Diagnostic aids in orthodontics

SUPERVISED BYProf. Dr. Md. Zakir Hossain. Head of dept, of Orthodontics. Dhaka Dental College and Hospital.

presented by> Dr.Suraiya islam dina. > Dr.Lubna akter. > Dr.Sharmin sultana.

Extra oral examination:

1. Shape of head. 2. Shape of face. 3. Examination of facial profile. 4. Facial divergence. 5. Facial symmetry. 6. Transverse facial proportion. 7. Vertical facial proportion 8. Re evaluation of vertical facial proportion and evaluation of mandibular plane angle. 9. Assesment of skeletal pattern. 10. Nasolabial angle. 11. Mento labial sulcus. 12. Examination of lip. 13. Examination of nose. 14. Examination of chin. 15. Examination of T.M.J. 16. Evaluation of path of closure. 17. Examination of breathing pattern. 18. Examination of swallowing or deglutition pattern

Introduction:
The most important part of orthodontic management is the patient assessment. If it is decided that extractions are needed and since the process is irreversible they must be carefully considered in treatment planning process. Otherwise orthodontic treatment can produce adverse result and it is essential that full examination of skeletal form,soft tissue relationship and occlusal features are performed prior to undertaking treatment. Assessment should be carried out in a logical order.

Extra oral examination:

1. SHAPE OF HEAD: To see the shape of head patient should be sitting upright on a chair,not reclining . Examiner should stand behind the patient.
Shape of head can be classified as: Dolicocephalic Brachycephalic Mesocephalic
Cephalic Index:

It is ratio of the maximum width to the maximum length of a head or skull. Cephalic index is calculated by following ways:If the head is 150 mm in width and 200 mm in length then the cephalic index is 150/200 X 100 = 75.0

A. Dolichocephalic - When cephalic index is between 70 to 74.9 it is dolichocephalic. The patient with dolichocephalic head had have a tendency for class II malocclusion.

B. Brachycephalic When cephalic index is between 80 to 84.9 it is brachycephalic. They have tendency for class III type of malocclusion and a prognathic mandible or a bi maxillary protrusion.

C. Mesocephalic - When cephalic index is between 75 to 79.9 it is mesocephalic.

There are many combination of dolichocephalism and brachycephalism head form.some authors have used -hyperdolichocephalic,hyperbrachycephalic,and ultrabrachycephalic head forms. >Less than 70-hyperdolichocephalic. >Between 85 to 89.9 hyperbrachycephalic >More then 90 Ultrabrachycephalic

2. SHAPE OF FACE: According to Classification of Leon Williams , Face is classified in to 3 types: 1.Square 2.Tapering 3.Round
To see the shape of face examiner should stand in front of the patient. It is measured by imaging two lines, one on either side of face running

about 2.5 cm of the tragus of ear, and through the angle of the jaw. If these lines are I. Almost parallel the type is square face. II. Converge towards the chin the type is tapering face. III. Diverge at the chin it is round face.

When the line is almost parallel the type of face is square.

Fig: square face

When the line diverge at the chin ,then this type of face is rounded.They have tendency for class iii malocclusion and a prognathic mandible or a bi-maxillary protrusion.

Fig: round face

When the line converge towards the chin,then this type of face is tappering. They have tendency for class ii malocclusion and this features are characterised by caucasian.

Fig:tappering face

3. EXAMINATION OF FACIAL PROFILE:

This can be done by sitting upright or standing but not reclining in a dental chair and examiner should stand on side of the patient and patients floor of the mouth should be parallel to the floor. It is measured by a line drawn from the 3 points nasal bridge, base of the upper lip and chin. The relationship between two lines one drawn from the bridge of the nose to the base of the upper lip and second one extending form that point downward to the chin. These line segment should form a nearly straight line. An angle between them indicate either profile convexity or concavity

fig: A-convex profile,B-straight profile,C-concave profile.

> Straight profile: in normal occlusion we can see straight profile.

Fig:straight profile

> Convex profile: Convex profile associated with maxillary protrusion and may be just posterior divergence profile when the chin is recessive. Convex profile are associated with skeletal class II malocclusion.

Fig: convex profile

> Concave profile:

A concave profile associated with mandible protrusion or retrognathic maxilla or both. In lateral view a line makes an obtuse angle at base of upper lip outside and acute angle towards face. It is associated with class III malocclusion.

