Diagnosis and Diagnostic Aids – Case

History and Clinical Examination

Department of Orthodontics and Dentofacial Orthopedics

 CONTENTS
I. DIAGNOSIS III. CLINICAL EXAMINATION
• Diagnosis Format
• DIAGNOSTIC AIDS A. GENERAL EXAMINATION
• Essential Diagnostic Aids 1. Height
• Supplemental Diagnostic Aids 2. Weight
3. Gait
4. Posture
II. CASE HISTORY 5. Body build
• Personal Details • Ectomorphic
• Mesomorphic
• Chief Complaint • Endomorphic
• Family History 6. Head type
• Prenatal History • Mesocephalic
• Postnatal History • Brachycephalic
• Dental History • Dolichocephalic

• Medical History (including allergies)

 CONTENTS
B. EXTRAORAL EXAMINATION
II. PROFILE
FACIAL PROFILE ANALYSIS / POOR MAN’S CEPHALOMETRIC ANALYSIS
1. Facial profile
I. FRONTAL • Straight
•Facial form • Convex
• Concave
• Mesoprosopic 2. Facial divergence
• Leptoprosopic • Anterior
• Posterior
•Facial symmetry 3. Incisor Protrusion /Nasolabial angle
•Rule of 5 • Acute
•Bird’s eye view and worm’s eye view • Obtuse
• Straight
•Rule of 3 (vertical facial proportions) 4. Clinical FMA
•Occlusal cant (asymmetry in transverse plane) • Average
•Interlabial gap • High
• Low
•Upper lip length 5. Lip posture (FRONTAL)
• Competent
•Mentalis activity • Incompetent
•Lip posture/tonicity • Potentially incompetent
• Everted
•Incisor and gingiva visibility
•Smile arc – consonant/non-consonant
 CONTENTS
6. Vertical Facial Proportions (rule of 3) (FRONTAL) D. INTRAORAL EXAMINATION
------------------------------------------------------------- 1. Soft tissues
•Mentolabial sulcus
2. Hard tissues
•Chin position
•Nose- size and shape • Intra-arch examination
•E-lIne (Rickett’s) • Inter-arch examination

•Ballard’s technique
Dentofacial Deformity- Diagnostic Features
•Clinical VTO (If patient has a moderate to severe Class II
or Class III skeletal base)
•Assessment of submental soft tissues: DIAGNOSIS
C. FUNCTIONAL EXAMINATION
1.Postural rest position PROGNOSIS
2. Mouth opening
3. Path of closure
4. TMJ examination •Pitch, Roll and Yaw
5. Orofacial dysfunction •Macro, Mini and Micro—Aesthetics
• Swallowing
• Tongue •Smile Analysis
• Lips
• Respiration
• Speech
DIAGNOSIS
 DIAGNOSIS

Diagnosis is a systematic procedure

that permits identification of
clinical problem, its nature and
extent.

It is a statement of a patient’s
problems expressed in terms of
deviation from normal.
 Diagnosis Format (old format)
• A _ _ year old pre/post-pubertal male/female patient with
• Angle’s Class I/II/III malocclusion on a
• Class I/II/III skeletal base with a
• Class I/II/III canine relation and

• skeletal problem (if present) in sagittal/transverse/vertical planes and

• dental problems (intra-arch if present) and (inter-arch- if present) in sagittal/transverse/vertical planes and

• Soft tissue problems (if present) e.g. convex/ concave profile, increased/decreased nasiolabial angle, and
deep/shallow mentolabial sulcus, incompetent/potentially incompetent lips and
• habits (if present)

Patient’s chief complaint must be addressed in the diagnosis.

Mention Angle’s molar relation, skeletal base and canine relation (whether normal or abnormal) and then mention only abnormal findings.

E.g.
A 20 year old post-pubertal female patient with Angle’s Class I malocclusion on Class I skeletal base with Class I canine relation and
severe crowding in the lower anteriors, with an overjet of 5mm and overbite of 4mm with a convex profile and an acute nasolabial
angle.
 Diagnostic Aids

Comprehensive orthodontic diagnosis is established after collecting

maximum useful clinical information using diagnostic aids.

Orthodontic diagnostic aids can be broadly classified into two types:

I. Essential diagnostic aids

II. Supplemental diagnostic aids
 ESSENTIAL DIAGNOSTIC AIDS
1. CASE HISTORY
2. CLINICAL EXAMINATION
3. Functional analysis
4. Study Models
5. Radiographs—periapical, bitewing,
and panoramic
6. FACIAL PHOTOGRAPHS
7. Smile analysis
SUPPLEMENTAL DIAGNOSTIC AIDS
• Special X-ray views
• Lateral cephalometric radiographs
• Frontal cephalometric radiographs
• Oblique cephalometric radiographs
• Hand–wrist radiograph
• Electromyography
• Cervical vertebrae maturation
• Kesling’s diagnostic set-up
• Occlusograms
• 3D imaging
• Computerized cephalometric systems
Essential diagnostic aid:

Facial photographs-
extraoral
Essential diagnostic aid:

Facial photographs-
Intraoral
CASE HISTORY
 Case History
Case history involves eliciting all relevant
information by the direct questioning of the
patient or parent.

The process of recording case history starts with

recording the personal details of the patient like
name, age and sex.

Knowing the patient’s name helps in

communication.
Knowing the patient’s age helps in
identifying and anticipating certain
transient problems in the mixed
dentition. It also helps in treatment
planning.

The timing of growth spurts differ in

males and females. So knowing the
patient’s sex is essential for treatment
planning.
Education/Occupation:

Knowing the education and occupation of the patient can tell us several things including:

• Patient expectations with regards to aesthetics of treatment: Patients whose professions depend on their appearances may expect a
‘Hollywood smile’.

• Socioeconomic factors may limit the type of treatment the patients can afford.

• Some patients are more likely to be knowledgeable of treatment options. Others may require extensive explanations to make sure that
they are able to give an informed consent.

Informed consent basically means that the patient is made aware of all aspects of the treatment including the drawbacks,
alternatives, as well as consequences of no treatment.
• Certain occupations are likely to cause certain dental defects.

• Adult patients and those whose occupation depends on their appearance may be
concerned about the esthetics of the treatment itself. They might want treatment
options such as ceramic brackets, lingual orthodontics or clear aligners (invisible
orthodontics).
Case history also helps to explore the motivation of the patient.

