivation for treatment,
what he or she expects as a result of treatment
• Self-motivation for treatment often does not develop until
adolescence.
• Children or adults who feel that the treatment is being done for
them will be much more receptive patients than those who view
the treatment as something being done to them.
• CLINICAL • General state
EXAMINATION • Special
clinical
examination
General state
• Examination of the constitution and physique of the patient,
height and weight in relationship to chronological age and
development of facial skeleton.
• An evaluation of the somatogram provides an indication of the
general growth tendency.
• Other factors include nutritional status, assessment of mental
development, dental age and skeletal age.
 Dental Age
• Chronological age and dental age
are synchronous in the normal
patient.

Dental age
• A child labeled as an early/late Stage of eruption
developer if there is difference of
years from the average value. Stage of tooth
• If the chronological age is younger mineralization on
than the dental age, one can rely radiograph
on increased growth to a greater
degree than when dental age is
retarded in relation to the
chronological age.
Biological age and hand radiographs
• The biological age is determined from skeletal, dental and
morphological age and the onset of puberty.
• Assessment of the skeletal age is often made with the help of a
hand radiograph which can be considered as ‘biological clock’.
• Since ossification of hand bones shows considerable
interindividual variations, skeletal age determination from hand
radiographs alone may not be accurate.
Evaluation of hand radiographs is indicated in the following cases:
• Prior to Rapid palatal expansion.
• When maxillomandibular changes are indicated in the treatment
of Class III cases, skeletal Class II cases or skeletal open bites.
• In patients with marked discrepancy between dental and
chronological age.
• Orthodontic patient requiring orthognathic surgery if undertaken
between ages of 16 and 20 years.
Adolescent Growth
Stages Versus Secondary
Sexual Characteristics
CEPHALIC AND FACIAL EXAMINATION
• Cephalic index:
Maximum skull width Maximum skull length

• (By Martin and Sellar 1957)

 Dolicocephalic (Long skull): x-75.9
 Mesocephalic: 76.0-80.9
 Brachycephalic (Short skull): 81.0-85.4
 Hyperbrachycephalic: 85.5-x
Facial index:
Morphological facial height (N-GN) Bizygomatic width
(By Martin and Sellar 1957)
Hypereuryprosopic: x-78.9
Euryprosopic: 79.0-83.9
Mesoprosopic: 84.0-87.9
Leptoprosopic: 88.0-92.9
Hyperleptoprosopic: 93.0-x
 Narrow face (Leptoprosopic)

• Reduced bizygomatic width.

• The apical base is often narrow in transverse direction.
• Therefore, in cases of maxillary crowding, not only is there
crowding of the coronal arch, but also in the apical region.
• Extraction therapy should be considered in long facial type.
Broad face (Euryprosopic)

• In these patients, the apical base of the jaw is wide in

transverse direction.
• If there is dental crowding in such cases, the teeth inclination
would be confined to coronal part  Coronal crowding.
• Transverse expansion is indicated.
Vertical proportion of face
Left- Harmonious lip profile
Middle-Short upper lip
Right-Short upper and lower lip
Left- acute nasolabial angle because of protruded upper lip.
Right- obtuse naseolabial angle due to the retrusive upper lip
to nose position.
Middle-protruding chin with marked mento labial sulcus.
Right- negative chin formation with absence of mentolabial
sulcus.
Labial frenum

Upper lip is held away and a pull is exerted to frenum the

interdental tissue and the area around the incisive papilla
becomes balanced
Left- lip profile-positive lip step
Middle-normal lip profile
Right – negative lip step
Facial symmetry:
• In the frontal view, one looks for bilateral symmetry in the fifths of
the face and for proportionality of the widths of the eyes, nose,
and mouth.
• A small degree of bilateral facial asymmetry exists in essentially all
normal individuals.
• This “normal asymmetry,” which usually results from a small size
difference between the two sides, should be distinguished from a
chin or nose that deviates to one side, which can produce severe
disproportion and esthetic problems.
Evaluation of
symmetry is
best performed
by examining a
face from under
the chin while
the head is tilted
backwards.
Such a view is
necessary for
the assessment
of the facial
asymmetry
particularly of
the nostrils
zygoma and
upper lip.
Profile Analysis:
• The examiner should stand at the side of the patient while the
patient is asked to stand and look straight preferably into a
mirror.
• An imaginary line is drawn connecting the bridge of the nose, the
base of the nose and the chin.
Classification of the facial profile according to Downs

