Case History and Clinical Examination in orthodontics
Presented by : Dr. Rajesh Gyawali ([email protected])
Resident, Department of Orthodontics and Dentofacial Orthopaedics
Faculty of Dentistry, Institute of Medicine, Kathmandu Guided by :
Dr. Basant Kumar Shrestha Associate Prof. and Head Department of
Orthodontics and Dentofacial Orthopaedics Faculty of Dentistry,
Institute of Medicine, Kathmandu
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 and1
any associated family history. The aim is to establish a rapport
with the patient and to obtain information about individuals
complaint. 1. Personal details A. Name The patients 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 patients 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
1. Chief Complaint The patients 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
2
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
patients 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. 2. Medical History Knowledge of
the patients 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.
3. Dental History The patients 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. 4. 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. 5. 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. 6. Post-natal History3
It should include information on type of feeding, presence of
habits and milestones of normal development. 7. 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. 8. Physical Growth
evaluation The parents should be questioned about the childs 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. 9. Social
and Behavioral Evaluation It should explore patients 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.
Clinical Examination 1. General ExaminationEach 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.
4
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. C. Built Sheldon
classified body built into: i. Ectomorphic : Tall and thin physique
ii. Mesomorphic : Average physique iii. Endomorphic : Short and
obese physique
1. Extra-oral ExaminationA. 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 Saller as: Cephaic and
index Maximum skull width = Ma ximum skull length Mesocephalic
Brchycephalic Dolicocephalic Hyperbrachycephalic : I = 76.0 -80.9 :
I = 81.0- 85.4 Broad and short head : I < 75.9 Long and narrow
head : I > 85.5
A. 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 > 93.05
A. 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 A. 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. A. 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. A. 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.6
B. 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.C.
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. D. 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.A. 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. A. 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.
7
B. 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.
1. Intra-oral ExaminationA. 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. B. Palate Palate is examined for the
following findingsi. 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 clefts v. The third
rugae is usually in line with the canine. It helps to assess
maxillary anteriors proclination. A. 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. B. Frenal attachments The
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.
8
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). C. Tonsils and Adenoids The
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. D.
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.
1. Functional ExaminationNormal 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 includeA. Assessment of postural rest position and
inter-occlusal clearance 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 jaws
which is called interocclusal clearance or freeway space which is
normally 3mm in canine region.9
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 arei. 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 patients musculature is relaxed and the mandible reverts to the
postural rest position. B. Evaluation of path of closure The 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. C. Examination of TMJ
The 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
functions10
i. Respiration Humans exhibit three types of breathing- nasal,
oral and oronasaal. There are some tests which helps to diagnose
the mode of respirationa. 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. i. Tongue
thrusting ii. 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 /s/, /z/ (sibilants) /t/, /d/ (linguoalveolar stops) /f/, /v/
(labiodentals fricatives) Th, sh, ch (linguodental Problem Lisp
Difficulty production Distortion Distortion Related malocclusion
Anterior open bite, large gap between incisors in Lingual position
of maxillary incisors Skeletal Class III Anterior open bite
11
fricatives [voiced or voiceless]) iii. Swallowing In 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 ofProtrusion of the tip of the tongue. Contraction of
perioral muscles during swallowing. No contact at the molar region
during swallowing. iv. Lips
1. Evaluation of Facial and Dental AppearanceA 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 proportion Whether 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 clinically because
soft12
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 Analysis Profile
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 mans cephalometric analysis.
1) Assessment of jaw position in antero-posterior plane of space It
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 linesline 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 doesnt
indicate a problem where as concavity or convexity does. 1)
Evaluation of lip posture and incisor prominence 2) 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 bite13
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 relationships
b. Smile Analysis i. Amount of incisor and gingival display
ii.Transverse dimension of smile relative to upper arch iii.The
smile arc iv. 3. Dental Appearance: Micro Esthetics a. Tooth
proportions i. Width relationships and Golden Proportion ii.Height-
Width relationships b. Gingival heights, shape and contour c.
Connectors and Embrasures d. Embrasures: Black Triangles? e. Tooth
Shade and Color
Case HistoryCase 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 individuals complaint. 1. Personal details
A. Name The patients 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. Sex14
The patients 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. 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. 1. Chief
Complaint The patients 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 patients
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. 2. Medical History Knowledge of the patients
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 as15
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.
3. Dental History The patients 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. 4. 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.5. 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. 6. Post-natal History It
should include information on type of feeding, presence of habits
and milestones of normal development.
7. 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. 8.
Physical Growth evaluation The parents should be questioned about
the childs 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.
16
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. 9. Social and Behavioral Evaluation
It should explore patients 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.
Clinical Examination1.
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. C. Built Sheldon
classified body built into: i. Ectomorphic : Tall and thin physique
ii. Mesomorphic : Average physique iii. Endomorphic : Short and
obese physique
1.
Extra-oral ExaminationA. Shape of Head17
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. 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.
18
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 100 Cephaic index skull width = Maxim um skull
length
Mesocephalic Brchycephalic Dolicocephalic
Hyperbrachycephalic
: I = 76.0 -80.9 : I = 81.0- 85.4 Broad and short head : I <
75.9 Long and narrow head : I > 85.5
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 width19
A. Shape of the face The shape of the face is assessed by
morphologic facial index which was given by Martin and Saller(1957)
as: 100 Morphologic facial height Facial index (I) 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.