Motivation is external, if the pressure is from another individual.

Individual’s perception of his/her problem leads to internal motivation.

 Chief Complaint
The chief complaint of the patient is recorded with emphasis on whether the
patient is seeking orthodontic care for functional or aesthetic improvement or
both.

Impaired dentofacial aesthetics can lead to psychosocial problems.

The chief complaint is recorded in the patient’s own words.

The main objective of chief complaint is to find out what is important to the
patient.
 Family History

Recording the family history is important in

inherited conditions like skeletal class III,
skeletal class II malocclusions, skeletal
open bite and cleft lip and palate.

Family history throws light on the possible

hereditary aspect of the patient’s problem. Many of the kings and queens of the
Spanish Habsburg dynasty, had a distinctive
facial deformity: an elongated jaw that later
became known as the "Habsburg jaw’’.
It provides information on parents’ This was due to consanguineous
knowledge about orthodontic treatment. marriage. Consanguineous marriage is a
marriage between individuals who are
closely related.
 Prenatal History
Health of mother during pregnancy, history of
premature delivery, type of delivery and drugs
used at the time of pregnancy are noted.

Forceps delivery causes trauma to the

condylar region and results in micrognathia.

Some drugs, like tetracycline, cause

pigmentation of the teeth.
Teratogens

Chemical or other agents which

cross the placental barrier and
produce embryologic defects are
called teratogens.
 Postnatal History
Duration and frequency of feeding, milestones
reached during growth, presence of habits and
history of childhood diseases are the important
areas in postnatal history.

Milestones correlate with development of an

individual.

Chronic medical problems can result in

alterations of growth status of patients.
Habits can explain some aspects of
malocclusion seen in the patient.

Habit can include thumb sucking,

mouth breathing, lip biting, tongue
thrusting, bruxism, etc.

If patient gives a history of a habit,

enquire about the duration,
frequency and intensity of the
habit.
 HABIT MALOCCLUSION TREATMENT
   
Proclined upper incisors
 
Beta Dunlop Hypothesis
Thumb-sucking Retroclined lower incisors Behaviour Therapy
Increased overjet Reminder Therapy
Anterior openbite Palatal crib/tongue guard appliance
Posterior crossbite Blue grass appliance

   
Proclined, spaced upper anteriors- resulting in increased overjet.
 
Palatal crib/tongue guard appliance and
Tongue thrusting Proclined lower anteriors. active labial bow
Anterior open bite  
Posterior crossbite Double oral screen
Bimaxillary protrusion

   
Increased overjet
 
Oral screen
Mouth breathing Anterior openbite Lip exercises
Posterior crossbite Rapid maxillary expansion
High palatal vault

   
Attrition of dentition.
 
Occlusal splint
Bruxism TMJ pain Occlusal Equilibration

   
Protrusion of maxillary incisors and retroclined lower anteriors
 
Lip bumper/plumper
Lip biting Cracking of lip

   
Rotation of incisors,
 
Beta Dunlop Hypothesis
Nail biting Wear of incisal edge Behaviour therapy
Minor crowding Reminder Therapy
 Dental History
Dental history is elicited with focus on
history of toothache, sensitivity, bleeding
from gums, pain in the TMJ region,
trauma, previous dental visit, etc.

Orthodontic treatment in the presence of

periodontal disease is contraindicated.

Trauma to teeth interferes with tooth

movement due to the possibility of root
resorption.

Previous history of orthodontic treatment

should be elicited.
 Medical History
Essential medical history for orthodontic treatment plan:

• Current and past medications taken?

• Current and past medical conditions?
• Any visits to a hospital or doctor in the past? Any surgeries?
• History of allergies?
History of blood dyscrasias:

Require special management, if

extractions are required.

Doctor and nurse should be protected

against HIV and hepatitis B since
these patients undergo frequent
blood transfusions.
History of rheumatic fever or cardiac
anomalies:

These patients have traditionally been

recommended antibiotic prophylaxis.

They should be treated using bonded

attachments as bands produce bacteraemia.

Chronic medical problems can result in

alterations of growth status of patients.
History of exanthematous fever. They
cause hypoplasia and retarded growth.

History of chronic painful conditions.

Patients under corticosteroid therapy,

tooth movement will be impeded.
Steroids interfere with prostaglandin
synthesis.

Nonsteroidal anti-inflammatory
analgesics impede tooth movement.
History of epilepsy:

• Epilepsy should be controlled before

orthodontic treatment.
• The patient should be treated with fixed
appliances as the patient may swallow
removable appliances at the time of
seizures.
History of diabetes:

Controlled diabetes patients can undergo orthodontic treatment.

History of trauma
History of allergies:

• Allergy to any drugs

• Allergy to latex
• Allergy to nickel-containing alloys
• Allergy to acrylic, impression materials
 CLINICAL
EXAMINATION
The goals of clinical examination are to evaluate and document:

• Facial problems
• Occlusal problems
• Functional problems
Clinical examination consists of:

• Examination of body
• Functional examination
• Extraoral examination
• Intraoral examination
 GENERAL
EXAMINATION
 GENERAL EXAMINATION

Examination of general state of the patient involves recording height,

weight, posture, gait and body build.

Recording of height and weight is to assess the patient’s growth status.

Posture is the way a person stands.

Gait is the way a person walks.
Head posture

• Faulty head posture can effect

changes in bones.

• Curvature of the neck and cervical

spine causes forward and upward
positioning of head. This situation
exists in some class II problems.

• Orthostatic head posture is advised

for normal development of face.

42
Gait of child: As child walks into the dental office, the Orthodontist can quickly ascertain
whether the gait (manner of walking) is normal or affected.

Abnormal gait is usually seen with sick child walking with unsteady gait of weakness. It
might indicate a neuromuscular condition which can affect their growth and development.

Types of Gait:

i. Waddling (walk with short step)

ii. Equinus (walking like a horse)
iii. Scissor (two legs move like a pair of scissor)
iv. Hemiplegic’s walking
v. Shuffling walking
vi. Wobbly walking (move unsteadily from side to side due do illness, tiredness or anxiety.
vii. Staggering gait (walk unsteadily as if about to fall)
viii. Ataxic gait (ataxic walking)
 Body Build

Sheldon has classified body build into

three types:

1. Ectomorphic: Tall and thin – body tissue

is made of primarily skin and neural
elements.

