Case History and

Clinical Examination
in orthodontics

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

Guided by :
Dr. Basant Kumar Shrestha
Associate Prof. and Head
Department of Orthodontics and Dentofacial Orthopaedics
Faculty of Dentistry,
Institute of Medicine, Kathmandu

Case History
Case History is the information gathered from the patient or parent
or guardian to aid in overall diagnosis of the case. It includes personal
details, chief complaint, past and present medical and dental history and

1
any associated family history. The aim is to establish a rapport with the
patient and to obtain information about individual’s complaint.

1. Personal details

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

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

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

D. Address and contact number

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

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

F. Religion
G. Ethnic origin

1. Chief Complaint
The patient’s chief complaint should be recorded in his or her own
words. There are three logical reasons for patient concern about the
alignment and occlusion of the teeth: impaired dentofacial esthetics that
can lead to psychosocial problems; impaired function; and a desire to
improve dentofacial esthetics. It is important to establish their relative

2
 importance to the patient and their desires. The parents’ perception of
the malocclusion should be noted.
A series of leading questions, beginning with, "Tell me what
bothers you about your face or your teeth," may be necessary to clarify
what is important to the patient. The orthodontist may or may not agree
with the patient’s assessment – the judgement comes later. But, at this
stage, it is necessary to find out what is important to the patient.
This will help in setting treatment objectives and satisfying the
patient and or parents in general.

2. Medical History
Knowledge of the patient’s general health is essential and should
be obtained prior to the examination. It is best obtained by
questionnaire.
In most of the cases, orthodontic treatment can be undertaken but
precautions should be taken prior to surgical procedures. Patients with
rheumatic fever, cardiac anomalies, epilepsy, diabetes and blood
dyscrasias may require special precautions.
The medical history should include information on drug usage. The
use of certain drugs like aspirin (prostaglandin inhibitors) or bone
resorption inhibiting agents may impede orthodontic tooth movement.
Patients who are suffering from acute, debilitating conditions such as
viral fever should be allowed to recover prior to initiating orthodontic
treatment.
History of trauma should be noted. Trauma to the jaws or teeth is
often overlooked in child with other trauma, so a jaw injury may not
have been diagnosed at that time. This is significant as it affects the
future development of jaws and teeth.

3. Dental History
The patient’s dental history should include information on the age of
eruption and exfoliation of deciduous and permanent teeth, history of
extraction, decay, restorations and trauma. The past dental history will
also help in assessing the patients and parents’ attitude towards dental
health.

4. History of Habits
History of abnormal habits like finger, digit sucking, nail biting, lip
biting grinding, clenching, and mouth breathing should be taken as they
influence the development of dentoalveolar structures.

5. Pre-natal History
Pre-natal history should include information on the condition of the
mother during pregnancy and the type of delivery. Forceps deliveries
have been associated with injury to the temporomandibular joint (TMJ)
and may cause ankylosis and mandibular growth retardation. Nutrition
status and infections during pregnancy should also be noted.

6. Post-natal History

3
 It should include information on type of feeding, presence of habits
and milestones of normal development.

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

8. Physical Growth evaluation

The parents should be questioned about the child’s growth status.
(eg: Has your child had any recent rapid growth ?). Rapid growth during
the adolescent growth spurt facilitates tooth movement but growth
modification may not be possible in a child who is beyond the peak of
the growth spurt.
For children approaching puberty, questions about how rapidly the
child has grown recently, whether clothes sizes have changed, whether
there are signs of sexual maturation, and when sexual maturation
occurred in older siblings usually provide the necessary information
about where the child is on the growth curve.
In orthodontic clinic, measuring the height and weight regularly and
calculation of bone age from vertebrae as seen in the cephalometric
radiograph can be helpful. Serial cephalometric radiographs offer the
most accurate way to determine whether growth has stopped or is
continuing.

9. Social and Behavioral Evaluation

It should explore – patient’s motivation for treatment, what he or
she expects as a result of treatment and how co-operative or unco-
operative the patient is.
Motivation can be external or internal. External motivation is that
supplied by pressure from another individual, like child brought for
treatment by mother; older patient by his girlfriend. Internal motivation
comes from within the individual and is based upon his or her own
assessment of the situation and desire for the treatment.
What patient expects from the treatment should be explored
carefully especially in case of patients with primarily cosmetic problems.

Clinical Examination

1. General Examination
Each patient should be regarded as a whole person rather than as a
'pair of jaws'. The examination, therefore, begins immediately the patient
enters the clinic. If possible, both parents should be present at the
examination; this affords an opportunity to observe any hereditary
characters which may be present, and also an opportunity to discuss the
medical history, diagnosis and treatment.

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 A. Height and weight
It gives a clue to the physical growth and maturation of the
patient. The growth of the body in general is related to the growth
of the jaws and face particularly.

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

C. Built
Sheldon classified body built into:
i. Ectomorphic : Tall and thin physique
ii. Mesomorphic : Average physique
iii. Endomorphic : Short and obese physique

1. Extra-oral Examination

A. Shape of Head
The shape of head can be evaluated based on the cephalic
index which is based on the anthropometric determination of the
maximum width and maximum length of the head.
It is given by Martin
Cephaic and
index Saller as:
Maximum skull width =
Ma
ximum skull length

• Mesocephalic : I = 76.0 -80.9

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

A. Shape of the face

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

• Hypereuryprosopic : I < 78.9

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

5
A. Assessment of facial symmetry
A certain degree of asymmetry between right and left sides of
the face is seen in most of the individuals. The face should be
examined in the transverse and vertical planes to determine a
greater degree of asymmetry than the normal.
Gross facial asymmetries may be seen in patients with-
• Hemifacial atropy/hypertrophy
• Congenital defects
• Unilateral condylar hyperplasia
• Unilateral Ankylosis

A. Facial profile
The profile is examined from the side by making the patient
view at a distant object, with the FH plane parallel to the floor. The
profile is assessed by the two reference lines-
 A line joining the forehead and the soft tissue point A (deepest
point in the curvature of upper lip)
 A line joining point A and the soft tissue pogonion (most
anterior point of the chin)
Based on the relationship between these two lines, three
types of profile exists-
 Straight : The two lines form a nearly straight line
 Convex : The two lines form an angle with the concavity
facing the tissue. It occurs in cases of prognathic maxilla or
retrognathic mandible as seen in Class II Div I.
 Concave : The two reference lines form an angle with the
convexity towards the tissue. This type of profile is seen in
Class III patients.