Fig:concave frofile

Bi-maxillary protrusion: A significant variation of the profile exist in which protrusion of the upper and lower dentition and there by of mid face , upper and lower lips. The chin may be normal or retrusive.

Fig: bi-maxillary protrusion

4. FACIAL DIVERGENCE:

The facial angle formed by a line drawn from two point, nasal bridge to chin and Frankfurt horizontal line formed an angle and it is used to define the facial divergence.it can be orthognathic , anterior divergent and posterior divergent. a. Orthognathic face: The facial angle is approximately 90 degree. b. Posterior divergent face: The facial angle is less than 90 degree. It is associated with class ii malocclusion cases. c. Anterior divergent face: The facial angle is more than 90 degree. It is associated with class iii malocclusion cases.

fig: a-orthognathic face, b-posterior divergent, c-anterior divergent

5.FACIAL SYMMETRY: It is examined both in rest position of the mandible and in occlusion. Midline of nose , lips , chin , face should coincident. The important point to be examine are symmetry of the structures of the right and left side of the face. Asymmetry that are gross and detected easily should be recorded. It can occur as a result of i. Congenital defect. ii. Hemi facial atrophy or hypertrophy. iii. Unilateral condylar ankylosis, hyperplasia. iv. Muscular dystrophy. b v. Cerebral palsy asymmetry of face can cause > increase anterior face height. > distortion of facial proportion and mandibular form. > excessive eruption of posterior teeth. > narrowing of the maxillary arch. > anterior open bite.

Fig: a-symmetrical face,

Fig: asymmetrical face,

Fig: asymmetrical face,due to dystrophy of masseter muscle.

6.TRANSVERSE FACIAL PROPORTION: Transverse facial proportion also help to determine the facial symmetry.In the frontal view face is divided into five equal segment by vertical lines. The ideal measurements are--i.The mid segment is formed between two vertical planes passing at the inner canthus of eyes.In a well balanced face these planes should pass through the base of the ala of the nose. ii.The second segment is formed on either side between the plane passing at the inner canthus of the eye and the plane passing through the outer canthus of the eyes.The outer plane usally should be co_incident with the gonial angle. iii. The outer 2/5th segment essentially represent ears and their widths.the width of the mouth normally should be equal to the interpupillary distance.

Fig: transverse facial proportion

7.VERTICAL FACIAL PROPORTION IN FRONT PROFILE:

In vertical plane,the face can be divided into three equal partsfrom the hairline to supraorbital margin, supraorbital margin to base of the nose,and base of the nose to chin should be equal.The common aberration in facial height as viewed from front is an increase or decrease. The proportion of facial height can be calculated as follows---> Upper facial height(UFH)-------------------mms > Lower facial height(LFH)--------------------mms >Total facial height------UFH+LFH=---------mms

fig: vertical facial proportion

> Upper facial height: Ideal proportion of UFH is 45% of the total facial height.It is clinically
measured from the bridge of the nose to the lower border of the nose. The percentage of upper facial height to total facial height can be calculated as follows------UFH/TFH X 100--------------%

> Lower facial height: Ideal proportion of LFH is 55% of the total facial height.It is clinically measured from the lower border of nose to the lower of chin.From an orthodontic point of view we are concerned mainly about the LFH.Because we can bring about some changes only in the LFH. The percentage of lower facial height can be calculated as follows------LFH/TFHX100-----------%

fig: facial height

Lower facial height increase in---i. Skeletal open bite cases. ii. In long face syndrome.
Lower facial height decrease in------i.Growing children. ii.Skeletal deep bite cases. iii.Class ii division 2 cases. Importence of LFH in treatment: Anterior bite plane is indicated for the correction of deep bite in cases where the LFH is decreased,and anterior bite plane is contraindicated incase where the LFH is increased.

Fig: decreas lower facial height in skeletal deep bite cases

8.RE EVALUATION OF VERTICAL FACIAL PROPORTION,AND EVALUATION OF MANDIBULAR PLANE ANGLE:

Vertical Facial proportions can be observed during the full face examination,but sometimes can be seen more clearly in profile.in the clinical examination,the inclination of the mandibular plane to the true horizontal should be noted. The mandibular plane is visualized readily by placing a finger or dental mirror handle along the lower border.This is important because _ 1. A steep mandibular plane angle usally indicates long anterior facial vertical dimensions and a skeletal open bite tendency. 2. A flat mandibular plane angle often correlates with short anterior facial height and deep bite malocclusion.