Measuring bizygomatic width and the facial heightA. 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 Ankylosis20
A. 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.
Convex Concave
Straight
A. 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.
21
Straight diverging
Posteriorly
Anteiorly Diverging
A. 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.
B. 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.
22
C. 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.
D. 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. 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 lip23
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 behindFig a upper incisorsFig
b the 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 common in Class 224
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 d
b
c
(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.
A. 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.25
Contour: Shape can be straight, convex or crooked. Nostril:
Normally they are oval and bilaterally symmetrical. Asymmetry may
indicate nasal obstruction. A. 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. B. 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.
1. Intra-oral ExaminationA. 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
earlyonset 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. B. Palate Palate is examined for the following
findingsi. 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.
26
iii. Mucosal ulceration and indentations is feature of
traumatic
deep bite, especially in case of Class II malocclusion.iv. The
third rugae is usually in line with the canine. It helps to
assess maxillary anteriors proclination. v. Presence of clefts.
A. 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. B. Frenal attachments The 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). C.
Tonsils and Adenoids The 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.D. Dentition and dental arch
i. Status The 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 relation Molar
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.
27
Class II: Mesio-buccal cusp of maxillary first molar occludes in
the groove between mandibular 2nd premolar and 1st molar.
Div 1: With proclined maxillary incisors. 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.
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.
Deweys modification of Angles Class I malocclusionTYPE 1:-Angles
class I with crowded maxillary anterior teeth. TYPE 2:- Angles
class I with maxillary incisor in labio-version (proclined). TYPE
3:- Angles class I with maxillary incisor teeth on linguoversion to
mandibular incisor teeth (anterior in cross bite)28
TYPE 4:- Molar and/or premolars are in bucco or
linguoversion,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) . Deweys modification of Angles Class
III malocclusionTYPE 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. Lischers
modification of Angles classificationLischer in 1933 further
modified angles classification by substitute names for Angles Class
I, II & III malocclusion he also proposed terms to designate
individual tooth malpositions 1) Neutroocclusion 2) Distoocclusion
3) Mesioocclusion i. Incisor relation British standards
relationship Class
Institute
Classification
of
incisor
I : Lower incisor edges occludes with or lie immediately below
the cingulum plateau of upper central incisors. plateau. Two
subdivisions of this category are Div 1 The upper central incisors
are proclined or of average inclination and there is an increase in
overjet. Div 2 The upper central incisors are retroclined. Overjet
is usually minimal or may be increased. plateau. The overjet may be
reduced or reversed.
Class II : Lower incisor edges lie posterior to cingulum
Class III : The lower incisor edges lie anterior to cingulum
29
Class I III
Class
Class II Div 1 Div 2
Class II
i. 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. Class III : Lower canine is displaced anteriorly to
the upper canine with no overlapping of upper and lower canine. i.
Overjet It 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.i. Overbite.
It is defined as the vertical overlap between maxillary and
mandibular incisors.30
Normal overbite: The upper incisors cover the incisal
Increased
third of the lower incisors. overbite (Deep bite): Lower
incisors converage more than normal. Complete deep bite: There is a
contact between the lower incisal edge and tooth or soft tissue of
the palate. 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. Anterior open bite: No overlap of incisors.
Posterior open bite: No overlap of posterior teeth.i. 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. ii.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 Transversion: Transposition of two teeth
Axiversion: Abnormal axial inclination of a tooth Torsiversion:
Rotation of tooth around its long axis. i. 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
(Thompsons Classification):31
Elliptical
Round
U- Shaped Shaped
V-
1. Functional ExaminationNormal 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 includeA. Assessment of postural rest position and
inter-occlusal clearance 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
32
is oriented by making the FH plane parallel to the floor.
Methods to assess postural rest position arePhonetic 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 patients musculature is relaxed and the mandible reverts to the
postural rest position.i.
B. Evaluation of path of closure The 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. C. Examination of TMJ The 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.33
D. Examination of oral functions
i. Respiration Humans exhibit three types of breathing- nasal,
oral and oronasal. There are some tests which help to diagnose the
mode of respirationa. 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.
i. 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 /s/, /z/ (sibilants) Problem Lisp Related malocclusion
Anterior open bite, large gap between incisors in Lingual position
of maxillary incisors Skeletal Class III
/t/, /d/ Difficulty (linguoalveolar production stops) /f/, /v/
(labiodentals Distortion34
fricatives) Th, sh, ch Distortion (linguodental fricatives
[voiced or voiceless])
Anterior open bite
ii. Swallowing In 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 ofProtrusion of
tip of the tongue. Contraction of perioral muscles during
swallowing. No contact at the molar region during swallowing.
1. 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 proportion Whether 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.35
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 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 Analysis Profile 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
mans cephalometric analysis.1) Assessment of jaw position in
antero-posterior
plane of space It 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 lines36
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 doesnt indicate a problem where
as concavity or convexity does. 1) Evaluation of lip posture and
incisor prominence Detection 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. 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 patients 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.2) 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 Estheticsa. Tooth-lip
relationships37
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
Analysis Facial 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 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 th view as well as the frontal and
profile views is important. The three things need to be considered.
i. Amount of incisor and gingival display The 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 doesnt 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 arch Depending 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 arc
The 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
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appearance, the contour of the teeth should match that of the
lower lip. A flattened smile arc decreases the attractiveness and
makes look older.
3. Dental Appearance: Micro Estheticsa. 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 relationships The 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.
b. Gingival heights, shape and contour Generally 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.
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c. Connectors and Embrasures The 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.
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 Color The teeth appear lighter and
brighter at a younger age, darker and dull as age progresses. A
normal progression of40
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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