2. Mesomorphic: Average – body tissue is

made of primarily mesodermal tissues:
muscular and robust individuals.

3. Endomorphic: Short and obese – body

tissue is made of primarily fat tissues.

Ectomorphic individuals are late maturers

whereas endomorphic individuals are early
maturers.
Head Type/ Cephalic Index

Head type is determined based on the

anthropometric determination of maximum skull
width and maximum skull length

1. Mesocephalic: Average-shaped head

2. Brachycephalic: Broad and round head
3. Dolichocephalic: Long and narrow head
EXTRA-ORAL EXAMINATION
 EXTRAORAL EXAMINATION
Extraoral examination can be broadly divided into frontal and
profile examination.

Frontal examination consists of all findings obtained from viewing

the patient from the front.

Profile examination consists of all findings obtained from viewing

the patient from the side.

During extraoral examination, the position of patient is very

important. Patient should be placed upright with the Frankfort
plane parallel to the floor.
EXTRAORAL EXAMINATION: FRONTAL
•Facial form
• Mesoprosopic
• Leptoprosopic
•Facial symmetry
•Rule of 5
•Bird’s eye view and worm’s eye view
•Rule of 3 (vertical facial proportions)
•Occlusal cant (asymmetry in transverse plane)
•Interlabial gap
•Upper lip length
•Mentalis activity
•Lip posture/tonicity
•Visibility- Incisor-at rest and on smiling
•Visibility- gingiva on smiling
•Smile arc – consonant/non-consonant
Facial form is estimated by dividing
morphological facial height by bizygomatic
width.

1. Mesoprosopic: Average facial form

2. Euryprosopic: Broad and short facial
form
3. Leptoprosopic: Long and narrow facial
form

Usually dolichocephalic head will have

leptoprosopic face and brachycephalic head
will have euryprosopic face.
Long and narrow faces are associated with high- angle cases, open bites, class II
division 1.

Broad and short faces are seen in low-angle cases like class II division 2.

Sometimes head form and facial form will vary.

They are called dinaric individuals

Broad palate seen in brachycephalic patient. Narrow palate in dolichocephalic patient.
Facial symmetry and proportions (rule of 5): The
face is examined in the frontal and lateral views

• In the frontal plane, intercanthal distance

equals width of the nose for symmetry.
• Interpupillary distance equals width of the
mouth.
• An ideally proportioned face can be divided into
central, medial and lateral equal fifths.
• The intercanthal distance constitutes the
central fifth and the width of the eyes form the
medial fifths.
• The nose and chin should be centred within
the central fifth.
 In a symmetrical face, the glabella, tip of the nose and chin fall in a straight
line.

Worm’s eye
view

Bird’s eye view

Vertical facial proportions (rule of 3):

• Vertical height of the midface should equal

the height of lower face.
• Forehead: The height of the forehead is
measured from hairline to glabella. It
measures one-third of the total facial
height. Forehead is flat, protruding or
steep.
• In normally balanced face, upper facial
height, middle face and lower facial height
should be equal.
a) Normally proportioned face divided into equal vertical thirds (Tri-G’, G’-Sn and
Sn-Me).
(b)  Lower anterior face height reduced in a short-faced patient. 
(c) Increased anterior face height in a long-faced patient .
In the lower face, mouth equals one-third between nose and chin.
Canting of the maxillary occlusal plane (asymmetry in the transverse plane)

A common method of assessing

canting of the maxillary occlusal
plane is by placing a wooden
tongue spatula across the
premolars and relating it to the
inter-pupillary line.

Care should be taken to avoid

being misled by over-erupted
teeth or canine cusps of different
lengths, which may tip the spatula
in a way that does not accurately
reflect the skeletal base.
Interlabial gap

Interlabial gap is measured in relaxed

lip position from upper lip inferior
(ULI) to lower lip superior (LLS)

1 to 5mm (females larger gap within

the normal range)

This measurement is also dependent

on lip lengths and vertical
dentoskeletal height.
Increased interlabial gap:
• Anatomic short upper lip
• Vertical maxillary excess
• Mandibular protrusion with open bite
secondary to cusp interferences

Decreased interlabial gap:

• Vertical maxillary deficiency
• Anatomically long upper lip
• Mandibular retrusion with deep bite
Upper lip length

Upper lip length is measured at

rest from subnasale to upper lip
inferior.

Normal range is from 19 to 22mm.

If the upper lip is anatomically

short (18mm or less), there can be
a gummy smile or increased
interlabial gap seen.
Mentalis activity:

Hyperactive mentalis activity is also seen along

with lip habits like lip sucking and thrusting.

Puckering of mentalis muscle can be

visualized.
Lip posture and
prominence:

Upper lip is protruded

slightly in relation to
lower lip in a balanced
face.

Two millimetres of
incisal edges of upper
incisors showing at rest
is considered normal.
Lip competency can be defined as the
ability to approximate the lips without any
strain.

Competent lips: Lips which are in slight

contact when the musculature is relaxed.

Incompetent lips: Anatomically, short lips

which do not contact each other when
the musculature is relaxed. Lip separation
greater than 3–4 mm.

Potentially incompetent lips: The lips are

normally developed but the patient is
unable to approximate the lips at rest due
to upper incisor proclination.

Everted lips: These are hypertrophied lips

with redundant tissue. They show weak
muscular tonicity.
Incisor and gingiva visibility
Incisor visibility is assessed at rest and on smiling.
Gingiva visibility is assessed on smiling.

Excessive incisor or gingival display could be due to short

upper lip or long face.

The ideal elevation of the lip on smile for adolescents is

slightly below the gingival margin with 2 mm of tooth
coverage, so that most but not quite all of the upper
incisor can be seen.

The acceptable range of tooth display is from minimal

tooth coverage of 1 mm up to 4 mm coverage of the
incisor crown. Beyond that, the smile appearance is less
attractive.

The vertical relationship of the lip to the incisors will

change over time, with the amount of incisor exposure
decreasing.
In normal smile, the gingival margins of the canine should be
coincident with the upper lip. Lateral incisors should be positioned
slightly inferior.

Gummy smile will be associated with vertical maxillary excess.