A. Facial divergence
It is defined as an anterior or posterior inclination of the lower
face relative to the forehead. Facial divergence is determined by a
line drawn from forehead to the chin -
 Anterior divergence : The line is inclined anteriorly .
 Posterior divergence : The line is inclined posteriorly.
 Straight or orthognathic : The line is perpendicular to the floor,
no slanting.

A. Assessment of antero-posterior jaw relationship

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

6
B. Assessment of vertical jaw relationship
Normally, the distance between glabella to subnasale is equal
to the distance between the subnasale to the underside of the chin.
Reduced lower facial height is associated with deep bite while the
increased facial height is with anterior open bite.
The vertical skeletal relationship can also be assessed by
studying the angle formed between the lower border of the
mandible and the Frankfort horizontal plane. Normally, the two
planes intersect at the occipital region. In case the two planes meet
beyond the occipital region, it indicates a low angle case or
horizontal growing face. If the two planes meet anterior to the
occipital region it indicates a high angle case or a vertical growing
face.

C. Evaluation of facial proportion

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

D. Lips
Normally, the upper lip covers the entire labial surface of
upper anteriors except the incisal 2-3mm. The lower lip covers the
entire labial surface of the lower anteriors and 2-3 mm of the incisal
edges of the upper anteriors.
Lips can be classified into-
 Competent: Slight contact of lip when the musculature is
relaxed.
 Incompetent: Anatomically short lips which do not contact
when musculature is relaxed. Lip seal is achieved only be
active contraction of the orbicularis oris and mentalis muscle.
 Potentially competent: Normal lips which fail to form the lip
seal due to proclined upper incisors.
 Everted lips: Hypertropied lips with weak muscular tonicity.

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

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

7
 B. Chin
 Chin position and prominence: Prominent chin is usually
associated with Class III malocclusion while recessive chins
are common in Class II malocclusion.
 Mentolabial sulcus: It is the concavity present below the lower
lip. Deep sulcus is seen in class II cases where as shallow
sulcus is seen in bimaxillary protrusion.
 Mentalis activity: Normally, the mentalis muscle does not
show any contraction at rest. Hyperactive mentalis activity is
seen in some malocclusion such as Class II division 1 cases. It
causes puckering of the chin.

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

B. Palate
Palate is examined for the following findings-
i. Variations in palatal depth are associated with variation of
facial form. Brachycephalic patients have broad and shallow
palates where as dolicocephalic patients have deep palates.
ii. Presence of swelling indicates impacted tooth, cysts or bony
pathology.
iii. Mucosal ulceration and indentations are feature of traumatic
deep bite.
iv. Presence of clefts
v. The third rugae is usually in line with the canine. It helps to
assess maxillary anteriors proclination.

A. Gingiva

The gingiva should be examined for inflammation, recession,

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

B. Frenal attachments
The maxillary labial frenum can be thick, fibrous and have low
attachment. Such attachments prevent the two maxillary central
incisors from approximating each other leading to midline diastema.

8
 Mandibular labial frenum if has high attachment, may lead to
recession of gingiva.
Abnormal frenum attachments can be diagnosed by blanch
test( when the upper lip is stretched upwards and outwards,
blanching in the region of the interdental papilla indicates abnormal
frenum attachment).

C. Tonsils and Adenoids

The size and inflammation of tonsil should be examined.
Abnormally inflamed tonsils cause alteration in tongue and jaw
posture thereby upsetting the oro-facial balance leading to
malocclusion.

D. Dentition

i. Status- the number of teeth present, unerupted or missing.

ii.Presence of caries, restoration, malformation, hypoplasia,
wear and discoloration.
iii.Molar relation.
iv.Overjet, overbite.
v.Midline of the face and its coincidence with the dental
midline.
vi.Individual tooth irregularities like rotation, displacement,
fracture.
vii.Shape and symmetry of the upper and lower jaws.

1. Functional Examination
Normal functioning of stomatognathic system promotes normal
growth and development of oro-facial complex. Improper functioning
can result in various malocclusions. Therefore, orthodontic diagnosis
should not be restricted to static evaluation of teeth and their
supporting structures but should include examination of the functional
units of stomatognathic system.
It is important to note in the beginning whether the patient has
normal coordination and movements. If not, as in an individual with
cerebral palsy or other types of gross incoordination, normal
adaptation to the changes in tooth position produced by orthodontics
may not occur, and the equilibrium effects may lead to post-treatment
relapse.
The functional examination should include-

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

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

9
 The postural rest position should be determined with the
patient relaxed and seated upright with back unsupported. The head
is oriented by making the F_H plane parallel to the floor. Methods to
record the postural head position are-

i. Phonetic method: The patient is told to pronounce some

consonants like “M” or words like “Mississippi” repeatedly.
The mandible returns to the postural rest position 1-2 seconds
after the exercise.
ii. Command method: The patient is asked to perform selected
functions like swallowing. The mandible then returns
spontaneously to rest position.
iii. Non command method: The patient is observed as he speaks
or swallows. The patient is not aware that he is being
examined. While talking, the patient’s musculature is relaxed
and the mandible reverts to the postural rest position.

B. Evaluation of path of closure

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

Backward path of closure: Class II division 2 cases exhibit premature

incisor contact due to retroclined maxillary incisors. Thus the
mandible is guided posteriorly to establish occlusion.

Lateral path of closure: Lateral deviation of the mandible is

associated with occlusal prematurities and a narrow maxillary arch.

C. Examination of TMJ
The functional examination of TMJ should include auscultation
and palpation of the temporomandibular joint and the musculature
associated with mandibular opening. The patient is examined for the
symptoms of TMJ problems like clicking, crepitus, pain of the
masticatory muscles, limitation of jaw movement, hyper mobility
and morphological abnormalities.
The maximum mouth opening is determined by measuring the
distance between the maxillary and mandibular incisor edge with
the mouth wide open. The normal inter incisal distance is 40-45
mm.

