SRI AUROBINDO COLLEGE OF DENTISTRY, 1

INDORE
DEPARTMENT OF ORTHODONTICS & DENTOFACIAL

ORTHOPEDICS
SEMINAR PRESENTATION - 01
“CASE HISTORY AND DIAGNOSIS”

PRESENTATION BY-MADHU MEENA

PG 1ST YEAR
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CONTENTS

 Introduction
 Diagnostic aids
 Case history
 Habits
 Intra oral examination
 Extra oral examination
 Functional analysis
 Conclusion
 References
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INTRODUCTION

 Diagnosis is a Greek word;

Dia - Apart and
Gnosis- to come to know meaning to discern among to know
differences between, therefore, diagnosis is the determination of the
presence or absence of the abnormal or undesired problems.
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 Orthodontic diagnosis deals with recognition of various

characteristics of the malocclusion.
 Diagnosis includes case history, clinical examination, and other
diagnostic aids such as study casts, radiographs, and
photographs.
 Itinvolves collection of pertinent data in a systemic manner to
help in the identifying the nature and cause of the problem.
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RELEVANCE OF DIAGNOSIS

 A proper diagnosis is essential for a better treatment plan

because the recognition and systematic designation of
anomalies, the practical synthesis of the findings,
permitting therapy to be planned and indication to be
determined, thereby enables the doctor to act.
THOMAS RAKOSI
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GOAL OF ORTHODONTIC DIAGNOSIS

 The goal of orthodontic diagnostic process is to produce a

comprehensive description of the patient's problem and
then to synthesize the various elements of description into
a rational problem list.
 Profit calls this process a search for truth.
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RECOGNISING THE PROBLEM

FORMULATING THE PROBLEM

CARRYING THE NECESSARY EXAMINATIONS

INTERPRETATION OF THE RESULT

DIAGNOSIS
PROBLEM ORIENTED APPROACH- DIAGNOSIS 8
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Once patient’s orthodontic problems have been identified, four

issues must be faced in determining the optimal treatment plan.
1. Timing of treatment.
2. Complexity of treatment that would be required.
3. Predictability of success with given treatment approach.
4. Patient’s goals and desire.
COMPREHENSIVE DIAGNOSIS 10
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 Comprehensive orthodontic diagnosis is established by clinical

implementation called diagnostic aids.
 Orthodontic diagnostic aids are of two types namely:
1 ) Essential diagnostic aids.
2 ) Supplemental diagnostic aids.
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ESSENTIAL DIAGNOSTIC AIDS:

 Case history
 Clinical examination
 Study models
 Certain radiographs
 Bitewing
 Panoramic
 Facial photographs
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SUPPLEMENTAL DIAGNOSTIC AIDS:

Specialized radiographs,
 Estimation of basal metabolic rate
 Cephalometric radiographs
 Diagnostic setup
 Occlusal intraoral films
 Occlusograms
 Cone shift techniques
 Electromyographic examination of
muscle activity
 Hand-wrist radiography to assess bone
age or maturation age
 Endocrine tests
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CASE HISTORY

 Case history involves eliciting and recording of relevant

information from the patient and parent to aid in overall
diagnosis of the case.
 Aim is to establish a rapport with the patient & to obtain an
accurate account of their complaints, which following
examination will enable, a diagnosis to be made.
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CASE HISTORY

 Personal details.
 Chief complaint.
 Past & present dental & medical history.
 Family history.
 Natal & post natal history.
 Habits.
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 Injuries.
 Motivation.
 Physical status.
 Extra oral examination.
 Intra oral examination- hard tissue.

soft tissue.
 Functional examination.
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PERSONAL DETAILS:

 NAME : The patient’s name should be recorded for the

purpose of communication and identification .
 To establish communication, calling patient by his / her
name induces familiarity , there by has positive
psychological effect.
 It gets the patient to think that the clinician is interested in
his well-being.
 In case of children it is wise to record their pet names.
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 AGE : Chronologic and dental age should be recorded. It helps

in diagnosis, treatment planning and timing of the treatment.
 Age signifies the time of growth spurts. Females precede
males in the onset of growth spurts, puberty and termination of
growth.
 Dictates some treatment protocols – growth modification
/surgery.
 Certain transient condition (ugly duckling stage) that occurs
during development that are considered normal for that age.
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GROWTH SPURTS:

 Defined as periods of growth acceleration.

 Sex-linked
just before birth
One year after birth
juveline growth spurt ( boys 8-11 yrs, girls 7-9yrs )
pre-pubertal growth spurt ( boys 14-16yrs . Girls 11-13yrs )
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 Dental age can be determined by two different methods;

 Stage of euption
 Stage of tooth mineralisation in radiographs
In children it help to correlate with the skeletal maturity and to
recognize the time of growth spurts and when growth modification
procedures are mandatory/necessary.
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EXAMPLES-

 Functional appliances are best given in an adolescent and surgical

treatment should be planned only after the cessation of growth.
 Likewise, what may appear, as malocclusion may be normal for that
age, as in ugly duckling stage.
 During growth spurts, arch expansion and rapid skeletal expansion
can be undertaken.
 Tooth movement can be achieved rapidly during growth spurts.
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 SEX : This is important in planning treatment, as the timing

of growth events such as growth spurts is different in males
and females.
 Females usually precede males in onset of growth spurts,
puberty and termination of growth.
 So, hence it is important in planning treatment and timing in
preadolescent patients.
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 Date & Out Patient record number:

For future reference.
 Phone Number:
For future correspondence.
For management of recall / appointments.
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 ADDRESS AND OCCUPATION. Recording of the address

and occupation helps in evaluation of the socio-economic
status of the patient and parents.
 This helps in selection of appropriate appliance.
 To know for convenience of patients to come on appointments.
 To find out endemic and pandemic outbursts.
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 CHIEF COMPLAINT : The patient’s chief complaint should

be recorded in his or her own words.
 This would help the clinician in identifying the priorities and
desires of the patient.
 Patient perception of his orthodontic treatment is an important
piece of information to be considered during treatment planning.
Alignment and occlusion of the teeth.
Impaired dentofacial esthetics.
Impaired function.
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MEDICAL HISTORY

 QUESTIONS TO BE ASKED ????

1.Whether the patient was suffering from any disease before ?
2. Duration and treatment ?
3. Whether the treatment was beneficial or not ?
4. Whether he has an allergy ?
5. Previous hospitalizations ?
6. Blood transfusion ?
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CHRONIC ALCOHOLISM –

 COMPLICATIONS –
Liver cirrhosis , neuropathies ,
Osteoporosis , bone fractures
Inhibits synthesis of vitamin D3

Impede calcium homeostasis

Increased PTH hormone

ROOT RESORPTION
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 In condition like nasopharyngeal diseases and disturbed

respiratory function e.g. adenoid enlargement leads to mouth
breathing, resulting in a particular type of facial form and
dentition.
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SYNDROMES RELATED TO
OCCLUSAL IRREGULARITIES ARE:

1)Crouzons syndrome.
2)Fetal alcohol syndrome.
3)Pierre robin syndrome.
4)Treacher collins syndrome.
5)Synostosis syndrome.
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 Crouzons syndrome: is an
craniofacial disorder
characterized by the premature
closure of cranial bone sutures.
 Clinical features include:
 Maxillary hypoplasia
 Short upper lip
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 Widely spaced eyes,

shallow orbits, protruding
eyeballs, short head.
 Calcified styloid ligaments.
 Maxillary hypoplasia.
 Two thirds of crouzon
patients exhibits a
unilateral or bilateral cross
bite.
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FETAL ALCOHOL SYNDROME:

 Prenatal exposure to alcohol can cause a spectrum of disorders.

 One of the most severe effects of drinking during pregnancy is fetal
alcohol syndrome.
 Clinical features include:
 Small for gestational age or small in stature in relation to peers.
 Facial abnormalities such as small eye openings.
 Poor co ordination
 Hyperactive behaviour
 Sleep and sucking disturbances in infancy
 PIERRE ROBIN SYNDROME IS A CONDITION PRESENT AT 40
BIRTH THAT IS CHARACTERIZED BY A VERY SMALL
LOWER JAW. THE TONGUE TENDS TO FALL BACK AND
DOWNWARD AND THERE IS CLEFT SOFT PLATE.