• William B. Downs described four basic facial types as viewed on the

lateral profile keeping chin prominence as a significant consideration
and a major point of reference.
• His classification of profile type was given essentially in relation to
cephalometric analysis.
1. Retrognathic with recessive chin (convex profile)
2. Mesognathic with straight profile normal chin (straight profile)
3. Prognathic, where chin is prominent (Concave profile)
4. Prognathism when the mandible is large
Poorman’s Cephalometric analysis:

• Also known as facial profile analysis.

• The three goals of facial profile analysis are approached in
three clear and distinct steps.
1. Establishing whether the jaws are proportionately positioned in
the anteroposterior (AP) plane of space.
2. Evaluation of lip posture and incisor prominence.
3. Reevaluation of vertical facial proportions and evaluation of
mandibular plane angle.
Establishing whether the jaws are proportionately positioned in
the anteroposterior (AP) plane of space.

• Patient is placed in natural head position.

• One line dropped from the bridge of the nose to the base of
the upper lip, and a second one extending from that point
downward to the chin.
• These line segments ideally should form a nearly straight line.
• >10 Deviation  convexity/concavity
Evaluation of lip posture and incisor
prominence.
• Lip posture and incisor prominence should be evaluated by
viewing the profile with the patient’s lips relaxed.
• The teeth protrude excessively if two conditions are met:
(1) The lips are prominent and everted and
(2) the lips are separated at rest by more than 3 to 4 mm (which is
sometimes termed lip incompetence).
• On the other hand, if the lips are prominent but close over the
teeth without strain, the lip posture is largely independent of tooth
position.
• In evaluating lip protrusion, it is important to keep in mind that
everything is relative, and in this case the lip relationships with
the nose and chin affect the perception of lip fullness.
 Lip prominence is evaluated by observing the distance
that each lip projects forward from a true vertical line
through the depth of the concavity at its base, which are
soft tissue points A and B—that is, a different reference
line is used for each lip.
Lip prominence of more than 2 to 3 mm in the presence
of lip incompetence indicates dentoalveolar protrusion
Re-evaluation of vertical facial
proportions and evaluation of
mandibular plane angle.
• The mandibular plane is visualized
readily by placing a finger or mirror
handle along the lower border.
• A steep mandibular plane angle
usually accompanies long anterior
facial vertical dimensions and a
skeletal open bite tendency, whereas
a flat mandibular plane angle often
correlates with short anterior facial
height and deep bite malocclusion.
Golden Proportion of face:

• Divine proportions have been beautifully illustrated in the drawings of

the human body by Leonardo da Vinci.
• The mathematical formula for the perfect face has been defined based
on a simple mathematical ratio of 1:1.618, otherwise known as phi, or
the divine proportion.
• Ideal facial proportions are universal regardless of race, sex and age,
and confirm to divine proportions.
• If the width of the face from cheek to cheek is 10 in., then the length of
the face from the top of the head to the bottom of the chin should be
16.18 in. to be in ideal proportion.
• The ratio of phi also applies to many other facial proportions
References
• Color atlas of dental medicine, Orthodontic diagnosis; Thomas
Rakosi, Irmtrud Jonas, Thomas M. Graber.
• Contemporary orthodontics, William R. Proffit (6th edition).
ORTHODONTIC DIAGNOSIS

Name – Guneet Singh Sodhi

PG Resident
Orthodontics and dentofacial
orthopaedics
CONTENTS

• Clinical examination
• General & Extra oral
• Intra oral
• Smile analysis

• Functional examination
Clinical examination
Clinical examination has 2 purposes

 To evaluate and document

 Oral health – hard & soft tissues separately

 Jaw function
 Facial proportions & smile characteristics

 To determine which are the diagnostic records

needed.
Armamentarium
Clinical examination

Cursory examination
according to Moyers
1. General examination

2. Extra oral examination

The purpose is to provide the

3. Intraoral examination minimal necessary facts on
which tentative diagnosis and
classification can be made
4. Functional examination
Examination of facial & dental appearance

• Macro esthetics
• Face in all 3 planes of space
• Symmetry, facial height, etc

• Mini esthetics
• Smile framework

• Micro esthetics
• Teeth
• Tooth proportions, gingival shape, etc.
Frontal examination of face
Vertical facial proportions

Renaissance artists like Durer & Leonardo

da Vinci established proportions for
drawing anatomically correct human
faces.