D. Examination of oral functions

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i. Respiration
Humans exhibit three types of breathing- nasal, oral and oro-
nasaal.
There are some tests which helps to diagnose the mode of
respiration-
a. Mirror test: A double sided mirror is held between the nose
and mouth. Fogging on the nasal side of the mirror indicates
nasal breathing while fogging towards the oral side indicates
oral breathing.
b. Cotton test: A butterfly shaped piece of cotton is placed over
the upper lip below the nostrils. If the cotton flutters down it
indicates nasal breathing. It helps to determine unilateral
nasal blockage.
c. Water test: The patient is asked to fill the mouth with water
and retain it for a while. Nasal breathers do it easily while
mouth breathers feel difficult.
d. Observation: In nasal breathers, the external nares dilate
during inspiration. In mouth breathers, there is either no
change in the external nares or they may constrict during
inspiration.

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

Speech Difficulties Related to Malocclusion:

Speech Sound Problem Related

malocclusion
/s/, /z/ (sibilants) Lisp Anterior open bite,
large gap between
incisors
/t/, /d/ Difficulty in Lingual position of
(linguoalveolar production maxillary incisors
stops)
/f/, /v/ (labiodentals Distortion Skeletal Class III
fricatives)
Th, sh, ch Distortion Anterior open bite
(linguodental

11
 fricatives [voiced or
voiceless])

iii. Swallowing
In a new born, the tongue is relatively large and
protrudes between the gum pads and takes part in
establishing the lip seal. This kind of swallow is called infantile
swallow and is seen till 1.5 to 2 yrs of age. Infantile swallow is
replaced by mature swallow as the buccal teeth erupt. The
persistence of infantile swallow can be a cause of
malocclusion. The persistence of infantile swallow is indicated
by the presence of-
Protrusion of the tip of the tongue.
Contraction of perioral muscles during swallowing.
No contact at the molar region during swallowing.

iv. Lips

1. Evaluation of Facial and Dental Appearance

A systematic examination of facial and dental appearance should be done
in three steps:
1. The face in all three planes of space (macro-esthetics)
2. The smile framework (mini-esthetics)
3. The teeth (micro-esthetics)

1. Facial Proportions: Macro Esthetics

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

b. Facial Esthetics vs Facial proportion

Whether a face is considered beautiful or not is determined by
ethinc and cultural factors, a disproportionate face becomes a
psychosocial problem. Distorted and asymmetric facial
features are a major contributor to facial esthetic problems;
where as proportionate features are acceptable if not always
beautiful. So the goal of the facial examination is to detect the
facial disproportion.
i. Frontal Examination
A small degree of facial asymmetry exists in all normal
individual. This normal symmetry should be
distinguished from severe disproportion caused due to
deviation of chin or nose to one side.
Some of the measurements could be made on a
cephalometric radiograph but many could not. It is
better to make measurements clinically because soft

12
 tissue proportions as seen clinically determine facial
proportion.
The distance from the hair line to base of the nose, base
of the nose to bottom of nose and bottom of nose to
chin should be same.
Similarly, an ideal proportional face can be divide into
central, medial and lateral equal fifths. The separation of
the eyes and the width of the eyes which should be
equal, determine the central and medial fifths. The nose
and chin should be centred within the central fifth, with
width of the nose the same as or slightly wider than the
central fifth. The interpupillary distance should be equal
the width of the mouth.
Low set eyes or ears that are unusually far apart
(hypertelorism) may indicate either the presence of a
syndrome or a microform of a craniofacial anomaly. If a
syndrome is suspected, hands should be examined
because there are a number of dental digital
syndromes.

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

1) Assessment of jaw position in antero-posterior

plane of space
It is examined by placing the patient in physiologic
natural head position (FH plane is parallel to the
ground). The profile is assessed by the two
reference lines-
 line joining the forehead and the soft tissue point A.
 line joining point A and the soft tissue pogonion.
These two lines nearly form a straight line. A
straight profile whether it is anteriorly or
posteriorly diverging doesn’t indicate a problem
where as concavity or convexity does.

1) Evaluation of lip posture and incisor prominence

2) Re-evaluation of vertical facial proportions, and

evaluation of mandibular plane angle
The mandibular plane is visualized
clinically by placing a finger or mirror handle along
the lower border of the mandible. A steep
mandibular plane angle indicates long anterior
facial vertical dimension and a skeletal open bite

13
 tendency, while a flat mandibular plane angle
often correlates with short anterior facial height
and deep bite malocclusion.

2. Tooth –lip relationship: Mini Esthetics

a. Tooth-lip relationships
b. Smile Analysis
i. Amount of incisor and gingival display
ii.Transverse dimension of smile relative to upper arch
iii.The smile arc
iv.
3. Dental Appearance: Micro Esthetics
a. Tooth proportions
i. Width relationships and “Golden Proportion”
ii.Height- Width relationships
b. Gingival heights, shape and contour
c. Connectors and Embrasures
d. Embrasures: Black Triangles?
e. Tooth Shade and Color

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

1. Personal details

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

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

C. Sex

14
 The patient’s sex also helps in treatment planning. The timing of
growth related events including growth spurts, eruption of teeth and
onset of puberty are different in males and females. Psychological
reaction of males and females may be different towards the same
malocclusion. Females are more concerned about facial esthetics.

D. Address and contact number

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

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

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

1. Chief Complaint
The patient’s chief complaint should be recorded in his or her own
words. There are three logical reasons for patient concern about the
alignment and occlusion of the teeth: impaired dentofacial esthetics that
can lead to psychosocial problems; impaired function; and a desire to
improve dentofacial esthetics. It is important to establish their relative
importance to the patient and their desires. The parents’ perception of
the malocclusion should be noted.
A series of leading questions, beginning with, "Tell me what
bothers you about your face or your teeth," may be necessary to clarify
what is important to the patient. The orthodontist may or may not agree
with the patient’s assessment – the judgement comes later. But, at this
stage, it is necessary to find out what is important to the patient.
This will help in setting treatment objectives and satisfying the
patient and or parents in general.