 Clinical features :
 Characterized by retrognathia
or micrognathia, glossoptosis
and airway obstruction.
 An incomplete cleft of the
palate is associated with the
syndrome in approximately
50% of these patients.
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TREACHER COLLINS SYNDROME

 In this congenital syndrome, both

the maxilla and mandible are
underdeveloped or misaligned.
 Clinical features include:
 Underdevelopment of bones and
face.
 Chin may also be
underdeveloped.
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 The jaws is generally short

and slopes at an angle rather
than being horizontally
aligned with skull.
 CLEFT LIP CLEFT
PALATE AND HEART
DEFECTS.
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 Syndromes which increase the growth:

 Gigantism.
 Acromegaly.
 Caffeys disease.
 Craniofacial dysostosis.
 Osteisis deformans.
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 Syndromes which causes supernumerary tooth:

 Cleidocranial dysplasia.
 Gardners syndrome.
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 Syndromes which causes facial asymmetry

 Hemifacial microsomia
 Hemifacial hypertrophy
 Juvenile rheumatoid arthritis
 Pierre robin syndrome
 Aschers syndrome
 Median cleft face syndrome
 Miescher’s syndrome
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 Syndromes which causes missing teeth:

 Herediatory ectodermal dysplasia.
 Cleidocranial dysplasia.
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 Congenital syphilis
 Mulberry molars and crew driver shaped incisors.
 Rhagades (fissuring and scaring of the corner of the
mouth).
 Frontal bossing and saddle nose.
 Short maxilla and high palatal arch.
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DRUG HISTORY –

 DRUG HISTORY –
 DRUGS INHIBITS ORTHODONTIC TOOTH MOVEMENT –
 1.BISPHOSPHONATES –
Alendronate ( Fosamax )
Risedronate ( Actonel )
 USE – Treatment of osteoporosis.
 Mechanism – acts as specific inhibitors of osteoclast-mediate
bone resorption.
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 2. NONSTEROIDAL ANTIINFLAMMATORY DRUGS

( NSAIDs )
 Indomethacin
 Aspirin
 Ibuprofen
 Mechanism - COX- 1 inhibitors – inhibits PG-E2 synthesis
 3. CORTICOSTEROIDS –Inhibits conversion of arachidonic
acid in to prostaglandins.
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FAMILY / GENETIC HISTORY

 Any siblings of the patient require any orthodontic

treatment.
 Parents ever underwent orthodontic treatment.
 The tissues primarily affected are:
 NEUROMUSCULAR SYSTEM
 TEETH: Size, shape , number.
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A strong influence of heredity on facial features is obvious at a

glance-it is easy to recognize familial tendencies in the tilt of the
nose, the shape of the jaw, and the look of the smile.
 Certain types of malocclusion run in families. The Hapsburg
jaw, the prognathic mandible of the European royal family is the
best known example, but dentists routinely see repeated
instances of similar malocclusions in parents and their offspring.
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CONTEMPORARY ORTHODONTICS, FOURTH EDITION Copyright O

2007,2000,1993, 1986 by Mosby, Inc., an affiliate of Elsevier Inc.
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 For much of the 20th century, thoughts about how malocclusion could be
produced by inherited characteristics focused on two major possibilities-
 The first would be an inherited disproportion between the size of the teeth
and the size of the jaws, which would produce crowding or spacing.
 The second would be an inherited disproportion between the size or shape
of the upper and lower jaws, which would cause improper occlusal
relationships.

CONTEMPORARY ORTHODONTICS, FOURTH EDITION Copyright O 2007,2000,1993, 1986 by Mosby, Inc., an affiliate
of Elsevier Inc.
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 Examining parents and older siblings helps gain information

regarding treatment needs of the child.
 According to Niswander, frequency of malocclusion is decreased
among siblings of index cases with normal occlusion whereas the
siblings of index cases with malocclusion tend to have the same
type of malocclusion more often.
 The genetic basis for the resemblance is mainly polygenic.

Mills, L. F., Niswander, J. D., Mazaheri, M., Brunelle, J. A.. 1968: Minor Oral and Facial Defects in Relatives of Oral Cleft
Patients. The Angle Orthodontist: Vol. 38, No. 3, pp. 199–204
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 Correlation coefficient for a parent and child in context to

skeletal dimension is 0.5 and for dental characteristics it
varies between 0.5 to 0.15 for each feature.
 When these correlations are used to predict facial growth,
errors are considerably reduced. However the current
morphology of the patient is the primary source of
information about the future growth.

Orthodontics Current Principles and Techniques Thomas Graber

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JAW

 SIZE: Hereditary micrognathia or macrognathia.

 SHAPE: Asymmetries – Crouzon’s disease, Cleidocranial
dysostosis.
 LOCATION: Prognathism, retrognathism.
 Class II div.2, Mandibular prognathism, Bimaxillary dentoalveolar
protrusion, skeletal open bite, skeletal mandibular retrognathism.
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SOFT TISSUE

 Facial clefts.
 Microstomia.
 Anomalies of the frenum.
 Ankyloglossia.
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HISTORY OF ORTHODONTIC TREATMENT

 Type of appliance: Fixed or Removable.

 Duration of treatment.
 Reasons for discontinuing,
 Unhappy with the progress
 Did not maintain follow ups
 Financial reasons
 This information helps us plan the treatment to enable patient satisfaction.
 In cases of relapse the etiology of the problem should be found out and the
case be treated accordingly.
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PRE NATAL HISTORY

 It should include information of the condition of the mother during

pregnancy and the type of delivery.
 Infection during pregnancy like german measles can result in
congenital deformities of the child.
 The history should be recorded for three basic points:
1)Fetal molding
2) Birth injury during pregnancy.
3) chemicals, drugs taken by mother (teratogens)
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FETAL INTRAUTERINE MOLDING:

 Pressure against the

developing face
prenatally can lead to
distortion of rapidly
growing areas.
 On rare occasions an arm
is pressed across the face
in utero, resulting in
severe maxillary
deficiency at birth.
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 Occasionally a fetus is flexed tightly against the chest in utero,

preventing the movable mandible from growing forward normally.
 This result in small mandible usually accompanied by cleft palate.
The combination of mandible and cleft palate is the pierre robin
syndrome.
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BIRTH HISTORY:

 Trauma occurs during the time of delivery , its due to the types or
the complexity in the delivery.
 In some difficult births the use of forceps to the heads to assist in
delivery might damage either or both TMJ’s , which sometimes
causes the ankylosis of the mandibular joints.
 It is seen that most of the cases of forceps delivery has class 2
malocclusion.
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 1. Use of forceps -

 Damage to TMJ.
 Underdevelopment of the mandible.
 Pressure Ankylosis Mandibular growth
retardation.
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 Itwas noted that forceps delivered group had a higher percentage of bruxism
and TMJ problems. The non forceps group had a higher incidence of
posterior cross bite and narrower molar arch width .
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CONDITION OF MOTHER DURING PREGNANCY –

 Medication – History of drug taking during pregnancy.

 TERATOGENS – Chemical and other drugs capable of
producing embryologic defects if given at the critical
time.