Amount of incisor proclination can affect how much they are displayed
on smile.

Flared incisors tend to reduce incisor display and upright maxillary

incisors tend to increase incisor display
 Smile Arc:
consonant/non-consonant
The smile arc is defined as the contour of the
incisal edges of the maxillary anterior teeth
relative to the curvature of the lower lip
during a social smile

For best appearance, the contour of the

incisal edges of these teeth should parallel
the curvature of the lower lip. If the lip and
dental contours match, they are said to be
consonant.

A flattened (nonconsonant) smile arc can

pose either or both of two problems: It is less
attractive, and it tends to make you look
older (because older individuals often have
wear of the incisors that tends to flatten the
arc of the teeth).
 EXTRAORAL EXAMINATION: PROFILE
FACIAL PROFILE ANALYSIS / POOR MAN’S CEPHALOMETRIC
ANALYSIS
1. Facial profile
• Straight
**6. Vertical Facial Proportions (rule of
• Convex 3) (FRONTAL)**
• Concave
2. Facial divergence
• Anterior •Mentolabial sulcus
• Posterior
3. Lip posture •Chin position
• Competent •Nose- size and shape
• Incompetent
• Potentially incompetent •E-lIne (Rickett’s)
• Everted
4. Incisor Protrusion /Nasolabial angle
• Acute •Ballard’s technique
• Obtuse
• Straight •Clinical VTO (If patient has a moderate
5. Clinical FMA to severe Class II or Class III skeletal
• Average
• High
base)
• Low
 FACIAL PROFILE ANALYSIS / POOR MAN’S CEPHALOMETRIC
ANALYSIS

Includes the examination of:

1. Profile
2. Divergence
3. Incisor Protrusion (Nasolabial angle)
4. Clinical FMA
5. **Lip Posture (lip competence) (FRONTAL)**
6. **Vertical Facial Proportions (rule of 3) (FRONTAL)**
1. Facial profile is examined by viewing the patient from the side.

• Three landmarks and two lines are used to assess the facial profile.
• The landmarks are soft tissue nasion, subnasale and soft tissue
pogonion.
• The first line is dropped from soft tissue nasion to subnasale and the
second line is dropped from subnasale to soft tissue pogonion.

Helps in analysing the anteroposterior positioning of the jaws

1. Straight profile: The lines form a straight
line.

2. Convex profile: The lines form an angle

which is pointed away from the face;
associated with class II skeletal pattern.

3. Concave profile: The lines form an angle

which is pointed towards the face; associated
with class III skeletal pattern.

Diagnostic factor in differentiating pseudo

class III malocclusion is abnormal path of
closure from rest position to occlusion.
2. Facial divergence determines the
position of lower part of the face relative to
the forehead.

Divergence was described by Milo Hellmann.

Divergence can be defined as the inclination
of lower face relative to forehead.

• It uses two soft tissue landmarks, namely

soft tissue nasion and soft tissue pogonion.
• A line is drawn between the forehead and
the chin in the natural head position.
1. Posterior divergent face: The
line is inclined posteriorly in the
chin region; seen in class II cases.

2. Straight or orthognathic face:

The line is perpendicular to the
floor; seen in class I cases.

3. Anterior divergent face: The

line is inclined anteriorly in the
chin region; seen in class III
cases.
 3. Incisor Protrusion
(Nasolabial angle)

It tells us about the

proclination/retroclination of upper
incisors.

It is the angle formed by tangent to base

of the nose and a tangent to upper lip.

• Normal angulation is 110°.

• NLA is acute or decreases with
proclination of upper incisors.
• NLA is obtuse or increased in
retroclination of incisors.
 4. Clinical FMA
It tells us if a patient has a vertical or horizontal growing
mandible.

The inclination of mandibular plane angle to the Frankfort

horizontal plane should be noted.

• In patient’s face, one scale is placed over the Frankfort plane.

• Another scale is placed along the lower border of mandible.

• Position where the posterior ends of the two scales meet is

noted.

In average FMA cases, the lines meets behind the occiput.

In a high-angle case, the posterior ends
of the angle meet behind the auricle or
within the occiput.

Steep mandibular plane angle is seen in

patients with long face and open bites.

In a low-angle case, the two lines are

parallel and meet very far away.
Flat mandibular plane angle is seen in
short faces and skeletal deep bite cases.
(A) Steep mandibular plane angle is seen in
patients with a long face.
(B) Flat mandibular plane angle is seen in short
faces and in skeletal deep bite.
 **5. Lip posture and
prominence
(FRONTAL):**

Upper lip is protruded slightly

in relation to lower lip in a
balanced face.

Two millimetres of incisal

edges of upper incisors
showing at rest is considered
normal.
Lip competency can be defined as the
ability to approximate the lips without any
strain.

Competent lips: Lips which are in slight

contact when the musculature is relaxed.

Incompetent lips: Anatomically, short lips

which do not contact each other when
the musculature is relaxed. Lip separation
greater than 3–4 mm.

Potentially incompetent lips: The lips are

normally developed but the patient is
unable to approximate the lips at rest due
to upper incisor proclination.

Everted lips: These are hypertrophied lips

with redundant tissue. They show weak
muscular tonicity.
Lips should be examined for habits like:

• Lip sucking.
• Lip thrust.
• Lip insufficiency.

Abnormal lip habits can be observed when the patient speaks or swallows.

Any lip activity during swallowing is abnormal.

 **6. Vertical facial proportions
(rule of 3)(FRONTAL)**:

• Vertical height of the midface should equal

the height of lower face.
• Forehead: The height of the forehead is
measured from hairline to glabella. It
measures one-third of the total facial
height. Forehead is flat, protruding or
steep.
• In normally balanced face, upper facial
height, middle face and lower facial height
should be equal.
a) Normally proportioned face divided into equal vertical thirds (Tri-G’, G’-Sn and
Sn-Me).
(b)  Lower anterior face height reduced in a short-faced patient. 
(c) Increased anterior face height in a long-faced patient .
In the lower face, mouth equals one-third between nose and chin.
• Mentolabial sulcus is shallow in
bimaxillary protrusion.
• Deep mentolabial sulcus is seen in
class II division 1 malocclusion.
 Chin
Position
Nose
The nasal length in the vertical
plane is one-third of total facial
height.

The aesthetic appearance of the

face is partly determined by
size, shape and position of nose.