2. Medical History
Knowledge of the patient’s general health is essential and should
be obtained prior to the examination. It is best obtained by
questionnaire.
In most of the cases, orthodontic treatment can be undertaken but
precautions should be taken prior to surgical procedures. Patients with
rheumatic fever, cardiac anomalies, epilepsy, diabetes and blood
dyscrasias may require special precautions.
The medical history should include information on drug usage. The
use of certain drugs like aspirin (prostaglandin inhibitors) or bone
resorption inhibiting agents may impede orthodontic tooth movement.
Patients who are suffering from acute, debilitating conditions such as

15
 viral fever should be allowed to recover prior to initiating orthodontic
treatment.
History of trauma should be noted. Trauma to the jaws or teeth is
often overlooked in child with other trauma, so a jaw injury may not
have been diagnosed at that time. This is significant as it affects the
future development of jaws and teeth.

3. Dental History
The patient’s dental history should include information on the age of
eruption and exfoliation of deciduous and permanent teeth, history of
extraction, decay, restorations and trauma. The past dental history will
also help in assessing the patients and parents’ attitude towards dental
health.

4. History of Habits
History of abnormal habits like finger, digit sucking, nail biting, lip
biting grinding, clenching, and mouth breathing should be taken as they
influence the development of dentoalveolar structures.

5. Pre-natal History
Pre-natal history should include information on the condition of the
mother during pregnancy and the type of delivery. Forceps deliveries
have been associated with injury to the temporomandibular joint (TMJ)
and may cause ankylosis and mandibular growth retardation. Nutrition
status and infections during pregnancy should also be noted.

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

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

8. Physical Growth evaluation

The parents should be questioned about the child’s growth status.
(e.g.: Has your child had any recent rapid growth?). Rapid growth during
the adolescent growth spurt facilitates tooth movement but growth
modification may not be possible in a child who is beyond the peak of
the growth spurt.
For children approaching puberty, questions about how rapidly the
child has grown recently, whether clothes sizes have changed, whether
there are signs of sexual maturation, and when sexual maturation
occurred in older siblings usually provide the necessary information
about where the child is on the growth curve.

16
 In orthodontic clinic, measuring the height and weight regularly and
calculation of bone age from vertebrae as seen in the cephalometric
radiograph can be helpful. Serial cephalometric radiographs offer the
most accurate way to determine whether growth has stopped or is
continuing.

9. Social and Behavioral Evaluation

It should explore – patient’s motivation for treatment, what he or
she expects as a result of treatment and how co-operative or
uncooperative the patient is.
Motivation can be external or internal. External motivation is that
supplied by pressure from another individual, like child brought for
treatment by mother; older patient by his girlfriend. Internal motivation
comes from within the individual and is based upon his or her own
assessment of the situation and desire for the treatment.
What patient expects from the treatment should be explored
carefully especially in case of patients with primarily cosmetic problems.

Clinical Examination

1. General Examination
Each patient should be regarded as a whole person rather than as a
'pair of jaws'. The examination, therefore, begins immediately the patient
enters the clinic. If possible, both parents should be present at the
examination; this affords an opportunity to observe any hereditary
characters which may be present, and also an opportunity to discuss the
medical history, diagnosis and treatment.

A. Height and weight

It gives a clue to the physical growth and maturation of the
patient. The growth of the body in general is related to the growth
of the jaws and face particularly.

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

C. Built
Sheldon classified body built into:
i. Ectomorphic : Tall and thin physique
ii. Mesomorphic : Average physique
iii. Endomorphic : Short and obese physique

1. Extra-oral Examination

A. Shape of Head

17
 The overall head shape is closely related to the bony structures
of the skull and to the shape of the underlying brain. Alterations in
head shape can be the result of unusual brain growth, but they may
also reflect a number of other factors such as premature synostosis of
cranial sutures or unusual intrauterine mechanical forces. Abnormal
planes of muscle pull, as in torticollis, can cause asymmetric skull
growth.

Five major sutures are present in the calvaria. Coronal, lambdoidal,

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

Fontanelles Sutures

Sutures and fontanelles

Dolichocephaly can occur with early closure of the sagittal suture,

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

18
 The shape of head can be evaluated based on the cephalic index
which is based on the anthropometric determination of the maximum
width and maximum length of the head.
It is given by Martin and Saller as:Cephaic index Maximum
×100
skull width =
Maxim
um skull length

• Mesocephalic : I = 76.0 -80.9

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

Skull Length is the maximum dimension of the sagittal axis

of the skull. It is measured as the distance between the glabella (the
most prominent point on the frontal bone above the root of the nose,
between the eyebrows) and the opisthocranion (the most prominent
portion of the occiput, close to the midline on the posterior rim of the
foramen magnum).
Skull width is measured between the most lateral points of the
parietal bones (eurion) on each side of the head. The measurement is
done with spreading calipers.

Measuring skull length and skull width

19
A. Shape of the face
The shape of the face is assessed by morphologic facial index
which was given by Martin and Saller(1957) as:
Facial index (I) ×100
Morphologic facial height
= Bizygomatic width

• Hypereuryprosopic : I < 78.9

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

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

Bizygomatic width is the maximal distance between the most

lateral points on the zygomatic arches (zygion), localized by palpation.

Measuring bizygomatic width and the facial

height

A. Assessment of facial symmetry

A certain degree of asymmetry between right and left sides of
the face is seen in most of the individuals. The face should be
examined in the transverse and vertical planes to determine a
greater degree of asymmetry than the normal.
Gross facial asymmetries may be seen in patients with-
• Hemifacial atropy/hypertrophy
• Congenital defects
• Unilateral condylar hyperplasia
• Unilateral Ankylosis

20
A. Facial profile
The profile is examined from the side by making the patient
view at a distant object, with the FH plane parallel to the floor. The
profile is assessed by the two reference lines-
 A line joining the forehead and the soft tissue point A (deepest
point in the curvature of upper lip)
 A line joining point A and the soft tissue pogonion (most
anterior point of the chin)
Based on the relationship between these two lines, three
types of profile exists-
 Straight : The two lines form a nearly straight line
 Convex : The two lines form an angle with the concavity
facing the tissue. It occurs in cases of prognathic maxilla or
retrognathic mandible as seen in Class II Div I.
 Concave : The two reference lines form an angle with the
convexity towards the tissue. This type of profile is seen in
Class III patients.