Hairline

Base of nose

Bottom of nose

Chin

Lower third also has thirds.

 In frontal view forehead is
For harmonious face ,height of considered in relation to
forehead should be 1/3rd of entire bizygomatic width and described
face height and therefore as mid as narrow or wide.
1/3rd and lower 1/3rd Cases with steep forehead tend to
develop prognathic dental bases
Vertical relations : LAFH : UAFH

But the middle thirds and the lower thirds are rarely equal.
Horizontal facial proportions

Divide into 5 equal fifths-

Central,2 Medial,2Lateral
halves
.
Nose and chin should be
centered in central half,
Interpupilary distance equals
the width of the mouth
 Facial profile

• Poor man’s cephalometric

analysis

• Relation between 2 lines

• Convex profile

• Straight profile

• Concave profile
Facial divergence :coined by Milo Hellman

• The inclination of lower

face relative to forehead.
• Straight
• Posterior
• Anterior

• Is influenced by racial and

ethnic background.
• Asians, American Indians-
anterior
• North European Whites-
posterior
A straight profile regardless of whether the face is divergent does not
indicate a problem, convexity or concavity does.
Growth pattern & Mandibular plane angle
HORIZONTAL GROWTH PATTERN

Demands thick
zygomatic Prominent
Strong muscles of buttress to Malar
mastication transmit and region
dissipate forces

Tooth movements are limited in these individuals :

• Thick cortical bone and reduced spongy bone.
• Heavy masticatory forces and good intercuspation.

Avoid extraction line of treatment (especially in lower arch) and any treatment
which will demand great amount of tooth movement.
Vertical growth pattern

Malar bones Creases

Less biting force not prominent parallel to
lower eyelid

From a biomechanical point of view, do not use the following appliances

if growth pattern is clearly vertical:

1. Expansion appliances (RME)

2. Reverse pull headgear (face mask)
3. Cervical pull headgear
4. Intermaxillary elastics

• Reason : further increase in lower anterior face height

Lip morphology
• Competent lips- Lips in contact
when the musculature is relaxed

• Incompetent lips- Anatomically

short lips with a wide gap Absent cupid’s bow
between the upper and lower lip
in relaxed state. Motionless
while speaking

• Potentially incompetent lips-

labially placed upper incisors
interpose between the lips and
prevent the normal lip seal.

• Everted lips – hypertrophied lips

with redundant tissue and weak
muscle tonicity, often with
bimaxillary dental protrusion.
Korkhaus : Lip step

• positive lip step ,a symptom of class III profile.

• slightly negative lip step seen in normal profile.
• negative lip step, a symptom of class II profile.
Lip tonicity & color

• Palpate upper and lower lips to see if

they are of equal tonus and muscular
development.

• Lip color-reveal the activity of lips.

Hyperactive lips will be redder, heavier,
smoother and moister whereas the
less active lips are lighter in color and
chapped
Inter labial gap
• With the lips relaxed and
teeth in contact a space of 1-
5 mm is considered normal.
• Females show a larger gap.
• Lip incompetence refers to an
excessive inter labial gap at
rest, more than 5 mm.

Significance
Significance On the other hand if lips are
Excessive protrusion of incisors is prominent and close over the
revealed by prominent lips that are teeth WITHOUT STRAIN, lip
separated at rest, so that patient posture is largely independent
must STRAIN to bring lips together of teeth position. Here
over protruding teeth. In such retraction will have little effect
patients retracting teeth will on lip function and
improve esthetics and lip function. prominence.
Lip incompetence

• Causes are short philtrum, vertical maxillary excess and

excessive overjet.

• Vertical maxillary excess causing lip incompetence will also

have increased lower facial height accompanying it unlike lip
incompetence caused due to short upper lip.
Anterior seal

Tongue to lower lip contact

• If we see lips are

incompetent, then we
must wonder and Lower lip drawn up behind upper
evaluate how is it that incisors
the patient achieves
anterior seal ?