 “Teratogens produces specific defects if present at low

levels but if given in higher doses, do have lethal
effects”.
TERATOGENS 68
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POST NATAL HISTORY :

 The post natal history includes informations on the types of

feeding, presence of habits and on the milestones of normal
development.
 The feeding method during infancy is considered important with
regard to the aetiology of a retruded mandibular position in
deciduous dentition.
 Higher functional loading during the first few months of the life
helps to move the mandible anteriorly and compensate for the
physiologic retruded antero-posterior jaw relationship that exist at
birth.
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 Consistency of diet : once the primary molars have erupted , it is

important for the development of normal dentition, that the child is
given solid food from this point on.
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 Premature loss of deciduous teeth has a physical effect in the

etiology of many abnormalities of the jaws and the dentition.
 Primary effect is the reduction in the masticatory potential, which
leads to insufficient functional loading and can impede jaw
development in saggital, transverse and vertical planes.
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 Chronic disturbance in the nasal breathing or habitual mouth

breathing is which causes impeded maxillary growth. This
maldevelopment of the maxilla result in narrow jaw with a high
palate and dental crowding as well as retrognathism or prognathism
of the mandible.
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HABITS

 Habit can be defined as a fixed or constant practice established by

frequent repetition.
 Buttersworth[1961] defined as a frequent or constant practice or
acquired tendency, which has been fixed by frequent repetition.
 Mathewson[1982] oral habits are learned patterns of muscular
contractions.
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CLASSIFICATION

• BY WILLIAM JAMES (1923):- Useful habits (nasal breathing)

• Harmful habits (eg:- Thumb sucking, Tongue thrusting)
• Useful habits:- The habits that considered essential for normal function
such as proper positioning of tongue, respiration, normal deglutition.
• Harmful habits:- Habits that have deleterious effect on the teeth and their
supporting structures.
• BY KINGSLEY (1956):-Functional oral habit (mouth breathing)
• Muscular habits (tongue thrusting)
• Combined muscular habits (thumb and finger sucking)
•
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 BY MORRIS AND BOHANA (1969):- Pressure. (lip sucking,

thumb sucking, tongue thrusting)
 Non pressure (mouth breathing)
 Biting habit (nail biting, pencil biting, lip biting)
 Pressure habit:- Habit that apply force on teeth & supporting
structure.
 Non-pressure habit:- Habit that does not apply force on teeth &
supporting structure.
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• BY FINN (1987):- • Compulsive • Non-compulsive

• Compulsive :- These are deep rooted habits that have acquired a fixation in child.
The child tends to suffer increased anxiety when attempt made to correct
• Non-compulsive:- These are habits that easily learned and dropped as the child
matures. 9
• 10. BY KLEIN (1971):- • Empty/unintentional habits • Meaningful/intentional
habits
• Empty habit:- They are habits that are not associated with deep rooted psychological
pattern.
• Meaningful habits:- They are habits that have psychological bearings.
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BUCCINATOR MECHANISM

 Starting with the decussating fibers of the orbicularis oris the buccinator
runs laterally and posteriorly around the corner of the mouth it inserts into
the pterygomandibular raphe just behind the dentition.
 Here it mingles with the fibers of superior constrictor which attaches to
pharyngeal tubercle of occipital bone.
 Thus completely encircling the face.
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ROLE OF BUCCINATOR MECHANISM

 Maintaining arch form and teeth maintaining arch form and teeth
position.
 The integrity of dental arches and the relationship of the teeth to
each other within each arch and with opposing members are result
of morphogenetic pattern as modified by stabilizing and active
function forces of muscle the tongue on one side and lips and cheek
on other side.
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HABITS:

 The bad habit in children have a definite bearing in the

development of occlusion.
 Few harmful habits are:
 Thumb sucking habit.
 Tongue thrusting habit.
 Mouth breathing habit.
 Bruxism.
 Lip biting.
 Nail biting.
 THUMB AND DIGIT SUCKING IS DEFINED AS 80
PLACEMENT OF THE THUMB OR ONE OR MORE
FINGERS IN VARYING DEPTHS INTO THE MOUTH.
IT CAUSES :

1) Labial tipping of maxillary anterior teeth

resulting in proclination.
2) Lingual tipping of lower anterior occurs.
3) Anterior open bite.
4) Narrow maxillary arch.
5) Upper lip is generally hypotonic.
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DIAGNOSIS – THUMB SUCKING

1. HISTORY -
Should be obtained from the parents.
Frequency
Duration
Intensity
2. EXTRA- ORAL EXAMINATION –
a. Fibrous/roughened wart like callus on superior aspect of the digit,
ulceration, corn formation.
b. Dishpan thumb- Digit-reddened, with clean thumb and short
nails/finger.
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c. Redness, wrinkling and blisters due to regular sucking.

d. Cleaner digit.
e. Rarely finger deformity.
f. Short upper lip.
 EFFECTS OF DIGIT SUCKING 84

 1. MAXILLA- 2.MANDIBLE -
 Proclination of maxillary Retroclination of lower
incisors. incisors.
 Increased arch length. Increased inter-molar width.

Distal placement of mandible.
Increased anterior placement
of apical base of maxilla.
 Constricted maxilla.
 Increased clinical crown
length of incisors.
 Trauma to the incisors.
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 3.INTER-ARCH
RELATIONSHIP –
1)Decreased inter-incisal angle.
2)Increased overjet.
3)Posterior cross-bite.
4)Anterior open-bite.
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 LIPS:
 Chronic thumb sucking is frequently
characterized by a short hypotonic
upper lip and hyperactive lower lip.
 Upper lip is passive or incompetent
during swallowing.
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 OTHERS –
 Lip incompetence.
 Hypotonic upper lip.
 Hyperactive lower lip.
 Tongue thrust.
 Lower tongue position.
 Affects psychological health.
 Speech defects ( lisping ).
TONGUE THRUST HABIT IS A CONDITION IN WHICH THE 88
TONGUE MAKES CONTACT WITH ANY TEETH ANTERIOR
TO THE MOLARS DURING SWALLOWING.

 Tongue thrust can be classified as:

 Simple tongue thrust.
 Complex tongue thrust.
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SIMPLE TONGUE THRUST

 Good prognosis.
 Normal tooth contact posteriorly.
 Anterior open bite.
 Good intercuspation of teeth.
 Tongue is thrust forward during swallowing to help
establish an anterior lip seal.
 Diminishes with the age.
 Abnormal mentalis muscle activity is seen.
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COMPLEX TONGUE THRUST


More diffuse open bite.
 Teeth apart swallow.
 Absence of temporalis muscle activity.
 Contraction of lips, mentalis muscles and other circum oral
musculature.
 History of chronic naso-respiratory disease and allergies.
 Inflamed tonsils.
 Does not diminish with age.
 Poor prognosis.
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RETAINED INFANTILE SWALLOW

 Strong contractions of lips and facial musculature

especially buccinator.
 Anterior and lateral thrusting.
 Inexpressive face.
 Difficulty in mastication.
 Poor prognosis.
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CLINICAL FEATURES

 1. LIP POSTURE
 Greater lip separation - at rest as well as in function.
 Lack of lip compensatory activity during swallowing.
 2. FACIAL FORM
 Increased anterior facial height.
 3. MANDIBULAR MOVEMENTS
 No correlation between tongue tip and the mandible itself.
 Mandibular movement upward and backward and tongue tip
 moving forward.
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4. TONGUE FUNCTION
Swallowing sequences – Jerky and inconsistent.
Movements are irregular from one swallow to another.
5. MALOCCLUSION
Proclination of upper anteriors.
Anterior or posterior open bite.
Protrusion of anterior segment of both arches.
Constricted maxillary arch.
Posterior cross bite.
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 DIAGNOSIS
 1. HISTORY
 Check for hereditary etiological factors.
 Determine whether or not remedial speech was ever provided.
 Information regarding URT infections, sucking habits &
neuromuscular problems.
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TESTS FOR DIAGNOSIS -

 a. When the jaw drops and mentalis muscle contracts

strongly while swallowing, there is probably a tongue
thrust .
 b. You may part the lips while swallowing to watch
tongue thrust & in doing so, you will feel the strong
muscle contractions.
 c. Cine-flourography.
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MOUTH BREATHING HABIT

 Habitual respiration through the mouth instead of nose.

 It can be caused by physiologic or anatomic conditions.
 Mouth breathers can be classified into 3 types:
1) Obstructive.
2) Habitual.
3) Anatomic.
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 Anatomic: Lip morphology does not permit complete

closure of mouth.
E.g. Short upper lip.

 Habitual: It becomes deep rooted habit.

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 Obstructive: Complete or Partial nasal obstruction may be

due to –
1) Deviated nasal septum.
2) Narrow nasal passage associated with narrow maxilla.
3) Inflammatory reaction of nasal mucosa or edema.
4) Allergic reaction to nasal mucosa.
5) Obstructive adenoids.
6) Nasal polyps.
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CLINICAL FEATURES

 Long and narrow face (Adenoid face).

 Narrow nose and nasal passage.
 Short and flaccid upper lip.
 Contracted upper arch with possibility of posterior cross
bite.
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 An expressionless or blank face.