Convex Straight
Concave

A. Facial divergence
It is defined as an anterior or posterior inclination of the lower
face relative to the forehead. Facial divergence is determined by a
line drawn from forehead to the chin -
 Anterior divergence : The line is inclined anteriorly.
 Posterior divergence : The line is inclined posteriorly.
 Straight or orthognathic : The line is perpendicular to the floor,
no slanting.

21
 Straight Posteriorly Anteiorly
Diverging
diverging

A. Assessment of antero-posterior jaw relationship

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

B. Assessment of vertical jaw relationship

Normally, the distance between glabella to subnasale is equal
to the distance between the subnasale to the underside of the chin.
Reduced lower facial height is associated with deep bite while the
increased facial height is with anterior open bite.
The vertical skeletal relationship can also be assessed by
studying the angle formed between the lower border of the
mandible and the Frankfort horizontal plane. Normally, the two
planes intersect at the occipital region. In case the two planes meet
beyond the occipital region, it indicates a low angle case or
horizontal growing face. If the two planes meet anterior to the
occipital region it indicates a high angle case or a vertical growing
face.

22
C. Evaluation of facial proportion
A well proportioned face is divided into three equal vertical
thirds using four horizontal planes- at the level of the hair line, the
supraorbital ridge, the base of the nose and the inferior border of
chin.
Within the lower face, the upper lip occupies one third of the
distance.

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

 Competent: Slight contact of lip when the musculature is

relaxed.
 Incompetent: Anatomically short lips which do not contact
when musculature is relaxed. Lip seal is achieved only by
active contraction of the orbicularis oris and mentalis muscle.
 Potentially competent: Normal lips which fail to form the lip
seal due to proclined upper incisors.
 Everted lips: Hypertropied lips with weak muscular tonicity.

If they are of sufficient size to be together at rest then lip

closure will not place extra forces on the teeth. If the lips at rest are
apart, then muscular contraction will be required to bring them
together during swallowing and speech, and such contraction will
impose extra forces on the erupting teeth. Furthermore, some
people, whose lips do not meet at rest, maintain a conscious lip

23
closure for much of the time, again imposing muscular forces on the
teeth. The effect of these forces on the erupting teeth depends to a
large extent on the sagittal relationship of the lips.

The sagittal relationship of the lips is almost entirely

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

For example, with a skeletal Class 2 relationship the lower lip

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

It is equally possible for lip activity to produce Class 2 or Class

3 occlusal relationships on a Class I skeletal relationship by altering
the inclination of the incisor teeth during eruption.

The level at which the lips meet together in normal function is

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

The lip-line may be

low, in which case part of
the lower lip may
function behind the
upper incisors, causing
proclination. If the lower
lip functions completely
behind the upper incisors
the definition of lip-line is
not strictly applicable.
The lip-line may be high,
as is common in Class 2

24
 Division 2 occlusal relationship. This is usually brought about by the
fact that retroclination of the incisors results in the incisors not
meeting correctly, with consequent continued development of upper
and lower incisors and related alveolar bone in the vertical
dimension. The upper incisors are thus too far down in relation to
the lips, and the lip-line is high

a b c
d

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

The Ricketts‘ E-line, the reference line connecting the tip of

the nose with the soft tissue pogonion, passes about 4 mm in front
of the upper lip and 2 mm in front of the lower lip.

A. Nose
The nose, with its central position, plays a major role in facial
aesthetics and the parameters that one must consider in clinical
nasal analysis are impressive.

 Size: Normally nose is one third of the total facial height.

25
  Contour: Shape can be straight, convex or crooked.
 Nostril: Normally they are oval and bilaterally symmetrical.
Asymmetry may indicate nasal obstruction.

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

B. Chin
 Chin position and prominence: Prominent chin is usually
associated with Class III malocclusion while recessive chins
are common in Class II malocclusion.
 Mentolabial sulcus: It is the concavity present below the lower
lip. Deep sulcus is seen in class II cases where as shallow
sulcus is seen in bimaxillary protrusion.
 Mentalis activity: Normally, the mentalis muscle does not
show any contraction at rest. Hyperactive mentalis activity is
seen in some malocclusion such as Class II division 1 cases. It
causes puckering of the chin.

1. Intra-oral Examination
A. Tongue
Abnormalities of tongue can upset the muscle balance and
equilibrium leading to malocclusion because it counteracts the
action of buccinator. Short lingual frenum called tongue tie leads to
impaired tongue movement.

Presence of excessively large tongue is indicated by the

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

B. Palate
Palate is examined for the following findings-
i. Variations in palatal depth are associated with variation of
facial form. Brachycephalic patients have broad and shallow
palates where as dolicocephalic patients have deep palates.
ii. Presence of swelling indicates impacted tooth, cysts or bony
pathology.

26
 iii. Mucosal ulceration and indentations is feature of traumatic
deep bite, especially in case of Class II malocclusion.
iv. The third rugae is usually in line with the canine. It helps to
assess maxillary anteriors proclination.
v. Presence of clefts.

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

B. Frenal attachments
The maxillary labial frenum can be thick, fibrous and have low
attachment. Such attachments prevent the two maxillary central
incisors from approximating each other leading to midline diastema.
Mandibular labial frenum if with high attachment, may lead to
recession of gingiva.
Abnormal frenum attachments can be diagnosed by blanch
test (when the upper lip is stretched upwards and outwards,
blanching in the region of the interdental papilla indicates abnormal
frenum attachment).

C. Tonsils and Adenoids

The size and inflammation of tonsil should be examined.
Abnormally inflamed tonsils cause alteration in tongue and jaw
posture thereby upsetting the oro-facial balance leading to
malocclusion.