Fig: mandibular plane angle is visualised by placing a dental mirror,for this patient the mandibular plane angle is normal.

a
9.ASSESMENT OF SKELETAL PATTERN:

Anteroposterior assessment: Clinically,two finger test can be used to examine the anteroposterior relationship.The index finger is placed at a point corresponding to the point A soft tissue area and middle finger is placed at a point corresponding to point B soft tissue. > In case of class I skeletal cases,the index finger is slightly ahead of the middle finger. > In case of class ii skeletal cases, index finger is considerably ahead of the middle finger. > In case of class iii skeletal cases,the middle finger is ahead of the index finger.

10.NASO-LABIAL ANGLE: It is the angle formed by the tangent drawn along the lower border of the nose and upper lip with the tip of upper lip i.e upper lip anterior.Range of the angle is 85-105. > Decreased naso-labial angle is seen in patient having proclination of anterior teeth or a prognathic maxilla. > increased naso-labial angle is seen in patient with retrognathic maxilla or retroclined maxillary incisors. > If the angle is open (more than 105)retraction of anterior teeth orthodontically or surgically should be avoided in treatment planning. a b c

Fig: normal naso labial angle

Fig: decrease naso labial angle

fig: increase naso labial angle

11.MENTOLABIAL SULCUS: It is the groove or depression between chin button and lower lip. 1.Normal-in class-I case. 2.Deep-in Angles class II division 2 malocclusion. 3.Shallow-in bimaxillary protrusion. > In class II division 2 situation--*deep labio-mental sulcus is the outcome of excessive activity of the mentalis muscle *chin become more prominent and *there is a deep bite with retroclined maxillary incisors.

a
fig:Normal mento labial sulcus

b
fig:deep mento labial sulcus

c
fig:shallow mento labial sulcus

12. EXAMINATION OF LIP: lips can be classified into 4 types-a.Competent lip. b.Incompetent lip. c.Potentially competent lip. d.Everted lip.

Fig: a-competent lip, b-incompetent lip, c-everted lip.

> Competent lip: lips are said to be competent when they can maintain a lips seal with the muscles of facial expression in relaxed position and mandible in resting posture.with competent lip morphology,the lips are habitually in contact with each other at rest.
>Incompetent lip: They are morphologically short lips,which do not form a lip seal in a relaxed state.the lip seal can only be achieved by active contraction of the perioral and mentalis muscles.

>Potentially competent lip: sometimes lips are of adequate size but fail to function properly due to the presence of malocclusion.EX-in class ii division I malocclusion cases.lower lip forms the oral seal with the lingual surface of maxillary incisors due to the proclination of the maxillary anterior teeth.
>Everted lip: lips are often full and everted.they are commonly associated with proclination of both upper and lower labial segment.EXbi-maxillary protrusion cases.

Lip line: Normally the upper lip covers the entire labial surface of upper anterior teeth except the incisal 2-3 mm.The lower lip covers the entire labial surface of the lower anterior teeth and 2-3 mm of the incisal edge of the upper anterior teeth. >If upper lips covers the entire labial surface of upper anterior teeth,including the incisal 2-3 mm then upper lip line is low. >If upper lip does not covers the entire labial surface,more exposure of upper anterior teeth than the normal lip line,then upper lip line is high.and it is called short upper lip. a b c

Fig: normal upper lip line

fig: upper lip line low

Fig: upper lip line high

>If lower lip does not covers the 2-3mm of the incisal edge of the upper anterior teeth, then the lower lip line is low. >If lower lip covers the upper incisal edge of anterior teeth more than 2-3mm,then the lower lip line is high.

fig: strap like lower lip line

Strap like lower lip: In certain individuals,the lips especially the lower lip retracts excessively during expressive behaviors.This may affect the position of anterior teeth.If the active lower lip line is low,i.e.not controlling the upper incisors and retract excessively in expressive behaviors,it may affect the developing mandibular alveolus so that anterior segment of mandibular alveolar process grows at a retruded position on its base with protruded chin.The lower incisors may also be retroclined.Firmly retracting lower lip with low lip line associated with class ii division I incisor relationship. When the lower lip line is high and of firmly retracting type,it may affect the upper incisors.This type of morphology and behavior may produce either a class ii division 2 or class ii division 1 incisor relationship.