Lips brought together with strain

Mentolabial sulcus

• The deep mentolabial sulcus is a

characteristic feature of
hyperactive mentalis muscle.

• This muscle dysfunction results in a

strap like effect on the lower lip and
impedes the forward development
of the anterior alveolar process of
the mandible.

• The specific clinical variable that

can affect the labiomental sulcus is
lower incisor position.
Lip prominence

• According to Proffit, lower lip should be at least

as prominent as the chin for best esthetics.
• Excess chin or deficient chin : not pleasing
Changes in lip thickness with age

Lip achieves maximum thickness around puberty in both sexes :

Males - 16-18 yrs,

Females- 14-16 yrs
and thinning thereafter

Clinical point : Effect of extraction on profile: thinning of lips after puberty.

Mini esthetics

• Symmetry- midlines
• Vertical relation of lips to
Tooth lip relations teeth – rest & smile
• Transverse cant/rotation
of dentition

• Amount of incisor and

gingival display
Smile analysis • Transverse dimensions
of smile
• Smile arc
Incisor to lip relationship
• Philtrum height

• In adults philtrum height should be roughly equal to commissural height

• In adolescent patients, philtrum height is commonly

shorter than the commissural height. This is normal since
a lot of vertical lip growth is still remaining.
Incisor exposure

• During speech

• During smile

• Rest -Normal range is

• 1-5mm

• Males show less upper incisor and more lower Incisor at rest
• and with females it is vice versa.
• Excessive incisor show is
judged better at rest than VME
on smile because lip
elevation is variable.

Causes :
• Short philtrum
• Vertical maxillary excess
• Excessive crown height
• Lingually tipped maxillary
incisors
Inadequate incisor display

• Excessive philtrum height

• Vertical maxillary deficiency
• Inadequate crown height
• Flared maxillary incisors

Flared incisors
Why is upper incisor show significant?
 Care should be taken when correcting an
excessive incisor show.

 The amount of maxillary incisor that shows

at rest is a crucial esthetic parameter
because one of the inevitable
characteristics of ageing is diminished
upper incisor show.

 This is of clinical significance because

surgical or orthodontic over intrusion of
the maxilla or the maxillary teeth may
result in esthetically disastrous aging of
patient’s face.
 SMILE ANALYSIS

• Facial attractiveness is determined more by smile

than by soft tissue relationships at rest, hence it is
very important to analyze the smile.
Types of smile
Posed / Social smile Emotional smile

Reproducible
Variable
This is the focus of orthodontic
diagnosis.
 1.LIP LINE

AVERAGE

2.SMILE ARC

NON-CONSONANT

3.UPPER LIP
CURVATURE

UPWARDS AND STRAIGHT

( AVERAGE )
4.LATERAL NEGATIVE
SPACES

MINIMAL

5.SMILE SYMMETRY

ASYMMETRIC

6.OCCLUSAL
FRONTAL PLANE

ASYMMETRIC CANT
OF MAXILLARY
FRONTAL OCCLUSAL
PLANE
Exposure of upper incisor and gingival tissue when smiling

• Ideally ranges from three-fourth of the crown length to

2mm of gingival tissue.

• Less than 100% incisor show – less esthetic

• Males show less upper incisor exposure and more lower

incisor exposure than females because of their
characteristically longer upper lips.
Gummy smile

• Young children

• Short philtrum

• Vertical maxillary excess

• Short crown height

• Detorqued & Upright maxillary incisors

Transverse dimensions of smile relative to upper arch

• Buccal corridor space

• Wide - unaesthetic (negative space)
• Absent - unaesthetic

• Should be related to facial width

• Related to
• Maxillary width
• A-P position of maxilla

• 13% of buccal corridor space is

considered ideal.
Smile arc
Defined as the contour of the incisal edges of
maxillary anterior teeth relative to the curvature of
lower lip during smile.

• Consonant

• Flattened arc of teeth -------lengthen maxillary incisors by

• Orthodontics
• Laminates
Micro esthetics

• Width relations and golden proportion - 62%

SIGNIFICANCE
Excellent guideline
when lateral incisors
are small and helps to
determine what the
post treatment size of
lateral incisor should be
or even when canines
are narrowed to
replace missing lateral
incisor.