D. Dentition and dental arch

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

ii.Presence of caries, restoration, malformation, hypoplasia,

wear and discoloration.

iii.Molar relation
Molar relation is defined as the relation betweeen
maxillary and mandibular first molars. It can be of -
⇒ Class I: Mesio-buccal cusp of maxillary first molar occludes
in the buccal groove of the mandibular first molar.

27
⇒ Class II: Mesio-buccal cusp of maxillary first molar occludes
in the groove between mandibular 2nd premolar and 1st
molar.

○ Div 1: With proclined maxillary incisors.

○ Div 2: Lingually inclined maxillary central incisors with
labially tipped lateral incisors overlapping the centrals.
Lingual inclination of central and lateral incisors with
canines labially tipped can also occur.

⇒ Class III: Mesio-buccal cusp of maxillary first molar occludes

in the groove between mandibular 1st and 2nd molar.

• When there is Class II molar relation on one side, and

Class I on other side, it is called Class II subdivision.
• When there is Class III molar relation on one side and
Class I on other side, it is called Class III subdivision.
• When there is Class II molar relation on one side and
Class II on other side, it is called Class IV relation.
• When mesiobuccal cusp of maxillary first molar
occludes with the mesiobuccal cusp of mandibular
first molar, it is called end-on molar relation.
• When mesiobuccal cusp relation is between Class I
and Class III, it is called Super Class I relation.

Dewey’s modification of Angle’s Class I malocclusion-

TYPE 1:-Angle’s class I with crowded maxillary anterior teeth.

TYPE 2:- Angle’s class I with maxillary incisor in labio-version

(proclined).

TYPE 3:- Angle’s class I with maxillary incisor teeth on linguo-

version to mandibular incisor teeth (anterior in cross bite)

28
TYPE 4:- Molar and/or premolars are in bucco or linguo-
version,but incsors & canines are in normal alignment
(posterior in crossbite) .

TYPE 5:- Molars are in mesioversion due to early loss of teeth

mesial to them (Early loss of deciduous molars or second
premolar) .

Dewey’s modification of Angle’s Class III malocclusion-

TYPE 1:- Individual arches when viewed individually are in
normal alignment, but when in occlusion the anterior are in
edge to edge bite.

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

TYPE 3:- Maxillary arch is underdeveloped, in cross bite with

maxillary incisors crowded & the mandibular arch is well
developed & well aligned.

Lischer’s modification of Angle’s classification-

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

i. Incisor relation
British standards Institute Classification of incisor
relationship-

⇒ Class I : Lower incisor edges occludes with or lie

immediately below the cingulum plateau of upper central
incisors.

⇒ Class II : Lower incisor edges lie posterior to cingulum

plateau. Two subdivisions of this category are –
○ Div 1 – The upper central incisors are proclined or of
average inclination and there is an increase in
overjet.
○ Div 2 – The upper central incisors are retroclined.
Overjet is usually minimal or may be increased.

⇒ Class III : The lower incisor edges lie anterior to cingulum

plateau. The overjet may be reduced or reversed.

29
 Class I Class
III

Class II Div 1 Class II

Div 2

i. Canine relation
⇒ Class I : The mesial incline of upper canine overlaps
the distal slopes of the lower canine.
⇒ Class II : Distal slope of maxillary canine occludes or
contact the mesial slope of lower canine.
⇒ Class III : Lower canine is displaced anteriorly to the
upper canine with no overlapping of upper and lower
canine.

i. Overjet
It is defined as the horizontal overlap between the
maxillary and mandibular incisors.
⇒ Normal overjet: The incisal edges of maxillary
incisors are 2-3mm ahead of mandibular incisors.
⇒ Increased ovejet: Horizontal overlap more than
normal.
⇒ Decreased overjet: Horizontal overlap less than
normal.
⇒ No overjet (Edge to edge): The incisal edges of
maxillary and mandibular incisors are in same
vertical plane.
⇒ Reverse overjet (Cross bite): Mandibular incisors
edges are forwardly placed than the maxillary
incisors edges.

i. Overbite.
It is defined as the vertical overlap between maxillary
and mandibular incisors.
30
 ⇒ Normal overbite: The upper incisors cover the incisal
third of the lower incisors.
⇒ Increased overbite (Deep bite): Lower incisors
converage more than normal.
○ Complete deep bite: There is a contact
between the lower incisal edge and tooth or
soft tissue of the palate.
○ Incomplete deep bite: There is no contact
between the lower incisor edge and tooth or
soft tissue of the palate.
⇒ Decreased overbite: The vertical overlap of the
mandibular incisors is less than normal.
⇒ Edge to edge bite: The incisal edges of upper and
lower incisors are in contact.
⇒ No overbite (open bite): No vertical overlap.
○ Anterior open bite: No overlap of incisors.
○ Posterior open bite: No overlap of posterior
teeth.

i. Midline of the face and its coincidence with the dental

midline.
The midline of the face should coincide with the
midline of the face. Deviations can be seen in crowding,
rotation of the dental arch around the vertical axis.

ii.Individual tooth irregularities like rotation, displacement,

fracture.
Lischer classified individual tooth irregularity as-
• Buccoocclusion: Buccal placement
• Linguoocclusion: Lingual placement
• Supraocclusion: Eruption beyond the normal level
• Infraocclusion: Not erupted to the normal level
• Mesioversion: Mesial to normal position
• Distoversion: Distal to normal position
• Transversion: Transposition of two teeth
• Axiversion: Abnormal axial inclination of a tooth
• Torsiversion: Rotation of tooth around its long axis.

i. Shape and symmetry of the upper and lower jaws.