The nasal contour can be

straight, convex or crooked.
 E-Line

Devised by Ricketts
Aka Esthetic Plane or “E” plane
A line drawn from the tip of the nose to the tip
of the chin. 

To have a pleasing facial profile, in the average

Caucasian face, the lower lip would be 2 mm
behind the line, and the upper lip 4 mm
behind the line, with variations being normal
for patients of different ethnic backgrounds.
An example of how the “E” plane would be
used is a patient with significant crowding of
both upper and lower arches.

The clinician must decide whether to consider

extracting teeth, such as first premolars or
expanding the arch. If the lips in profile were
on or in front of the “E” plane, the decision
would be extraction and anterior retraction,
improving the lip to “E” plane relationship.

If on the other hand the lower lip is 6 mm

behind the “E” plane, the decision would be to
align the teeth and expand the arch, moving
the anterior teeth and lips to a more anterior
and prominent position.
Ballard’s technique
Ballard’s technique helps determine clinically
whether a case is Skeletal Class I, II or III
Clinical V T O

ISUALISED
REATMEN
T
BJECTIVE
Clinical visualized treatment objective (VTO) helps in analysing whether
functional or orthopedic appliances will be beneficial for the patient.

An improvement in profile means positive VTO and functional or

orthopedic appliances are indicated.

It also helps in patient motivation.

Class II Visualized Treatment Objective
Procedure consists of asking the
patient to bring the mandible to
an edge-to-edge bite relationship.

Change in the appearance of the

patient is noted at two levels:

(i)One at edge-to-edge position

and

(ii) the other at a position midway

between the existing occlusion
and edge-to-edge position.
If the profile improves at edge-to-edge position, it means the fault lies in the
mandible. It is a case of mandibular retrognathism.

Functional appliances to stimulate mandibular growth are indicated.

If the profile worsens at edge-to-edge position, it means
the fault lies in maxilla.

It is a case of maxillary prognathism and appliances like

maxillary intrusion splint or headgears are advised.
➤ If the profile improves
midway, it is a case of
combination of maxillary
prognathism and mandibular
retrognathism.

Appliances like activator

headgear, twin block with
headgears are indicated.
Class III Visualized Treatment Objective
In cases of patients with class
III malocclusion, rolls of
cotton are kept in the upper
labial vestibules.

➤ In cases with maxillary

retrusion, the profile
improves with the cotton roll.

➤ In class III due to

prognathic mandible, the
profile worsens.
Assessment of submental
soft tissues:

Throat form is evaluated in terms

of the contour of the submental
tissues. Straight throat form is
better.

Chin–throat angle and throat

length are assessed.

The ideal chin–throat angle is 90°

and a longer throat is aesthetically
pleasing up to a specific point.
 FUNCTIONAL
EXAMINATION
 FUNCTIONAL EXAMINATION
Functional examination studies the dynamic nature of the
stomatognathic system for optimal function.

The teeth, periodontal ligament, TMJ, tongue and muscles of

mastication constitute the stomatognathic system.

Functional examination is important in identifying the aetiology of

malocclusion and, therefore, helps in planning the type of orthodontic
treatment initiated.
Detailed functional examination involves:

1. Examination of postural rest position and maximum intercuspation

2. Examination of path of closure
3. Examination of temporomandibular joint (TMJ)
4. Examination of orofacial dysfunctions
Postural rest position:

Postural rest position is that position of

mandible where the synergistic and
antagonistic muscular components are in
dynamic equilibrium with their balance
being maintained by basic muscle tonus.

When the mandible is in the rest position, it

is 2–3 mm below the centric occlusion
recorded in canine area.
Determination of postural rest position is accomplished when the
patient’s musculature is relaxed.
The postural rest position, once determined, is registered by various
methods.

1. Direct intraoral method – plaster core

2. Direct extraoral method – caliper measurements using the difference
between vertical relation at rest and at occlusion
3. Indirect extraoral method – best reliable methods; examples are
cephalometry, electromyography and kinesiography
Clinical significance of postural rest position:

• Increased freeway space is seen in true deep bite cases where there
is infraocclusion of posteriors. In such conditions, bite opening by molar
extrusion can be attempted.

• Pseudo deep bite with normal freeway space has normal eruption of
posteriors. Bite opening by intrusion of incisors is recommended.
Mouth opening:

• Intraoral examination begins with mouth

opening.
• Maximum mouth opening is recorded with
the help of dividers between the incisor
edges.
• Normal mouth opening is 45–55 mm for
adults.
• For children, it is less than 45 mm.
Path of closure:

The path of closure of mandible from the postural rest position to maximum
intercuspation is evaluated in sagittal, vertical and transverse planes.

A patient is examined for presence of functional shifts in the anterior,

posterior or lateral direction.
 Examination of TMJ

Palpation:
This involves palpation of TMJ and palpation of
musculature.

The TMJ is palpated for tenderness and synchrony of

action.

Muscles are palpated for tenderness.

TMJ can be palpated by 2 methods :

1.Preauricular palpation 2. Intra-auricular palpation

Palpate directly over the joint Place finger in the external

while the patient opens and auditory meatus and pressure
closes the mandible, and gently applied forwards.
extend of the condylar Condylar movement is easily
movement can be assessed. felt.
Auscultation: A
stethoscope is used for
checking the joint for
clicking or crepitus.

Clicking can be:

• Initial click
• Intermediate click
• Terminal click
• Reciprocal click
Functional analysis of TMJ:

The opening and closing movements of the mandible as well as its

protrusive, retrusive and the lateral excursions are examined.
 Examination of orofacial dysfunctions
Examination of orofacial dysfunction consists of analysis of the
following functions:

a. Swallowing
b. Tongue
c. Lips
d. Respiration
e. Speech
a. Examination of swallowing pattern: The normal swallowing pattern
has the following features:

• Contraction of mandibular elevators.

• The tongue is enclosed in the oral cavity.
• Teeth occlude momentarily.
• Dorsum of the tongue approaches the palate.
Infants swallow in a different manner.

Retained infantile swallow could lead to

malocclusion. Signs of infantile swallow are:

• Jaws are apart while swallowing.