GOLDEN PROPORTION
Height and width relations

• Width of upper Central incisor should be 80% of

height.

• Short crown height: Causes & treatment options:

• Incomplete eruption -
• Attrition -
• Excess gingival height -
• Distorted crown -
Gingival height & shape

• Height :
• Central Incisor highest, Lateral
is 1.5 mm lower and canine is
same as central incisor.
• Important when we plan to
replace lateral with canine

• Shape :
• Centrals, canine – elliptical,
ZENITH is distal to long axis
• Laterals – half oval or half
circle – zenith coincides with
long axis.
Connectors & Embrasures

• Black triangles
• Loss of interdental papilla due to PDL disease.
• Appear when crowded or rotated incisors are
corrected.
• Patient should be prepared for reshaping the teeth
to minimize the problem.
Tooth shade and color

• Changes with age

• Due to deposition of
Secondary dentin and
Regression of pulp and
Thinning of facial enamel

• Changes with position of teeth

• Becomes darker as we progress posteriorly.

Esthetic line of dentition

• Facial edges of maxillary anterior and posterior

teeth.

Angle’s line of occlusion

Esthetic line of dentition
• Pitch, Roll & Yaw of this line is a useful way to
evaluate the relation of teeth to soft tissues that
frame their display.
Downward Pitch Downward Roll on Fox plane Yaw to left
right side
 Radix

Examination of nose : Arnett

Dorsum

Scroll
Supratip

Tip
• Length-1/3 of total facial height
rd
Columella

• Alar base Width – 70% of length

• Nasal projection
 Cranially growing nose Caudally growing nose

• Columella cants cranially • Excess retraction can be equally

detrimental
• Tip points upwards

• Obtuse nasolabial angle • As chin and nose keep growing,

the smile will sink into the face
• Retraction will be detrimental

In evaluating facial esthetics, it is important to remember that

everything is relative….
The larger the nose, the more prominent the chin must be to
balance it and greater amount of lip prominence will be esthetically
acceptable.
Nasal growth

• In both males & females

nose grows more vertically Cl I M
Cl I F
than antero-posteriorly,
but boys show more
growth.

• Important to prevent
extraction and over Cl II M
Cl II F
retraction in cases where
this will increase nasal
prominence.
Nasolabial angle

• Normal ( 1020 +/- 8o)

• Depends on 4 factors :

• AP position of maxilla

• AP position of maxillary teeth

• Vertical position and projection of

nasal tip (Cant of nose)

• Soft tissue thickness of upper lip

Chin

• Soft tissue chin depends on :

• Underlying bone
• Thickness and tone of soft tissues & muscles

• Chin height is also important because overdevelopment alters position of

lower lip and interferes with lip closure.

Throat form

• Though not considered in treatment planning, it is important to know in

facial esthetics.

• Obtuse cervicomental angle is seen in

• Chin deficiency
• Lower lip procumbency
• Excess sub mental fat
• Mandibular deficiency
Intra oral examination
53/175
Soft Tissue
• Oral hygiene status & Brushing
habits
Anterior inflamed –
• Gingiva mouth breathing
• Thick Vs Thin ??
• Healthy / Inflamed – signs of active
disease, bleeding on probing

• Position of mucogingival
junction ??

• Oral mucosa Occlusal trauma

• Palate- swelling, ulcers,
scar, indentations
• Floor of mouth
• Labial & buccal mucosa
indentations
Measurements taken in Periodontally Healthy cases.
Abbreviations-A- IE, B-GM, C-Deepest point of VES,
VD. VES – Vestibule, VD – Vestibular depth, IE –
Incisal Edge, GM – Gingival Margin
 56/175

Frenal attachment
• Upper
• Lower

• Types : Placek 1974

• Mucosal
• Gingival
• Papillary
• Papilla penetrating

• Blanch test

• Supported by IOPA Positive Blanch test

Faucial pillars and throat

Alteration in Swallowing &

Inflamed, tongue posture, breathing
hypertrophied or mandibular patterns altered
infected tonsils posture

Tonsillitis
Tongue
• Size, color, length and
width, lingual frenum
should be checked.

• A broad and low lying

tongue, as seen in class lll
cases, will extend over
the dental arches and
will have lateral
indentations.