Arch can be bilaterally symmetric or asymmetric.
Asymmetry within the dental arch, but with symmetric arch
form, also can occur. It usually results either from lateral
drift of incisors or from drift of posterior teeth unilaterally.
Tansparent ruled grid placed over the upper dental arch
and oriented to the midpalatal raphe can make it easier to
see a distortion of arch form.
The arch form can be classified as (Thompson’s
Classification):

31
 Elliptical Round

U- Shaped V-
Shaped

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

It is important to note in the beginning whether the patient has

normal coordination and movements. If not, as in an individual with
cerebral palsy or other types of gross incoordination, normal
adaptation to the changes in tooth position produced by orthodontics
may not occur, and the equilibrium effects may lead to post-treatment
relapse.
The functional examination should include-

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

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

The postural rest position should be determined with the

patient relaxed and seated upright with back unsupported. The head

32
 is oriented by making the FH plane parallel to the floor. Methods to
assess postural rest position are-

i. Phonetic method: The patient is told to pronounce some

consonants like “M” or words like “Mississippi” repeatedly.
The mandible returns to the postural rest position 1-2 seconds
after the exercise.
ii. Command method: The patient is asked to perform selected
functions like swallowing. The mandible then returns
spontaneously to rest position.
iii. Non command method: The patient is observed as he speaks
or swallows. The patient is not aware that he is being
examined. While talking, the patient’s musculature is relaxed
and the mandible reverts to the postural rest position.

B. Evaluation of path of closure

The path of closure is the movement of mandible from rest
position to habitual occlusion. Abnormalities of path of closure are
seen in some form of malocclusion.

Forward path of closure: Many children and adults with a skeletal

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

Backward path of closure: Class II division 2 cases exhibit premature

incisor contact due to retroclined maxillary incisors. Thus the
mandible is guided posteriorly to establish occlusion.

Lateral path of closure: Lateral deviation of the mandible is

associated with occlusal prematurities and a narrow maxillary arch.

C. Examination of TMJ
The functional examination of TMJ should include auscultation
and palpation of the temporomandibular joint and the musculature
associated with mandibular opening. The patient is examined for the
symptoms of TMJ problems like clicking, crepitus, pain of the
masticatory muscles, limitation of jaw movement, hyper mobility
and morphological abnormalities.
The maximum mouth opening is determined by measuring the
distance between the maxillary and mandibular incisor edge with
the mouth wide open. The normal inter incisal distance is 40-45
mm.

33
D. Examination of oral functions
i. Respiration
Humans exhibit three types of breathing- nasal, oral and oro-
nasal.
There are some tests which help to diagnose the mode of
respiration-
a. Mirror test: A double sided mirror is held between the nose
and mouth. Fogging on the nasal side of the mirror indicates
nasal breathing while fogging towards the oral side indicates
oral breathing.
b. Cotton test: A butterfly shaped piece of cotton is placed over
the upper lip below the nostrils. If the cotton flutters down it
indicates nasal breathing. It helps to determine unilateral
nasal blockage.
c. Water test: The patient is asked to fill the mouth with water
and retain it for a while. Nasal breathers do it easily while
mouth breathers feel difficult.
d. Observation: In nasal breathers, the external nares dilate
during inspiration. In mouth breathers, there is either no
change in the external nares or they may constrict during
inspiration.

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

Speech Difficulties Related to Malocclusion:

Speech Sound Problem Related

malocclusion
/s/, /z/ (sibilants) Lisp Anterior open bite,
large gap between
incisors
/t/, /d/ Difficulty in Lingual position of
(linguoalveolar production maxillary incisors
stops)
/f/, /v/ (labiodentals Distortion Skeletal Class III

34
 fricatives)
Th, sh, ch Distortion Anterior open bite
(linguodental
fricatives [voiced or
voiceless])

ii. Swallowing
In a new born, the tongue is relatively large and
protrudes between the gum pads and takes part in
establishing the lip seal. This kind of swallow is called infantile
swallow and is seen till 1.5 to 2 yrs of age. Infantile swallow is
replaced by mature swallow as the buccal teeth erupt. The
persistence of infantile swallow can be a cause of
malocclusion. The persistence of infantile swallow is indicated
by the presence of-
Protrusion of tip of the tongue.
Contraction of perioral muscles during swallowing.
No contact at the molar region during swallowing.

1. Evaluation of Facial and Dental Appearance

A systematic examination of facial and dental appearance should be done
in three steps:
1. The face in all three planes of space (macro-esthetics)
2. The smile framework (mini-esthetics)
3. The teeth (micro-esthetics)

1. Facial Proportions: Macro Esthetics

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

b. Facial Esthetics vs Facial proportion

Whether a face is considered beautiful or not is
determined by ethnic and cultural factors, a disproportionate
face becomes a psychosocial problem. Distorted and
asymmetric facial features are a major contributor to facial
esthetic problems; whereas proportionate features are
acceptable if not always beautiful. So the goal of the facial
examination is to detect the facial disproportion.
i. Frontal Examination
A small degree of facial asymmetry exists in all
normal individual. This normal symmetry should be
distinguished from severe disproportion caused due to
deviation of chin or nose to one side.

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 Some of the measurements could be made on a
cephalometric radiograph but many could not. It is
better to make measurements clinically because soft
tissue proportions as seen clinically determine facial
proportion.
The distance from the hair line to base of the
nose, base of the nose to bottom of nose and bottom of
nose to chin should be same.
Similarly, an ideal proportional face can be divided
into central, medial and lateral equal fifths. The
separation of the eyes and the width of the eyes which
should be equal, determine the central and medial
fifths. The nose and chin should be centred within the
central fifth, with width of the nose the same as or
slightly wider than the central fifth. The interpupillary
distance should be equal the width of the mouth.
Low set eyes or ears that are unusually far apart
(hypertelorism) may indicate either the presence of a
syndrome or a microform of a craniofacial anomaly. If a
syndrome is suspected, hands should be examined
because there are a number of dental digital
syndromes.

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

1) Assessment of jaw position in antero-posterior

plane of space
It is examined by placing the patient in physiologic
natural head position (FH plane is parallel to the
ground). The profile is assessed by the two reference
lines-

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  line joining the forehead and the soft tissue point A.
 line joining point A and the soft tissue pogonion.
These two lines nearly form a straight line. A
straight profile whether it is anteriorly or posteriorly
diverging doesn’t indicate a problem where as
concavity or convexity does.