• Tongue is placed between the teeth.
• Mandible stabilized by contraction of lips
and tongue.
• Muscles of facial expression involved.
• Nodding of head.
• Anterior mandibular thrust.
• Caving-in of cheeks.
 Deglutition / Adult or Mature Swallow

Mature swallowing patterns are observed usually by 18 months of

age.

The transition to adult chewing pattern occurs during the eruption

of permanent canines (at about 12 years of age).

The features of adult swallow:

• Teeth are together.

• Mandible is stabilized by muscles of mastication.
• Tongue tip is placed against the palate above and behind
incisors.
• Minimum contractions of the lips during swallow.
• Mature swallow is usually seen by 18 months of age.
Examination of tongue:

• The posture, size, shape and function of

the tongue are assessed.
• The most common functional aberration
of tongue is tongue thrust.
• Tongue posture is very important.
Tongue size:

• Microglossia

• Small tongue and collapsed arch.

• Macroglossia

• Spaced dentition and crenations in

lateral border of tongue will be
seen. (B) large tongue with scalloped
margins
Tongue thrust: Types of
tongue thrust:

• Anterior tongue thrust

• Lateral tongue thrust
• Complex tongue thrust
• Endogenous tongue thrust
• Habitual tongue thrust
• Adaptive tongue thrust
Anterior tongue thrust is associated
with anterior open bite.

Lateral open bite is seen in lateral

tongue thrust.

Complex tongue thrust patient occludes

teeth only in the molar region.
Tongue posture:

• Position of tongue is very important in

creation of malocclusion.

• Position or posture is analysed by the

following methods:
1. Direct intraoral method
2. Cephalometric method
3. Palatographic method
4. Cinefluororadiographic method
Normal resting position of the
tongue is retracted tip lying just
behind the lower incisors and lateral
border resting on the linguo-occlusal
surfaces of lower posterior teeth.

• In class II, tongue tip is more

retruded in rest position.

• In class III, tongue tip lies far

forward.
c. Examination of lips:

Lips are assessed for configuration, functioning

and presence of dysfunctions.

The common lip dysfunctions are:

• Lip sucking
• Lip thrust
• Lip insufficiency

The lip dysfunctions can be observed when the

patient is speaking or swallowing.
Pronounced lip activity during swallowing is
unphysiologic.
d. Examination of respiration:

• The mode of respiration is examined to

establish whether nasal breathing is impeded
or not.

• Prolonged difficulty in nasal breathing leads

to mouth breathing.

• Mouth breathing results in disturbed

orofacial musculature which leads to long face
syndrome (adenoid facies)
Investigations

1. History: Patient’s parents usually give history of the child sleeping with mouth open.

2. Study the patient’s breathing without informing the patient: Nasal breathers lips will
contact during relaxed breathing. Mouth breathers keep the lips apart.

3. Ask the patient to take deep breath: Many respond by inspiring through mouth. Nasal
breather will inspire through nose with lips closed.

4. Ask the patient to close the lips and take deep breath: Nasal breathers demonstrate
good reflex control of the alar muscles, there is dilation of the external nares on inspiration.
Mouth breathers, even if they are capable of breathing through nose, do not change the
size or shape of the external nares.
Tests to assess mouth breathing:
e. Examination of speech:

Speech is affected in a variety of

dysfunctions or structural defects
involving the palate, tongue, lips,
dentition, etc.

The pronunciations of different

consonants are a guide to locate the
area of abnormality.
Diagram and associated table show positions for the oral and pharyngeal musculature during articulation of consonants.
 INTRA-ORAL
EXAMINATION
INTRA-ORAL EXAMINATION

1. Soft tissues
2. Hard tissues
• Intra-arch examination
• Inter-arch examination
 Soft Tissues
Tongue:

Ankyloglossia
• The size, colour and configuration of tongue
should be assessed.

• The tongue can be small, long or broad.

 Palate:

• Palate is assessed for contour which depends upon the patient’s head
form.
• Palatal vault will be high in mouth breathers and congenital syphilis.
• Palatal mucosal surface is examined for ulcerations, indentations,
clefts or pathologic swellings.

A. Broad palate seen in brachycephalic patient. B. Narrow palate in dolichocephalic patient. C. Cleft Palate
Gingiva:

• The gingiva is examined for signs of

inflammation, hypertrophy or
recession.

• Orthodontic treatment is not

Marginal gingivitis in a patient
indicated in patients with with mouth breathing habit.
periodontal problems.
Frenal attachments:

Midline diastemas may arise due to

thick maxillary labial frenum.

Blanch test: This test is done to assess

the role of deep frenal attachment in
midline diastema. If the upper lip is
retracted and a pull is exerted on the
frenum, the interdental tissue and the
area around the papilla becomes
blanched or anaemic; then true
diastemas due to frenal attachment
exists.

High attachment of mandibular labial

frenum could lead to gingival recession.
Adenoid and tonsils: Examined for enlargement and inflammation.
Tonsils are two lymphoid organs situated at either side of the back of the throat.

The adenoid (pharyngeal tonsil or nasopharyngeal tonsil) is a mass of lymphatic tissue

located behind the nasal cavity, in the roof of the nasopharynx, where the nose blends
into the throat.
 Hard Tissue
Dentition: The following
factors are recorded:

• Number of deciduous teeth

• Number of permanent
teeth
• Presence of caries, attrition,
erosion, fractures, etc.
• Presence of supernumerary
tooth or missing tooth
• Size, shape and form of
teeth
Intra-arch examination:

• Assessment of arch shape, symmetry and alignment.

• Symmetry can be assessed with dividers.

• Crowding, spacing and contact areas are checked.

• Rotations of teeth are noted.

• Dental age of the patient is assessed.

Angle’s Line of Occlusion
There are two lines of occlusion:

1. Maxillary: Smooth curve

passing through the central
fossa of upper molars and
along the cingulum of upper
canines and incisors.
2. Mandibular: Runs along the
buccal cusps of posteriors and
incisal edges of the anteriors.
158
160
Interarch examination:

Midline shift between the maxilla

and mandible is recorded.