• Long tongue will reach

the tip of the nose.
Tongue posture

• Normal posture (A,B)

• Retracted or cocked C
• Protracted D

• Malocclusion:
• Class III
• Class II
 HARD TISSUE

• Teeth present
• Unerupted teeth
• Supernumerary teeth
• Missing teeth
• Retained teeth
• Shape, size, form of teeth
• Texture
• Caries
• Restored/Endodonticaly treated teeth
• Occlusal wear facets, fractures
• Mobility
SQUARISH ARCH FORM
TOOTH MORPHOLOGY

MACRODONTIA PEG LATERAL

Supernumerary teeth

• Cause
• Morphology :
• Supplemental
• Conical
• Tuberculate
• Odontome

Effects
•Failure of eruption
•Displacement
•Crowding
•No effect
 Depth of curve of Spee

Space
excess

Space
Classification of palatal vault form deficiency
Enamel hypoplasia and white spots

Significance of knowing
calcification times

To estimate timing of any

possible cause of localized
hypocalcification or hypoplasia

1 2 3 4 5 6 7 8

Max 3-4 10-12 4-5 18-21 24-27 Birth 30-36 84-108

(mont
h)
Mand 3-4 3-4 4-5 21-24 27-30 Birth 30-36 96-120
Importance of knowing eruption sequence

• Assess any delayed eruption

• If asymmetry in eruption pattern between

contralateral teeth, eg – right central incisor
erupted but no sign for 6 months of left – indication
for radiological evaluation
1 2 3 4 5 6 7 8

Max 7-8 8-9 11-12 10-11 10-12 6-7 12-13 17-25

(yr)

Mand 6-7 7-8 9-10 10-12 11-12 6-7 12-13 17-25

Causes of delayed eruption

Generalized
Localized

• Down’s syndrome • Congenital absence

• Cleidocranial dysplasia • Crowding
• Hereditary gingival
• Cleft lip and palate
fibromatosis
• Rickets • Delayed exfoliation of
primary predecessor
• Supernumerary
• Dilaceration
• Primary failure of
eruption
Dental age assessment

Stage of eruption Tooth mineralization- Demirjian

 Premature loss of primary teeth

SEQUELAE :

Incisors

Canine

First molar

Second molar
Retained deciduous teeth

• Difference of 6 months
between shedding of
contralateral teeth should be
regarded with suspicion

• If permanent tooth is
present and is favorably
located, must extract
primary tooth.
Ankylosed teeth

Evaluate history of trauma

Assess:

Occlusal levels
IOPA
Percussion

Submerged teeth
ATTRITION/ CLINICAL
APPEARANCE
• .
• .
• .
• .

Occlusal wear Facets

Midline considerations

• Facial
• Upper
• Lower

• Functional shift
• At rest
• In occlusion

 Maxilla, mandible, Combined

Deviation of midline  Dentoalveolar, skeletal, combined
• Dentoalveolar drift

Congenitally
missing lateral
incisor

Early loss of primary lower canine

How to Differentiate
Laterocclusion
Displacement on closure

• Effect of premature contacts

Laterognathy
 Antero-posterior relations

Molar & Canine relation

Class I Class II div 1

Class II div 2 Class III

Incisor classification
British standards institute

Class I Class II

Div 1 and Div 2

Class III
• Overjet
• How to measure
Ideal 2-3mm
• Spacing

• Rotations
VERTICAL RELATIONS
• Overbite
• Millimeter
• Percentage

Gingivally supported deep bite

• Deep bite
• Dentally supported
• Gingivally supported

• Open bites
• Anterior
• Lateral
• Complex
Transverse relations

• Cross bites

• Buccal non occlusion

• Lingual non occlusion

Scissor bite
Transient malocclusions

• Pre dentate period

• Retrognathic mandible
• Anterior open bite
• Infantile swallow pattern

• Primary dentition
• Anterior deep bite
• Flush terminal plane
• Spacing
• Edge to edge
Mixed dentition

• Anterior deep bite

• Anterior mandibular crowding
• Ugly duckling stage
• End on molar relation
 Functional
examination
Modern orthodontics is not only restricted to static evaluation
of teeth and their supporting structures, but also includes all
functional units of the masticatory system, i.e. the
Stomatognathic system.
Eschler 1952
 1. Determine PRP
Postural rest position and 2. Register PRP
maximum intercuspation 3. Evaluate
relations in 3
planes of
space.
Temporomandibular joint

Orofacial dysfunctions
What is postural rest position ?