1) Evaluation of lip posture and incisor prominence

Detection of excessive incisor protrusion or
retrusion is important because of the effect on space
within the dental arches. If incisors protrude, they align
themselves on the arc of a larger circle as they lean
forward.
The teeth protrude excessively if – (i) the lips are
prominent and everted, and (ii). The lips are separated
at rest by more than 3-4mm.
In other words, excessive protrusion of the
incisors is revealed by prominent lips that are
separated when they are relaxed, so that the patient
must strain to bring the lips together over the
protruding teeth. For such patients, retracting the teeth
tends to improve both lip function and facial esthetics.
On the other hand, if lips are prominent but close over
the teeth without strain, the lip posture is largely
independent of tooth position. For that individual,
retracting the incisor teeth would have little effect on
lip function or prominence.
Lip posture and incisor prominence should be
evaluated by viewing the profile with the patient’s lips
relaxed. This is done by observing the distance that
each lip projects forward from a true vertical line
through the depth of the concavity at its base (soft
tissue points A and B). Lip prominence of more than 2
to 3 mm in presence of lip incompetence indicates
dentoalveolar protrusion.

2) Re-evaluation of vertical facial proportions, and

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

2. Tooth –lip relationship: Mini Esthetics

a. Tooth-lip relationships

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 It is important to evaluate the relationship of dentition
to the face. The relationship of the dental midline of each arch
to the skeletal midline of that arch should be noted (the lower
incisor midline related to the midline of the mandible and the
upper incisor midline related to the midline of the maxilla).
The vertical relationship of teeth i.e. the amount of
incisor display to the lips at rest and on smile is noted.
Finally, it is important to note whether an up-down
transverse rotation of the dentition is revealed when the
patient smiles or the lips are separated at rest. It is often
called a transverse cant of the occlusal plane or transverse
roll of the esthetic line of the dentition.

b. Smile Analysis
Facial attractiveness is defined more by the smile than
by soft tissue relationship at rest. There are mainly two types
of smile- posed or social smile; and emotional smile. The
social smile is reproducible and is the one that is presented to
the world routinely. The emotional smile varies with the
emotion being displayed. The social smile is the focus of
orthodontic diagnosis.
In smile analysis, oblique ¾th view as well as the frontal
and profile views is important. The three things need to be
considered.

i. Amount of incisor and gingival display

The elevation of the upper lip on smile should stop
at or near the gingival margin so that the entire upper
incisor is seen. Some display of gingiva is acceptable
and can be both esthetic and youthful appearing. Lip
elevation that doesn’t reach 100% display of the incisor
crown is less attractive.
It is important to remember that the vertical
relationship of the lip to the incisor will change over
time with the amount of incisor exposure decreases with
age.

ii.Transverse dimension of smile relative to upper arch

Depending upon the facial index, a wide smile
may be more attractive than a narrow one. Wide dental
arch and narrow buccal corridor width (the distance
between maxillary posterior teeth- especially premolars
and the inside of the cheek) is preferred.

iii.The smile arc

The smile arc is defined as the contour of the
incisal edges of maxillary anterior teeth relative to the
curvature of the lower lip during a social smile. For best

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 appearance, the contour of the teeth should match that
of the lower lip.
A flattened smile arc decreases the attractiveness
and makes look older.

3. Dental Appearance: Micro Esthetics

a. Tooth proportions
i. Width relationships and “Golden Proportion”
The apparent width of the maxillary anterior teeth
on smile and their actual mesio-distal width differ
because of the curvature of the dental arch. For best
appearance, the appearance, the apparent width of the
lateral incisor should be 62% of the width of the central
incisor, the apparent width of the canine should be 62%
the width of the lateral incisor, same for the premolar.
This is called “Golden Proportion”.

ii.Height- Width relationships

The width of the tooth should be 80% of its height.
If the height is insufficient, there may be several cause:
incomplete eruption in a child, loss of crown height from
attrition in older person, excessive gingival height etc.
The disproportion and its probable cause should be
noted.

b. Gingival heights, shape and contour

Generally the central incisor has the highest gingival
level, the lateral incisor is approximately 1.5mm lower and the
canine gingival margin is at the level of the central incisor.
For best appearance, the gingival shape of the maxillary
lateral incisor should be symmetrical half-oval or half-circle.
The maxillary centrals and canines should exhibit a gingival
shape that is more elliptical and oriented distally to the long
axis of the tooth. The gingival zenith (the most apical point of
the gingival tissue) should be located distal to the longitudinal
axis of the maxillary centrals and canines, while the gingival
zenith of the maxillary laterals should coincide with their
longitudinal axis.

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c. Connectors and Embrasures
The connector (also referred to as the interdental
contact area) is where adjacent teeth appear to touch, and
may extend apically or occlusally from the actual contact
point. In other words, the actual contact point is very small
area and the connector includes the contact point and the
area above and below that are so close together they look as
if they are touching.
The normal connector height is greatest between the
central incisors and diminishes from the centrals to the
posterior teeth. The embrasures (triangular spaces incisal and
gingival to the contact area) are larger in size than the
connectors and the gingival embrasures are filled with
interdental papillae.

d. Embrasures: Black Triangles?

Short interdenal papilla leave an open gingival
embrasure above the connectors and these “black triangles”
can detract significantly from the appearance of the teeth on
smile.
In adult, black triangles are formed from loss of gingival
tissue related to periodontal disease. But when crowded and
rotated maxillary incisors are corrected orthodontically in
adults, the connector moves incisally and black triangles may
appear. So, both actual and potential black triangles should be
noted during the orthodontic examination and the patient
should be prepared for reshaping of the teeth to minimize this
esthetic problem.

e. Tooth Shade and Color

The teeth appear lighter and brighter at a younger age,
darker and dull as age progresses. A normal progression of

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

References:
• Contemporary Orthodontics,, Proffit, Fields, Sarver, FourthEdition
• Orthodontics: Principles and practice; Graber, Vananrsdall, Vig,
Fourth Edition
• Textbook of Orthodontics, Basic Principles and Practices, Sridhar
Premkumar, 4th
edition
• Textbook of Orthodontics : Gurkeerat Singh, 2nd Edition
• Orthodontics, The Art and Science: S.I. Bhalajhi , 3rd Edition

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