 Increased overjet as a result of flaring of the incisors.
 Speech defects- Nasal tone in voice.
 External nares – Disuse atrophy of lateral nasal cartilage.
 Slit like external nares and with narrow nose.
 Gummy smile.
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 Anterior marginal gingivitis can

occur due to drying of the
gingiva.
 The dryness of the mouth
predisposes to caries.
 Anterior open bite.
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DIAGNOSIS

1. HISTORY
a. Subjective Symptoms
 Good history from parents and patient.
 Nasal stiffness, nasal discharge, sore throat , repeated cold
attacks.
 Posterior nasal defects.
b. Objective Symptoms
 Hoarseness of voice.
 Mouth breathing malocclusion.
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 Restlessness at night.
 Mouth breathing gingivitis.
 Association with other habits.
 2. CEPHALOMETRICS
 3. RHINOMANOMETRY
 4. MIRROR TEST
 5. COTTON / MASSLER’S
BUTTERFLY TEST
 6. WATER TEST
 106
GENERAL EXAMINATION

 Itcomprises of the general assessment of the patient. An

observant clinician usually begins his general
examination as soon as the patient enters the clinics.
 107

 HEIGHT AND WEIGHT – They provide clue to the physical growth and
maturation of the patient.
 GAIT (way a person walks )Abnormalities of gait are usually associated
with neuromuscular disorders.
 110

 POSTURE – (way a person stands ) Abnormal postures can

predispose to malocclusion due to alteration in maxillo-mandibular
relationship.
 111
BODY BUILD (PHYSIQUE)

 A) AESTHETIC- Thin physique and narrow dental arches.

 B) PLETHORIC – Obese with large square dental arches
 C) ATHLETIC – Normally built, neither thin nor obese, normal sized dental arches.
 112
SHELDON CLASSIFICATION OF BODY BUILD

 A) ECTOMORPHIC – Tall and thin physique

 B) MESOMORPHIC – Average physique
 C) ENDOMORPHIC – Short and obese physique
 113

 Cephalic and facial examination : MARTIN and

SALLER (1957) formulated cephalic index and facial
index which concluded that:
 Cephalic index = maximum skull width/maximum skull
length
 115

 MESOCEPHALIC (76-80.9) average shape

of head.
They posses normal dental arches
 BRACHYCEPHALIC (81-85.4) broad and
short head
They have broad dental arches
 DOLICOCEPHALIC (<75.9)
Long and narrow head.
They have narrow dental arches.
 116
MORPHOLOGIC FACIAL INDEX
Facial height/bizygomatic width
Euryprosopic (80-84.9) broad and short face form.
Mesoprosopic (85-89.9) average or normal face form.
Leptoprosopic (90 n above) long and narrow face form.
 117

The type of facial morphology has a certain relationship to

the shape of the dental arch. E.g.
Euryprosopic face types have broad, square arches, border
line crowding in such cases should be treated by expansion.
On the other hand, leptoprosopic face types often have
narrow apical basal arches. Therefore. Extraction is
preferred over expansion.
 118
FACIAL SYMMETRY

 The symmetry can be assessed clinically

or on photographs and accurately on
frontal radiographs.
A certain degree of asymmetry between
the right and left sides of the face is seen
in most individuals. The face should be
examined in the transverse and vertical
planes to determine a greater degree of
asymmetry.
119
 120
FACIAL PROFILE

 The facial profile is

examined by viewing the
patient from the side. The
facial profile helps in
diagnosing the gross
deviation of maxillo-
mandibular relationship.
 121

 The profile is assessed by joining the

following two reference lines.
 1. A line joining the forehead and the soft
tissue point A (deepest point in the
curvature of the upper lip).
 2. A line joining point A and the soft tissue
pogonion ( most anterior part of the
chin ).
 122
 Based on the relationship between these two lines. Three types of profile exists .
 123
DIVERGENCE OF FACE

• Defined as an anterior or posterior inclination of the

lower face relative to the forehead.
• Divergence does not indicate facial or dental
disproportion whereas profile concavity or convexity
does indicate disproportion, but does not by itself indicate
which jaw is at fault.
 124
TYPES OF FACIAL DIVERGENCES
 125
ASSESSMENT OF ANTEROPOSTERIOR
JAW RELATIONSHIP

A fair picture of the sagittal skeletal relationship can be obtained

clinically by placing the index finger at the approximate point "A"
(deepest point in curvature of upper lip) of maxilla and middle
finger at approximate point "B" (deepest point in curvature of
lower lip) of the mandible.
 This can be done on the skin points or after lip retraction.
 126

 This is analogous to holding the hand and fingers like

gun. Ideally, the maxilla is 2-3 mm forward of the
mandibular skeletal base so that when the fingers are
placed at the respective points, the palm of the hand will
be straight or horizontal. Thus, in a patient with class I
skeletal pattern, the hand is at an even.
127
 128

Thus, in a patient with class I skeletal pattern,

the hand is at an even.
In class Il skeletal bases, the maxilla is CLASS I SKELETAL PATTERN
forwardly placed bringing the point 'A'
forwards. If palm is held straight only the index
finger touches at point 'A' and the middle finger
is short of point B.' In such cases, the palm of
the hand points upwards when the index finger
and middle finger are placed at point A and
point B, respectively.

CLASS II SKELETAL PATTERN

 129

 Similarly, in a skeletal Class Ill

patient, the mandible is forwardly
placed, bringing the point 'B'
forwards. If palm is held straight,
only the middle finger touches at
point 'B' and the index finger is
short of point A In such cases, the
palm of the hand points
downwards when the index finger
and middle finger are placed at
point A and point "B,' CLASS III SKELETAL PATTERN
 130
EVALUATION OF FACIAL
PROPORTIONS
 A well proportioned face can be
divided into three equal 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 a third of the
distance while the chin occupies
the rest of the space.
 131
ASSESSMENT OF VERTICAL SKELETAL
RELATIONSHIP
 This can be done by assessing either of:
 Therelationship between upper facial height
(UFH) and lower facial height (LFH).
 Clinical Frankfort mandibular plane angle
(angle FMA) Upper facial height (UFH) is the
distance between the glabella (point between
the eyebrows) and subnasale (junction of the
nose with upper lip).
 132

 Lower facial height (LFH) is the distance between subnasale to the menton
(under side of the chin). In normal vertical relationship, the ratio of LFH:UFH is
55:45.
 In other words, lower facial height is almost equal to the upper facial height.
Reduced lower facial height is associated with deep bites, while increased lower
facial height is seen in anterior open bites.
 The vertical skeletal relationship can also be assessed by studying the angle
FMA. It is the angle formed between the mandibular plane (lower border of the
mandible) and the Frankfort horizontal plane (a line between the most superior
point of external auditory meatus and inferior border of orbit).
133
134
135
 136
TRANSVERSE FACIAL PROPORTIONS

 In a transverse plane the ideal face is divided

sagitally into five equal parts or fifths. Each of
the segments should be equal in size to the
width of one eye.
 The five fifths are the central fifth of the face,
two medial fifths and the two lateral or outer
fifths of the face.
 The central fifth is between two vertical lines
that pass through the inner canthi of the eyes.
 137

 The medial fifth represents the width of the eye.

 The outer fifths of the face are measured from the outer
canthi of eye to the helix of the ear.
 In an ideal face the distance that separates the two eyes
should be equal to the width of the eye. The inter-
pupillary distance should equal the width of the mouth.
 138
EXAMINATION OF LIPS-

 Normally the upper lip covers the

entire labial surface of upper anteriors
except the incisal 2-3 mm.
 The lower lip covers the entire labial
surface of the lower anteriors and 2 -
3 mm of the incisal edge of the upper
anteriors.
 139
LIPS CAN BE CLASSIFIED INTO THE FOLLOWING FOUR TYPES :
 140
VERTICAL LIP RELATIONSHIP

 Configuration of lip
can be assessed by
lip length, width and
curvature.
 In a balanced face the
length of the upper
lip measures 1/3rd
and lower lip & the
chin 2/3rd of the
lower face height.
 141

 The upper incisal edge

exposure with the upper lip at
rest should be normally 2mm.
 Itis important to distinguish
excessive exposure of teeth
caused by over eruption of
the incisors from that caused
by underdevelopment of the
upper lip.
 142
INTERLABIAL GAP

NORMAL - 0 to 2 mm
Large gap indicates :

Excessive anterior facial height.