Sagittal relations: Molar

relationship on both sides, canine
relationship on both sides, overjet
and anterior crossbite are
recorded.
Overjet is the extent of horizontal
(anterior-posterior) overlap of the
maxillary central incisors over the
mandibular central incisors

Overbite refers to the extent of

vertical (superior-inferior) overlap of
the maxillary central incisors over the
mandibular central incisors measured
relative to the incisal ridges

Normal values of overjet and overbite

are approximately 2 to 3mm.
Angle’s Class I Molar and Class I Canine
Relation

Angle’s Class II
Molar and Class II
Canine Relation
(Division 1 and
Division 2)

Angle’s Class III Molar and Class III Canine

Relation
163
 IMAGE IS FOR REPRESENTATION ONLY.
ANGLE’S CLASSIFICATION IS CHECKED ON FIRST PERMANENT MOLARS
CANINE CLASSIFICATION
166
167
 Incisor Classification
British Standards Institute’s incisor relationship
classification (1983) is used commonly nowadays.

Class I: The lower incisor edges occlude with or lie

immediately below the cingulum of the upper
central incisors.

Class II: The lower incisor edges lie posterior to the

cingulum prominence of the upper incisors.
Division 1: The upper central incisors are proclined or of
average inclination. There is an increase in overjet.
Division 2: The upper central incisors are retroclined. The
overjet is usually minimal but may be increased.

Class III: The lower incisor edges lie anterior to the

cingulum prominence of the upper incisor. The
overjet is reduced or reversed. 168
169
Vertical relation: Deep bite,
open bite to be assessed
and recorded.

Transverse relation:
Posterior crossbites to be
checked for and recorded, if
any, on both sides.
 Summary of Clinical Examination
GENERAL EXAMINATION EXTRAORAL EXAMINATION

1. Height Head type

• Mesocephaly
2. Weight
• Brachycephaly
3. Gait • Dolichocephaly
4. Posture Facial form
5. Body build • Mesoprosopy
• Ectomorphic • Leptoprosopy
• Mesomorphic Facial symmetry (rule of 5 and bird’s and
• Endomorphic worm’s eye views)
 Summary of Clinical Examination
Facial Profile Analysis/ Poor man’s Cephalometry 5. Incisor Protrusion/ Nasolabial angle
1. Facial profile • Acute
• Obtuse
• Straight
• Straight
• Convex
• Concave 6. Clinical FMA
• Average
2. Facial divergence
• High
• Anterior
• Low
• Posterior
----------------------------------------------------------------
3. Vertical Proportions (rule of 3)
Nose
4. Lip posture and prominence
• Competent Chin
• Height
• Incompetent
• Mentolabial sulcus
• Potentially incompetent
• Hyperactive mentalis
• Everted
• Chin prominence
 Summary of Clinical Examination
Chin soft tissues
• Throat form
• Chin–throat angle • Swallowing
• Throat length
• Tongue
Esthetic Plane or “E” plane • Lips
• Respiration
Clinical VTO (in case of Class II or Class III skeletal discrepancy)
• Speech

FUNCTIONAL EXAMINATION
INTRAORAL EXAMINATION
1. Postural rest position 1. Soft tissues
2. Path of closure 2. Hard tissues
3. TMJ examination • Intra-arch analysis
4. Orofacial dysfunction • Inter-arch analysis
 Dentofacial Deformity- Diagnostic Features
CLINICAL FEATURES
MAXILLA SAGITTAL DEFICIENCY • Concave profile
• Retrusive upper lip
• Alar base narrow
• Lack of dental display
MAXILLA SAGITTAL EXCESS • Convex profile
• Acute nasolabial angle
MAXILLA VERTICAL EXCESS (LONG FACE • Convex profile
SYNDROME) • Lower facial height
increased
• Alar base constricted
• Nasolabial angle acute
• Excessive incisor show
• Excessive gingival show
• Lip incompetence
• Mentalis strain with lip
closure
• Chin vertically long,
retruded
SKELETAL ASSESSMENT DENTAL ASSESSMENT
• SNA decreased • Class III
• SNB normal • Maxillary dental
• ANB decreased crowding
• Maxillary incisors
proclined
• Mandibular incisors
normal or retroclined
• Class II, Class I
• Anterior open bite
• Maxillary arch
constricted
• Curve of Spee- flat or
accentuated
• Dental crowding
 Dentofacial Deformity- Diagnostic Features
CLINICAL FEATURES
MAXILLA VERTICAL DEFICIENCY (SHORT • Concave profile
FACE SYNDROME) • Lower facial height
decreased
• Nasolabial angle varies
• Alar base widened
• Lack of incisor show
• Edentulous appearance
• Chin protruded
MANDIBLE DEFICIENCY • Convex profile
• Retruded chin
• Lower lip everted
• Deep mentolabial crease
• Mentalis strain with lip
closure
MANDIBLE EXCESS • Concave profile
• Midface appears deficient
• Lower third broad
• Lower lip thin
SKELETAL ASSESSMENT DENTAL ASSESSMENT
• Lower facial height • Class II, Class I
decreased • Deep bite
• SNB increased • Crowding in lower
• ANB negative arch
• Palatal-occlusal plane • Curve of Spee is
decreased reverse
• Mandibular plane
angle acute
• SNA normal • Class II
• SNB decreased • Mandibular incisors
• ANB increased proclined
• Ar-Gn decreased • Maxillary incisors
proclined
• Curve of Spee
accentuated
• SNA normal • Class III
• SNB increased • Maxillary incisors
• ANB decreased proclined
• Mandibular incisors
retroclined
 Diagnosis Format (old format)
• A _ _ year old pre/post-pubertal male/female patient with
• Angle’s Class I/II/III malocclusion on a
• Class I/II/III skeletal base with a
• Class I/II/III canine relation and

•skeletal problem (if present) in sagittal/transverse/vertical planes and

• dental problems (intra-arch if present) and (inter-arch- if present) in sagittal/transverse/vertical
planes and

• Soft tissue problems (if present) e.g. convex/ concave profile, increased/decreased nasiolabial
angle, deep/shallow mentolabial sulcus, incompetent/potentially incompetent lips, high angle/low
angle case and
• habits (if present)
Patient’s chief complaint must be addressed in the diagnosis.
Mention Angle’s molar relation, skeletal base and canine relation (whether normal or abnormal) and then mention only abnormal findings.

E.g.
A 20 year old post-pubertal female patient with Angle’s Class I malocclusion on Class I skeletal base with Class I canine
relation and severe crowding in the lower anteriors, with an overjet of 5mm and overbite of 4mm with a convex profile
and an acute nasolabial angle.
PROGNOSIS
Prognosis can be Good/Fair/Poor.