• When mandible is in its rest position, the synergists and

antagonists of the orofacial system are in their basic
tonus and are balanced dynamically.

• This position results from the reaction to the force of

gravity and also short term influences like fatigue,
anxiety, stress etc.

• Rest position changes according to head posture, so it

must be examined standardized conditions.
Components affecting the PRP

Short term influences Long term influences

• Inconsistency in muscle • Attrition of dentition
tonicity • Premature loss of teeth
• Respiration • Diseases of
• Body posture neuromuscular system
• Stress
• TMJ dysfunctions

Speculum : A.M Schwarz

•Phonetic method
Methods to •Command method
determine PRP •Non-command method
•Combined method
To Relax muscles

• Tapping test

• Mild electric stimulus

“Myomonitor”

• When mandible is in rest it is usually 2-3 mm below and behind

centric occlusion, recorded in canine area.
• The space between the teeth, when mandible is at rest is the
freeway space or interocclusal clearance - 2-3 mm in adults, 4mm
in children in canine area.
Registering PRP

• Intraoral indirect
method – registration
with impression material

• Extraoral direct method

– skin reference points

• Extraoral indirect
methods –
• Roentgenocephalometri
c method –
advantageous

• Kinesiographic method
Evaluate relation between PRP & Habitual Occlusion

• Phases in closing movement of mandible :

• Free phase
• Articular phase

• In cases with functional equilibrium, articular phase does not

occur.

• Movements of mandible from rest to habitual occlusion :

• Pure rotation (hinge movement) In all 3 planes – sagittal,

• Rotation with anterior sliding vertical & transverse
• Rotation with posterior sliding
Evaluate in sagittal plane

Different movements divide class II malocclusion into 3 types:

Class 3 into 3 types :

• Class 2 malocclusion with posterior sliding action
from rest position to habitual occlusion has good
prognosis .

• Class 3 malocclusion with anterior sliding action

from rest position to habitual occlusion has good
prognosis
Evaluate in vertical plane

Pseudo deep bite True deep bite

• Small freeway space • Large freeway space

• Supraeruption of • Infraocclusion of molars
incisors • Prognosis for success
with functional methods
• Prognosis for is favorable.
functional therapy is
unfavorable.
Evaluation of TMJ
Functional Radiographic
Auscultation Palpation
analysis examination
• TMJ • TMJ • TMJ • TMJ
• Mandibular
• Musculature excursions
• Occlusion
• Rest position
• Premature
contacts
• symptoms • Dysfunctions

• Dislocations
• Crepitus • Palpatory pain • Dislocation
• Hyper mobility • Changes in
• Clicking • Limitation shape &
• Deviation structure
• Dysfunctions
Palpation : Masticatory muscles

Lateral pterygoid
Temporalis tendon

Temporalis Masseter
 Maximum opening

• Boley’s gauge

• Between upper and

lower incisal edges

• 40-45mm

• TMJ dysfunctions
Examination of orofacial dysfunctions
Swallowing
• Normal mature swallowing takes place without contraction of
muscles of facial expression.

• The teeth are momentarily in contact and tongue remains

inside the mouth.

• During the first few years of life, infants swallow viscerally, i.e.
with tongue between their gum pads. With eruption of buccal
teeth, a transitional type of swallow is seen. As the
deciduous dentition is completed the visceral swallow is
replaced by somatic swallow.

• Should visceral swallow persist after the 4th year of life, it is

considered as an Orofacial dysfunction.
Visceral Swallow

Characteristics of infantile swallow

The jaws are apart, with the tongue
between the gum pads
The mandible is stabilized by contraction
of the muscles of the 7th cranial nerve &
the interposed tongue.
The swallow is guided, & to a great extent
controlled by sensory interchange
between the lips & the tongue.
The tongue is positioned low in the mouth
and that the central furrow is depressed
(according to Graber, 1972).
 Characteristics are
MATURE SWALLOW

 The teeth are together

 The mandible is stabilized by contraction of

the mandibular elevators, which are
primarily 5th cranial nerve muscles

 The tongue tip is held against the palate

above & behind the incisors. There are
minimal contractions of the lips during the
mature swallow.