 143
LIP LENGTH

The average lip length at rest, as

measured from subnasale to the most
inferior portion of the upper lip at the
midline.
It is about 23mm in males
and 20mm in females.
 144
REVERSE-RESTING LIP LINE

A short lip length relative

to commissure height
results in an unesthetic
smile, called as reverse-
resting upper lip line.
 145
LIP LINE

 The lip line is the amount of

vertical tooth Exposure in
smiling—in other words, the
curvature and height of the
upper lip relative to the
maxillary central incisors.
 146

 As a general guideline, the lip line is optimal when the

upper lip reaches the gingival margin, displaying the total
cervico-incisal length of the maxillary central incisors,
along with the interproximal gingiva.
 A high lip line exposes all of the clinical crowns plus a
contiguous band of gingival tissue.
A low lip line displays less than 75% of the maxillary
anterior teeth.
 147

 In smiling, the upper lip is elevated by about 80% of its

original length, displaying 10mm of the maxillary incisors.
 Women have 3.5% more lip elevation than men.
 Actually, there is considerable individual variability in upper
lip elevation from rest position to the full smile, ranging from
2-12mm, with an average of 7-8mm.
 148
LIP STEP-KORKHAUS

Positive lip step slightly negative negative lip step

 149
LIP STEP-KORKHAUS

 Positivelip step: Protrusion of the lower lip in relation to

the upper lip. Seen in class III malocclusion.
 150
NORMAL LIP PROFILE

 Slightlynegative lip profile. The lower lip slightly behind

the upper lip.
 151
TONE

TONICITY :
Feel the lip consistency
 152
CHIN

 The configuration of the chin is

determined not only by the bone
structure, but also by the thickness
and tonicity of the mentalis muscle.
 Morphology & craniofacial relation
of the mandible.
 Recessive, adequate or prominent.
153
 154

 Hyperactive mentalis
activity produces puckering
effect in chin region called
as GOLF BALL
APPEARANCE.
 155
NOSE

 Size, shape and position of the nose determine the

esthetic appearance of the face.
 The vertical nasal length measures 1/3rd of the
total facial height (dist. From hairline to menton).
 The relationship between vertical & horizontal
length of the nose is 2:1.
 Before treatment it should be stressed that
orthodontic treatment will not improve the nasal
profile, and a rhinoplasty may be necessary later.
156
 157

INTRA-ORAL
EXAMINATION
 158
SOFT TISSUE EXAMINATION

● Oral hygiene
● Gingival examination
1) Color.
2) Texture.
3) Hypertrophy / fibrosis.
4) Clefts around severely retrusive or badly rotated teeth,
clefts usually reflect a lack of attached gingiva.
5) Fenestrations/Dehiscence.
 159

 Fenestrations (Round holes) and Dehiscence (vertical

splitting) are seen when the alveolar bone is very thin and
when the incisors are protrusive.
160
161
 162

 The Class II malocclusion group had greater prevalence of

fenestrations than the Class III and Class I groups.
 Although fenestrations had greater prevalence in the maxilla, a greater
number of dehiscences were found in the mandible for all groups.
 Alveolar defects were predominant in the buccal root surfaces.
 Most fenestrations in the maxilla were seen at the first premolars and
the first molars in all investigated groups.
 However, dehiscences were seen with greater frequency in the
mandibular incisors.
 163
FRENUM ATTACHMENT

 The Frenum of the maxillary and Mandibular

dental arches should be assessed to determine :
 (A) Its influence on the malocclusion:
Diastema
 (B) Its influence on mechanotherapy:
If the Diastema is more than 3mm, the
surgical removal of excess tissue is required after
the space is closed.
164
 165

 The labial and buccal Frenum are examined by the Blanch

test . If lateral tension on the lips or cheeks causes the
gingival margin too blanches, then some Frenum
involvement may be suspected.
 166
EXAMINATION OF TONGUE

 The posture, size, shape and function of

the tongue are significant.
 Tongue size:
 In macroglossia, the oral cavity is
filled by the tongue mass, indentations
are evident on the tongue periphery,
spaces exist between the incisors, the
tongue is protruded and an open bite is
evident.
 167
TONGUE SHAPE:

 Flat, low-lying, anteriorly postured tongues are factors in

the development of Class-III malocclusion.

 Nasal and pharyngeal blockage, allergies, and excessive

pharyngeal lymphoid tissue cause the tongue to naturally
posture forward to maintain open airway, otherwise, this
may lead the patient to became a mouth breather.
 168

 Tongue posture: MASON AND PROFFIT (1974): the tongue posture is

examined clinically with the mandible in postural rest position.
 Tongue tip withdrawn from all anterior teeth. Usually associated with
posterior open bite. May be associated with bilateral loss of several posterior
teeth.
1) Retracted
2) Protracted
Two forms- A) endogenous-retention of infantile postural pattern results in
open bite.
B) acquired-transitory adaptation enlarged tonsils, pharyngitis or
 169

 Function:
 Abnormal tongue posture and function can be primary
factors to retained infantile deglutitional patterns or they
may be secondary or adaptive to unfavorable
morphologic patterns.
 170

 The persistence of the infantile swallowing can be a cause

for malocclusion. The persistence of infantile swallow is
indicated by the presence of the following features :
 a. Protrusion of the tip of the tongue.
 b. Contraction of perioral muscles during swallowing.
 c. No contact at the molar region during swallowing.
 175

 The size and shape of tongue have many variations:

 Bulky and short, narrow and long, wide and long.
 Most common method to check whether the patient can touch the chin with
the tongue tip.
 A positive result from this test is considered as indication of macroglossia.
 Oral cavity filled with tongue mass.
 176

 Indentations are evident on the tongue periphery.

 Spaces exist between the incisors, which are procumbent.
 Tongue is protruded, and usually an open bite is evident.
 True macroglossia is often evident with certain
pathological conditions such as myxedema, cretinism,
down syndrome.
 177
LABIAL FRENA

A heavy maxillary labial frenum may

be the cause of a central diastema.
 The mandibular labial frenum is less
often associated with a median
diastema, however, it frequently has a
broad insertion which exerts a strong
pull on the free and attached gingiva;
this can lead to gingival recessions in
the lower anterior region already in the
mixed dentition stage.
 178
PALATE EXAMINATION

 The palate should be examined for the following

findings:
 Variation in palatal depth occurs in association
with variation of facial form.
 Usually , Dolicofacial patients have deep palates.
 Brachyfacial patients have wider and shallower
palates as compared to dolicofacial patients.
 A traumatic deep bite can lead to mucosal
ulcerations and indentations in anterior palatal
region.
 179

 Pathologic palatal swelling : Indicative of displaced /

impacted tooth, cysts , etc.
 Presence of clefts in the palate in associated with cleft
palate.
 Scar tissue following palatal surgery prevents normal
development of the maxillary arch.
 180
EXAMINATION OF HARD TISSUE

 The maxillary and Mandibular arches are evaluated to determine

the presence or absence of teeth. The missing teeth are also
indicated.
 If a tooth is not present in the arch, it is attributable to one of the
following reasons:
 Unerupted teeth / Impacted teeth.

 Congenitally missing.
 Lost due to disease or trauma.
 181

 Iftooth is missing, we will have to rely on intra-oral

radiographs and history.

 We should also observe the presence of –

 1) Retained primary teeth.
2) Supernumerary teeth.
 182
INTERARCH DISCREPANCIES

 1) Anteroposterior relationship of teeth.

( Over jet )
 2) Vertical relationship (Overbite)
■ Open bite ■ Deep bite

 3) Lateral relationship
( Cross bite )
183
 184
DEEP BITE

 According to GRABER :
 Defined “Deep bite as a condition of excessive overbite,
where the vertical measurement between the maxillary and
mandibular incisal margins is excessive when the mandible is
brought into habitual or centric occlusion.”
 Deep bite is more prevalent in mixed dentition.
 185
CLASSIFICATION

1. According to its origin:

a) Dental deep bite (simple).
b) Skeletal deep bite (complex).
2. According to functional classification:
a) True deep bite.
b) Pseudo deep bite.
 186

3. According to the extent of deep bite:

a) Incomplete overbite
b) Complete overbite
4. According to dentition:
a) Primary dentition deep bite
b) Mixed dentition deep bite
c) Permanent dentition deep bite
 187

A5 to 25% overlap of the mandibular anteriors is

considered normal.
 An overbite greater than 40% is considered abnormal and is
considered a deep bite.