• In case of syndromes or severe skeletal malocclusion, requiring

orthognathic surgery, prognosis drops from good to fair/poor.
• In case of periodontally compromised patients, prognosis drops from
good to fair/poor
• In case of complicated cases i.e. multiple impactions, multiple rotated
teeth, etc, prognosis drops from good to fair/poor.
• In case of a habit, prognosis can drop from good to fair, especially in
older patients.
Pitch, Roll and Yaw
 Pitch, Roll and Yaw

Pitch, roll and yaw of the aesthetic line of the

dentition are useful ways to evaluate the
relationship of the teeth to the soft tissues
that frame their display (Proffit WR).

Pitch: Excessive upwards or downwards

rotation of the dentition relative to the lips
and cheeks is noted as pitch. It can be up or
down, in front or back. (e.g. open bite/deep
bite)
Roll: It is described as rotation up or
down on one side or the other. Roll
consists of transverse orientation of
the dentition to both the soft tissues
and facial skeleton. (occlusal cant)

Yaw: Rotation of the jaw or dentition

to one side or the other, around a
vertical axis produces a skeletal or
dental midline discrepancy. This is
described as yaw. (midline shift)

Extreme yaw is seen in facial

asymmetries.
Macro, Mini and Micro-Aesthetics
 Macro-Aesthetics

Assessment of macro-aesthetics consists of evaluation of extraoral

proportions or facial proportions.

Analysing facial proportions consists of the following steps:

Frontal view assessment, profile analysis, divergence, evaluation of

lip posture, nasolabial angle, clinical FMA, throat form.
 Mini-Aesthetics
Mini-aesthetics involves assessing the following:

(i) Tooth–lip relationships; this is done in the following way:

• Note the relationship of the dental midline of each arch to the skeletal
midline of that jaw.
• Assess the vertical relationship of the teeth to the lips, at rest and on smile.
Note down the amount of incisor display. Excessive incisor or gingival display
could be due to short upper lip or long face.
• Record the transverse cant of the occlusal plane.
(ii) Smile analysis
 Micro-Aesthetics (dental appearance)
For optimum aesthetics, there should be ideal
proportions in the
shape of teeth.

Width relationships and golden proportion:

In frontal view, the apparent width of lateral

incisor should be 62% of the width of central
incisor, the apparent width of canine should be
62% of the width of lateral incisor, and the
apparent width of premolar should be 62% of
the width of canine. This recurring ratio of 62%
is referred to as the ‘golden proportions’.
Height–width relationships: The width of the
tooth should be 80% of the height.

Gingival heights, shape and contour:

Proportional gingival heights contribute to

normal and attractive dental appearance.

The central incisor has the highest gingival

level; the lateral incisor is about 1.5 mm lower
and canine at the level of central incisor.
Gingival shape refers to curvature of the
gingiva at the margin of tooth.

Ideal gingival shape for central incisor and

canine is elliptical and oriented distal to long
axis.

Lateral incisor should have symmetrical half-

oval or half-circle. The gingival zenith (most
apical point of the gingival tissue) should be
located distal to long axis of maxillary centrals
and canines, while in maxillary laterals it
should coincide with long axis.
Connectors:

The connector, also termed as

interdental contact area, is where
adjacent teeth appear to touch.

The contact points of maxillary

teeth move progressively gingival
from the central incisors to the
premolar.
Embrasures:

The triangular spaces incisal and gingival to the contact

area are called embrasures.

Short interdental papillae result in an open gingival

embrasure above the connectors which are called ‘black
triangles’.

Black triangles affect the appearance of teeth on smile.

All actual and potential triangles should be noted during

clinical examination.
Shade and colour of tooth:

A normal progression of
shade change from midline
towards posteriorly is
essential for an attractive
and natural smile.
Smile Analysis
 Smile Analysis

Creation of pleasing smile is an important aspect of orthodontic

treatment.

Assessment of smile is a prerequisite for proper treatment planning and

diagnosing the problem.
Types of smile:

1. Unposed smile
• It is natural and expresses authentic human emotion.
• It is dynamic.
• It is spontaneous and characterized by more lip
elevation.

2. Posed smile
• Posed smile is voluntary and need not be accompanied
by emotion.
• It is static, which means it can be sustained.
• It is a learned greeting and characterized by less lip
elevation.
FEATURES OF SMILE
1. VERTICAL CHARACTERISTICS

There are two main features of vertical characteristics:

• Pertaining to incisor display
• Pertaining to gingival display

Inadequate incisor display can be due to vertical maxillary deficiency,

restricted lip mobility and short clinical crown.
In normal smile, the gingival margins of the canine should be coincident with
the upper lip. Lateral incisors should be positioned slightly inferior.

Gummy smile will be associated with vertical maxillary excess.

Amount of incisor proclination can affect how much they are displayed on
smile.

Flared incisors tend to reduce incisor display and upright maxillary incisors
tend to increase incisor display
2. TRANSVERSE CHARACTERISTICS

There are three important features:

• Buccal corridor width

• Arch form
• Transverse Cant
Buccal Corridor Width

• Buccal corridor is calculated from the

mesial line angle of the maxillary first
premolars to the inner portion of the
commissures of lip.

• Corridor is represented by a ratio of

intercommissure width divided by the
distance from one maxillary first
premolar to opposite side first premolar.

• Excessively wide buccal corridor is

referred to as ‘negative space’.
Arch Form

• Arch form plays an important role in the form of smile.

• In patients with collapsed arch or narrow maxilla, smile also is narrow
and the buccal corridor is wide.
• Orthodontic expansion of the arch improves the smile by reducing the
buccal corridor.
• Transverse smile dimension is also improved.
• Transverse smile dimension is related to buccal projection of
premolars into the buccal corridors.
Transverse Cant

• Appearance of transverse cant or tilt

of the smile line could be due to
asymmetric vertical growth of the
arches or due to differential eruption of
teeth.

• Ideally, there should not be any

transverse cant.
3. OBLIQUE
CHARACTERISTICS

• Maxillary occlusal plane

from premolar to premolar
should be in consonant with
the curvature of the lower
lip on smile (smile arc).

• Deviation includes
downwards tilt of the
posterior maxilla or
upwards tilt of anterior
maxilla.
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