 The dorsum of the tongue is less concave

and approaches the palate during
swallowing (according to Graber, 1972).
Tongue Thrust Types :

Teeth together swallow Teeth apart swallow

• Complex tongue thrust
• Simple tongue thrust

• Facial muscles including lip and

mentalis contracts
• Contraction of elevator muscles.
• Inexpressive faces
• Well circumscribed open bite
• ill defined open bite
• Lip muscles contract to aid tongue
in sealing open bite – adaptive • Poor occlusal fit

• History of earlier digit sucking • History of chronic respiratory

habit problems
 Tongue thrust

Anterior Endogenous
Primary
Lateral Habitual
Secondary
Complex Adaptive

Significance of type of tongue thrust :

Adaptive tongue thrust will cease following treatment when lip to lip
contact is achieved whereas endogenous or primary tongue thrust will
not and this will lead to relapse.
 Lateral
Anterior

Complex
• Study of tongue is difficult because if the lips are parted with any
type of instrument , normal tongue activity is inhibited and cannot
be observed.

• Trick is to examine tongue and its function without displacing lips

and cheeks.

• Since most tongue functions are synchronized well with circumoral

muscles, abnormal function in one will result in accommodative
abnormal function in others.

• Abnormal lip function abnormal tongue function

 Observe tongue during types of swallow –

 Unconscious swallow – best

 Command swallow of saliva

 Command swallow of water –most apt to mislead

 Unconscious swallow during chewing

Lip dysfunctions

Lip sucking Lip thrust

Causes further protrusion of upper Seen in conjunction with

incisors and impedes forward hyperactive mentalis activity
and causes lingual
development of the lower anterior
inclination of lower incisors.
alveolar development
Mouth breathing
 Respiratory needs are the primary
determinant of the posture of the
jaws and tongue.

 An altered respiratory pattern ,such

as breathing through the mouth
could change the posture of the
head, jaw and the tongue.

 Mandible and tongue are lowered.

Head is tipped back to facilitate
breathing.

 Equilibrium of pressure on the jaws

and the teeth is altered affecting
both jaw growth and tooth
position.
Respiration

 Observe when patient is unaware.

 How to assess
 History,
 Lips,
 Nostrils, head posture, neck muscles & chest.

 What is nasal breathing ?

 What is mouth breathing ?

 On command respiration

 Shape of nostrils (Moyers)

 Nasal breathers
 Mouth breathers

 Mirror test
 Cotton butterfly test

 Why to know about mouth breathing ??

Typical clinical findings in a mouth
breather ( Adenoid Facies)

Stenosis of left nostril

Long face syndrome

 Excessive lower anterior facial height

 Lip incompetence.

 Tendency towards anterior open bite.

 Tendency towards mandibular deficiency and

class II malocclusion.

 Tendency towards a narrow maxilla and

posterior crossbite.
Cephalometrically,

 Rotation of the palatal plane down

posteriorly.
 Excessive eruption of the maxillary
posterior teeth.
 Rotation of the mandible down and
back.
 Excessive eruption of upper and lower
incisors.
 Speech

 Speech problems can be related to malocclusion, but normal speech is

possible even in presence of severe anatomic distortions.

Speech difficulties related to malocclusion

Th,sh,ch
S, Z (sibilants) t, d (linguoalveolar) F, v (labiodental)
(linguodental)
Difficulty in
Lisp Distortion Distortion
production

Ant open bite, Irregular incisors,

esp lingual upper Skeletal class III Anterior open bite
space between
incisors incisors
Mastication

 Patients with severe malocclusion often have problems with mastication,

not so much in chewing their food but in doing so in a socially acceptable
manner.

 They learn to avoid certain foods and may have problems with cheek and
lip biting during mastication.

 Unfortunately there are no reasonable diagnostic tests to evaluate

masticatory efficiency.
References

• Color Atlas of Dental Medicine: Orthodontic

Diagnosis; Rakosi, Jonas & Graber

• Contemporary Orthodontics : William R. Proffit

• Handbook of Orthodontics . Robert E. Moyers 4th

edition

• Orthodontics: Current Principles Techniques 4th ed:

Graber, Vanarsdall, Vig