 Overbite associated with two more terms:

 Cover bite.
 Closed bite.
 188

 COVER BITE is a condition that is characterized by complete

covering of the mandibular anteriors by the maxillary anteriors due
to excessive overbite and retroclination of the maxillary anteriors
such as in class II div 2 malocclusion.
 CLOSED BITE on the other hand is a condition where there is an
excessive overbite as a result of loss of posterior teeth. This
condition generally occurs in adults and rarely in children.
 189

DENTAL DEEP-BITE
Due to: Overeruptions of anteriors.
Infra occlusion of molars.

SKELETAL DEEP-BITE
Due to: Mal-relationship of alveolar bones and/or underlying mandibular or
maxillary bones.
An overgrowth or undergrowth of one or more alveolar segments.
 190

 Dento–alveolar deep bite is again classified into

1) True deep over bite.
2) Pseudo deep over bite.
 True – Due to infra occlusion of molars.
 Pseudo – Due to supra eruption of incisors often seen in class 2
malocclusion patients where there is an increased overjet and the
lower incisors have no incisal stop.
 These continue to erupt till they impinge upon the palatal mucosa.
 194
TONSILS AND ADENOIDS

 Tonsils are the two round lumps in the back of your throat.
 Adenoids are high in the throat behind the nose and the roof of
the mouth (referred to as your soft palate). They are not visible
through the mouth or nose without special instruments.
 They “sample” bacteria and viruses that enter through the mouth
or nose.
 195

 The tonsils are two areas of

lymphoid tissue located on
either side of the throat.
The adenoids, also
lymphoid tissue, are located
higher and further back,
behind the palate, where the
nasal passages connect with
the throat.
 196
TONSILS EXAMINATION

1) Normal
2) Enlarged
Enlarged tonsils cause alteration in tongue and jaw posture.
 197

 Technically, there are three sets of tonsils in

the body: the pharyngeal tonsils, commonly
known as adenoids, the palatine tonsils and
the lingual tonsils, which are lymphatic
tissue on the surface tissue of the base of the
tongue.
198
 199
RHINOSCOPY MIRROR
 200
RHINOSCOPE
201
 202

 Airway obstruction, resulting from nasal cavity or pharynx

blockage, leads to mouth breathing which results in postural
modifications such as open lips, lowered tongue position, anterior
and posteroinferior rotation of the mandible, and a change in head
posture.
 These modifications take place in an effort to stabilize the airway.
 203

 Facial structures are modified by postural alterations in

soft tissue that produce changes in the equilibrium of
pressure exerted on teeth and the facial bones .
 Additionally,during mouth breathing, muscle alterations
affect mastication, deglutition and phonation because
other muscles are relied upon.
 204
Is there a cause and effect relationship between
adenoids, nasal obstruction and malocclusion?

 Dentofacial changes associated with nasal airway blockage have been

described by CV Tomes in 1872 as adenoid facies.
 Tomes coined this term based on his belief that enlarged adenoids
were the principle cause of airway obstruction and resulted in
noticeable dentofacial changes.
 Tomes reported that children, who were mouth breathers, often
exhibited narrow V-shaped dental arches.
 205
CROSS BITE

 According to GRABER:
 “Crossbite is a condition where
one or more teeth may be malposed
abnormally – buccally/labially or
lingually with relation to opposing
tooth or teeth.”
 206

1. According to nature of position:

a) Anterior cross bite.
b) Posterior cross bite.
2. Based on etiology and anatomic location of crossbite:
a) Skeletal crossbite.
b) Dental crossbite.
c) Functional crossbite.
 207

3. According to number of teeth involved:

a) Single tooth cross bite.
b) Segmental tooth cross bite.

4. According to existence on one/both sides of arch:

a) Unilateral.
b) Bilateral.
 208

 When one tooth or several teeth are positioned more buccally or

lingually in relation to the opposing teeth, the malocclusion is
called “Crossbite”.
 Themore severe form of crossbite is “Scissors-bite” in which in
habitual occlusion the mandibular dentition is contained in the
maxillary arch. Scissors-bite may develop from a maxillary
buccal / mandibular lingual crossbite.
 209

 When scissors-bite on multiple molars

is a result of transverse skeletal
discrepancy, the malocclusion is termed
“Brodie bite.” Scissors-bite may appear
as unilateral or bilateral.

Treatment of a Bilateral Scissors-Bite in an Adolescent With Fixed Appliances Ahmad Sodaga et al. Iran J Ortho. In Press;
online 2016 May 30.
 210
SUNDAY BITE

 It occurs in young patients who realize they have an

under-bite so they “correct it” by posturing the mandible
forward from Class II to Class I dental. (Dual bite).

 This of course masks the problem but creates significant

potential TMJ problems. These patients commonly
present with early clicks.
 211
X-BITE

 “X-occlusion” or “alternate intercuspation” are two

terms used to define a characteristic mode of
occlusion observed among Australian Aborigines
living in their traditional lifestyle.
 Here, the dental arches exhibit two different centric
occlusions resulting from the upper arch being
wider than the lower. When there is maximum
intercuspation on the left side, the right side
displays a large overjet, and vice versa.
 212
INTRA-ARCH DISCREPANCIES

1) Arch form and dimensions: Dental arch forms will be broadly described
as U- shaped, tapered, square shaped.
*Arch form is related to the forces on the teeth and bones exerted by
lips, cheeks, tongue and occlusion.
2)Arch asymmetry

3) Arch inadequacy and redundancy : When an arch

length inadequacy is present, teeth the not properly aligned in the arch.
 213
SYSTEMATIC EXAMINATION OF
FACIAL AND DENTAL APPEARANCE

 We will discuss about systematic examination of facial and dental

appearance that should be done in the following three steps:
 MACROESTHETICS (Facial proportions)
 MINIESTHETICS (Tooth- lip relationships)
 MICROESTHETICS (Dental appearance)
214
 215
FACIAL PROPORTIONS: MACRO-
ESTHETICS

 It is a disastrous mistake for an orthodontist not to

evaluate the face carefully, because a major reason for
orthodontic treatment is to overcome psychosocial
difficulties related to facial and dental appearances and
enhance social well-being and QOL.
216
 217
FACIAL PROPORTIONS: MACRO-
ESTHETICS
 The three goals of facial profile analysis are-
 Establishing whether the jaws are proportionately positioned in the A-P plane.
 218
FACIAL PROPORTIONS: MACRO-
ESTHETICS
 Dentofacial characteristics that should noted as a part of facial examination :
 219
TOOTH LIP RELATIONSHIP: MINI-
ESTHETICS

3 aspects of mini- esthetics are:

 To note the relationship of dental midline of each arch to the
skeletal midline of that jaw.
 Vertical relationship of the teeth to the lips at rest and on
smile.
 Smile analysis: Facial attractiveness defines more by the
smile than by the soft tissue relationship at rest.
 220
TOOTH LIP RELATIONSHIP: MINI-
ESTHETICS
 221
DENTAL APPEARANCE: MICRO-
ESTHETICS

 Evaluation of the proportions and shape of the teeth and

associated gingival contours is necessary in the development of
an orthodontic problem list if an optimal esthetic result is to be
obtained.
 222
1
 223
DENTAL APPEARANCE: MICRO-
ESTHETICS

 Tooth proportions. Width relation with respect to other

teeth.
 Height-width relation of Individual teeth .
 224

 Connectors and embrasures:

 225

Classification
Of
Malocclusion
 226
ANGLE’S CLASS I

 Angle’s Class I malocclusion is characterized by the

presence of a normal inter-arch molar relation.
 The mesio-buccal cusp of the maxillary first permanent
molar occludes in the buccal groove of mandibular first
permanent molar.
 227

 The patient may exhibit dental irregularities

such as crowding, spacing, rotations, missing
tooth etc.
 These patients exhibit normal skeletal
relation and also show normal muscle
function.
 228
Angle’s Class II

 This group is characterized by a Class II molar

relationship where the disto-buccal cusp of the upper first
permanent molar occludes in the buccal grove of the
lower first permanent molar.
 229

 Angle has sub-classified Class II malocclusions into two

divisions:
 Class II, Division 1
 Class II, Division 2
 230
CLASS II, DIVISION 1

 This division is characterized by a Class II molar relation

and protruding maxillary incisors with increased overjet.
 Associated abnormal muscle function become a
deforming force instead of serving as a balancing and
stabilizing “splint’’.
 231

 Upper lip is short & hypotonic & unable to make lip seal.
 With the increase in overjet the lower lip cushions to the
palatal aspect of these teeth – lip trap.
 232

 The tongue no longer approximates the palate at rest.

During swallowing, abnormal mentalis muscle activity
and aberrant buccinator activity, together with
compensatory tongue function and changed tongue
position, tend to accentuate the narrowing of the
maxillary arch, the protrusion, labial inclination and
spacing of the maxillary incisors.
 233
CLASS II, DIVISION 2

 Angle’s Class II molar relation.

 Distinguishing feature is the excessive lingual inclination
of the maxillary central incisors with excessive labial
inclination of the maxillary lateral incisors.
 Overbite is quite excessive (closed bite).
 234

 In some cases variations occur in the maxillary incisor

positions. Both central and lateral incisors may be
lingually inclined and the canines labially inclined.
 Such an occlusion is traumatic and may be quite
damaging to the mandibular incisor segment supporting
structure.
 235

 Lower anterior segment is more frequently irregular, with

supraversion of the mandibular incisors.
 The mandibular labial gingival tissue is often traumatized .
 236

 In contrast with Class II, Division 1, perioral muscle

function is usually within normal limits as in Class I
malocclusions.
 Vertical height of the lower third of the face is
comparatively short, and the chin is usually prominent.
 237
Class II, Subdivision

 When a Class II molar relation exists an one side and a

Class I relation an the other, it is referred as Class II,
subdivision.
 238
ANGLE’S CLASS III

 This is the mesial relation of the mandibular arch to the

maxillary arch as shown by the relation of the
mesiobuccal cusp of the maxillary first permanent molar
fitting into the buccal embrasure between the mandibular
first and second permanent molars and the maxillary
second permanent premolar fitting into the buccal groove
of the mandibular first permanent molar.
 239

 Mandibular incisors are frequently in total cross-bite,

labial to the maxillary incisors.
 In most Class III malocclusions, the lower incisors are
inclined excessively to the lingual aspect, despite the
cross-bite.
 Individual tooth irregularities are frequent .
 240

 The space provided for the

tongue appears to be greater and
the tongue lies on the floor of the
mouth most of the time.
 The maxillary arch is constricted,
the tongue does not approximate
the palate as it does normally.
 241
TRUE CLASS III

 This is a skeletal Class III malocclusion of genetic origin that can

occur due to the following causes:
 Excessively large mandible.
 Forwardly placed mandible.
 Smaller than normal maxilla.
 Retro positioned maxilla.
 Combination of the above causes.
 242
PSEUDO CLASS III

 This type of malocclusion is produced by a forward

movement of the mandible during jaw closure, Thus it is
also called postural’ or ‘habitual’ Class III malocclusion.
 a. Presence of occlusal prematurities may deflect the
mandible forward.
 243

 b. In case of premature loss of deciduous posteriors, the

child tends to move the mandible forward to establish
contact in the anterior region.
 c. A child with enlarged adenoids tends to move the
mandible forward in on attempt to prevent the tongue
from contacting the adenoids.
 244
CLASS III, SUBDIVISION

 This is a condition characterized by a Class III molar

relation on one side and a Class I relation on the other
side.
 245
Class I Modifications of Dewey

 Type 1 :- Class I
malocclusion with bunched
or crowded anterior teeth.
 Type 2 :- Class I with
protrusive maxillary incisors.
 246

 Type 3 :- Class I malocclusion with anterior

crossbite.
 Type 4 :- Class I molar relation with
posterior crossbite.
 Type 5 :- The permanent molar has drifted
mesially due to early extraction of second
deciduous molar or second premolar.
 247
CLASS III MODIFICATIONS OF DEWEY

 Type 1 :- The upper and lower dental arches when viewed separately are
in normal alignment. But when the arches are made to occlude the patient
shows an edge to edge incisor alignment, suggestive of a forwardly moved
mandibular dental arch.
 248

 Type 2 :-The mandibular incisors are

crowded & are in lingual relation to the
maxillary incisors.
 Type 3 :- The maxillary incisors are
crowded and are in crossbite in relation to
the mandibular anterior.
 249
INCISORS CLASSIFICATION

 Based upon incisor relationship, proposed

in 1983. Do not consider molar relationship
in some cases.
 • CLASS I: The lower incisor edges
occlude with or lie immediately below the
cingulum plateau of upper central incisors.
 CLASS II: The lower incisor edges lie posterior to the 250
cingulum plateau of the upper incisors. There are two sub-
divisions: –

 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 or may be increased.
 251

 Von-Der-Linden classified Angle’s class II/2

malocclusion in to 3 types based on the severity of incisor
relationship :
 Type A:
 Maxillary central incisors and laterals are retroclined.
 Degree of retroclination is less severe in nature.
 252

 Type B:
 Maxillary lateral incisors are overlapping the retroclined
maxillary central incisors.
 253

 Type C:
 Maxillary central and lateral incisors Are retroclined and
are overlapped By the maxillary canines.
 254

 CLASS III: The lower incisor edges lies

anterior to the cingulum plateau of the
upper incisors. The overjet is reduced or
reversed.
 255
CANINE CLASSIFICATION

 CLASS I : When the mesial slope of upper canine

coincides with the distal slope of lower canine.

 CLASS II : When the mesial slope of upper canine is

ahead of the distal slope of lower canine.

 ClassIII : When the mesial slope of the upper canine lies

behind the distal slope of the lower canine.
 256
PREMOLAR CLASSIFICATION
257
258
 259

FUNCTIONAL
ANALYSIS
 260
FUNCTIONAL ANALYSIS

 Modern orthodontics is not only restricted to static

evaluation of the teeth and their supporting structures but
also includes all functional units of the masticatory
system (Acc. to Eschler, 1952).
 Itis not only significant for the etiological evaluation of
the malocclusion but also for determining the type of
orthodontic treatment indicated.
 261

3 aspects:
 Examination of the postural rest position and maximum
intercuspation.
 Examination of TMJ.
 Examination of orofacial dysfunctions.
 EXAMINATION OF THE RELATIONSHIP: 262
POSTURAL REST POSITION- HABITUAL OCCLUSION

 Determination of postural rest position.

 Registration of postural rest position.
 Evaluation of the relationship: postural rest position-
habitual occlusion, in three planes of space.
 The rest position should be determined with the pt in
relaxed and sitting position and the head can be
positioned with the FH parallel to the floor.
 263
DETERMINATION OF THE POSTURAL
REST POSITION

 Pt’s orofacial musculature must be relaxed, tapping test

can be used to help relax the musculature.
 When the mandible is in postural rest position, it is
usually 2-3mm below and behind the centric occlusion
(recorded in the canine area).
 264

 Space between the teeth is referred to as freeway space/

interocclusal clearance.
 Methods to determine the rest position:
 Phonetic method.
 Command method.
 Non- command method.
 Combined methods.
 266
DETERMINATION OF THE POSTURAL
REST POSITION
267
268
 269
REGISTRATION OF THE REST
POSITION

 Two most commonly used methods:

 Intra- oral methods.
 Extra- oral direct methods (skin reference point).
 Indirect extra-oral procedure-
 Roentgenocephalometric registration.
 Kinesiographic registration.
270
 271
REGISTRATION OF THE REST POSITION
 272

 Vernier calipers can be used directly in the patients

mouth in the canine or the incisor region to measure the
freeway space.
 Two marks are placed one on the nose, and another on
the chin in the mid-sagittal plane. The distance between
these two points is measured after instructing the
patient to remain at rest position. Later the patient is
asked to occlude the teeth and the distance between the
two points is again measured. The difference between
the two readings is the freeway space.
EVALUATION OF RELATIONSHIP- REST 273
POSITION AND HABITUAL OCCLUSION

 The movement of the mandible from the rest position to full

articulation is analyzed 3-dimensionally: in sagittal, vertical,
frontal planes.
 The closing movement of the mandible can be divided into two
phases:
 Free phase (rest position to initial contact).
 Articular phase (initial contact to habitual occlusion).
 274

 When closing from the rest position, mandible may

undergo both rotational and sliding movement.
 The objective of this analysis is to determine the amount
and direction of movement as well as the proportions of
rotational and sliding components.
 275

 Movements of mandible from rest position to habitual occlusion:

 Pure rotational
 Rotation with sliding

Movements of mandible from rest position to habitual occlusion:

1) Pure rotational.
2) Rotation with sliding.
EVALUATION OF REST POSITION- HABITUAL276
OCCLUSION IN TRANSVERSE PLANE

 This analysis is particularly relevant for the differential diagnosis

of cases with unilateral crossbite.
2 types mandibular deviation:
 Laterognathy.
 Laterocclusion .
 A lateral crossbite with laterognathy is termed as true crossbite.
 Inlaterocclusion, the deviation is observed only in occlusal
position and deviation is due to tooth guidance.
 277
OPENING AND CLOSING METHOD OF
THE MANDIBLE

 The opening and closing movements of the mandible as

well as its protrusive, retrusive and lateral excursion are
examined as part of the functional analysis.
 The size and direction of these actions are recorded
during clinical examination.
 Deviations in speed can only be registered with electronic
devices (Kinesiograph).
 278

 The first signs of initial temporomandibular joint

problems include deviations of the mandibular opening
and closing paths in the sagittal and frontal planes.
 In patients with malocclusion and malaligned teeth,
disturbances in mandibular movement are the result of an
asynchronic pattern of muscle contractions.
 279

 The path of closure is the movement of the mandible from

rest position to habitual occlusion.
 Abnormalities of the path of closure are seen in some
forms of malocclusion.
 Forward path of closure.
 Backward path of closure.
 Lateral path of closure.
 280

 A forward path of closure is seen in patients with an edge to edge

incisor contact. In such patients, the mandible is guided to a more
forward position to allow the mandibular incisors to go labial to
the upper incisors.
 A backward path of closure is seen in Class II division II 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 to the
left or the right side is associated with occlusal prematurities and a
narrow maxillary arch.
 281
EXAMINATION OF TMJ

 As a general guideline, if the mandible moves normally, its function

is not severely impaired, and by the same token, restricted
movement usually indicates a functional problem.
 Palpating the muscles of mastication and TMJ should be a routine
part of any dental examination, and it is important to note any signs
of TMJ problems such as joint pain, noise, limitation of opening, or
deviation on opening.
 282

 Symptoms of TMJ problems include:

 Clicking and Crepitus.
 Sensitivity in the Condylar region and masticating muscles.
 Functional disturbances –
Hypermobility,
Limitation of movement,
Deviation.
 Radiographic evidence of morphologic and positional abnormalities.
 283


The simplified examination of the TMJ area consists of
three steps.
 Auscultation
 Palpation
 Functional analysis
 284
AUSCULTATION OF TMJ
285
 286
TYPES OF CLICKING
 287
PALPATION OF TMJ
288
PALPATION OF MOM 289
290
291
 292
FUNCTIONAL ANALYSIS


Dislocation of condyles and discoordination of
movement are symptoms of functional disturbance.
 Functional movements of the mandible and condyle are
carefully assessed. The extent of maximum opening is
measured between the upper and lower incisors.
 293
RECORDING MAXIMUM INTERINCISAL
DISTANCE
 294
OPENING AND CLOSING
MOVEMENTS OF THE MANDIBLE

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

protrusive, retrusive and lateral excursion are examined as part of the
functional analysis.
 The path taken by the midline of the mandible during maximum mouth
opening is observed. Any alteration in opening are recorded.
 Two types of alteration can occur
 Deviation
 Deflection
 295

DEVIATION is any shift of the jaw midline

during opening that disappears with continued
opening(a return to midline).
DEFLECTION is any shift of the midline to
one side that becomes greater with opening
and does not disappear at maximum
opening(does not return to midline).
It is due to restricted movement in one joint.
 296
RADIOGRAPHIC EXAMINATION OF
TMJ

 Required only in limited cases, indicated for CHILDREN with functional

disturbances of the TMJ.
 While analysing the radiograph, we should check for-
 Position of condyle in relation to the fossa.
 Width of the joint space.
 Changes in shapes and structure of condyle head or the mandibular fossa.
 Adolescents with class II div 1 malocclusion and lip dysfunction are most
frequently affected by TMJ disorders.
 297
EXAMINATION OF ORO-FACIAL
DYSFUNCTION
 Swallowing
 Normal mature swallow takes place without contracting the muscles
of facial expression. The teeth are momentarily in contact and the
tongue remains inside the mouth.
 Abnormal swallowing is caused by tongue thrust, either as a simple
thrusting action or as “tongue thrust syndrome or complex tongue
thrust”.
 298

 The following are its symptoms:

 Protrusion of tip of the tongue.
 No tooth contact of molars.
 Contraction of perioral muscles during the deglutition
cycle.
 299

 During their first few years, infants swallow viscerally, i.e. with
the tongue between the teeth.
 As the deciduous dentition is completed, the visceral swallowing
is gradually replaced by somatic swallowing.
 Ifvisceral swallow persists after the fourth year of age, it is then
considered an orofacial dysfunction.
 Infantileswallow is seldom found in older children and, even if it
occurs, then only as a mixed type of visceral/somatic swallowing.
 300
SPEECH

 Certain malocclusions may cause defects in speech due to

interference with movement of the tongue and lips. This should
be observed while conversing with the patient.
 The patient can be asked to read out from a book or asked to
count from 1 – 20 while observing the speech.
 301

 Patients having tongue thrust habit tend to lisp, while cleft

palate patients may have a nasal tone.
 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.
 302

 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.
303
ANALYSIS OF DIAGNOSTIC RECORD 304
 305
RADIOGRAPHIC RECORDS

 OPG
 LATERAL CEPHALOGRAPH
 MP3/HAND WRIST X RAY
 IOPA WITH 11,12
 PA VIEW : a) ASSYMMETRY
 b) CLEFT LIP AND PALATE
 TMJ VIEW
 OCCLUSAL VIEW
 306
MODEL ANALYSIS
 307

 Skeletal
 Horizontal growth pattern.
 Class III skeletal pattern.
 308

 Dental
 Anterior Deep bite.
 Midline diastema in maxillary.
 Retrusive maxillary incisors and mandibular incisors.
 Class I molar relation on right side and class II left side.
 Class I incisor relation.
 Class I canine on right side and left side.
 Rotation 11,12,13,14,15,16,17,21,22,23,24,25,26,34.43,44,45.
 309

 Soft tissue
 Deep mentolabial sulcus.
 Lip strain (3mm).
 Acute nasolabial angle.
 Protrusive lower lip.
 310

 Orthodontic diagnosis is complete when a comprehensive

list of the patient's problems has been developed and
pathologic and developmental problems have been
separated.
 311

 Atthat point, the objective in treatment planning is to

design the strategy that a wise and prudent clinician,
using his or her best judgment, would employ to address
the problems while maximizing benefit to the patient and
minimizing cost and risk.
 312
THE SEQUENCE OF STEPS IN PLANNING
ORTHODONTIC TREATMENT

1) Separate any pathologic problems from the orthodontic

(developmental) problems.

.2) Put the orthodontic problems in priority order.

3) Note the treatment possibilities, being sure to be complete.

 313

 Evaluate the possible solutions, considering factors that

can affect the probable result.
 Establish the treatment plan concept in an interactive
session with the patient and parents.
 Develop the detailed plan of clinical steps and
procedures.
 314
CONCLUSION

 The modern orthodontics includes a series of different

types of treatment requiring precise diagnosis techniques
in order to produce a positive outcome.
 315
REFERENCES

 Burkets oral medicine: Green berg, Glick ship- 11th edition.

 Oral Diagnosis Oral medicine and treatment planning: Steven L.
bricker, Robert P. Langlais, Craig s. miller- 2nd edition.
 Oral and maxillofacial medicine; Scully 1stedition.
 Principal of practical oral medicine & patient evaluation by pramod
jhon r.
 Principles and practice of medicine, Davidson, 20thedition.
 316

 Carranza’s periodontology.
 Text book of endodontics-grossman.
 Fundamentals of oral medicine radiology by durgesh and
bailoor.
 Clinical manual for oral diagnosis by beena verma.
 Clinical manual on General Surgery, S, Das,3rdedition.
 Principles of practical Medicine, P.J.Mehta, 17thedition.
 317

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