13. EXAMINATION OF NOSE: *It plays an important role in the appearance or aesthetics of the patient. *shape and width of the nostrils is useful in assessing the breathing pattern of the patient. a.Shape of the nose: it can be-i.straight nasal bridge. ii.convex nasal bridge iii. crooked nose due to previous injury.

Fig:straight nasal bridge

fig: convex nasal bridge

Fig: crooked nasal bridge

b.Size of the nose:

The length of the nose should be about onethird of the total facial height.i.e.from hairline to gnathion. In normal cases,the relationship between vertical and horizontal length of the nose is 2:1

fig: normal size of the nose

fig:small size of the nose

fig:large size of the nose

c.Shape and width of the nostrils: *Nostrils are oval in shape and are bilaterally symmetrical. *The width of the nostrils is approximately 70% of length of the nose.
a b c

Fig: normal (oval and bi laterally symmetrical)

fig: wide nostril

Fig:asymmetrical nostril

14.EXAMINATION OF CHIN: Chin position and prominence: chin can be normal,recessive and prominent. *Prominent chin is usually associated with class III malocclusion. *Recessive chins are common in class II malocclusion.
a b c

Fig: normal

Fig: prominent

Fig: recessive

15.EXAMNATION OF TEMPORO-MANDIBULAR JOINT:

*It is done by-auscultation and palpation of the T.M.J. and musculature. *Mandibular opening should be routinely examined. >The patient is examined for symptoms of T.M.J. problems,such asa. clicking b. crepitus c. pain of the masticatory muscles d. limitation of jaw movement e. hypermobility and f. morphological abnormalities.

a. clicking of T.M.J.: It can be heard with special stethoscope with double drum heads for simultaneous review of both the joint. During auscultation,the patient is asked to open the mouth gently.The timing of click and the intensity is recorded.

b. crepitus: It is the continuous noise,heard during jaw opening and closing movement of joint.
c. Pain & tenderness: It is examined byThe pulp of index finger should be placed in the immediate preauricular area,gently applying pressure on the lateral head of the condyle,while the jaw is closed. . The level of pain & discomfort on each side should be assessed & compared.

Maximum mouth opening: It is determined by-measuring the distance between the maxillary & mandibular incisal edges with the mouth wide open. The normal inter-incisal distance is 40-45mm.

In case of T.M.J.dysfunction cases,inter-incisal distance increases,during the initial stages due to hypermobility of the T.M.J.Eventually the mouth opening is limited,there by the inter-incisal distance decreases.

Fig: maximum mouth opening

16.EVALUATION OF PATH OF CLOSURE:

The path of closure is the movement of the mandible from rest position to habitual occlusion.
*How to examine path of closure: 1.Place 4 points along the midline of the face,one each on the bridge of the nose,tip of the nose,philtrum or on the chin.Ask the patient to open the mouth widely & close it slowly.Observe carefully for any deviation of the point on the chin either while opening or closing of the mouth. 2.Ask the patient to relax,guide the mandible into centric occlusion & look for any cuspal interferences.

Fig: Point to be marked

fig: normal path of closure

fig: deviation path of closure

Condition which lead to altered path of closure:

Forward path of closure:

A forward path of closure is seen in cases of Angels class III malocclusion.

Backward path of closure:

Class II division 2 cases,exhibit premature incisor contact due to retroclined maxillary incisors. Lateral path of closure: Lateral deviation of the mandible to the left or the right side is associated with occlusal prematurities & a narrow maxillary arch.It is found in unilateral crossbite. Lingually or palatally erupting incisor lead to altered path of closure.

17. EXAMINATION OF BREATHING PATTERN:

Breathing can be of three types___________ i.Nasal breathing. ii.Mouth breathing. iii.Oro-nasal breathing/combination. i. Nasal breathing: when a person breathes normally through the nose. ii. Oro nasal breathing:when a person breathes partly through the nose and partly through the mouth. iii.Mouth breathing: altered mode of breathing through mouth is an adaptation to obstruction in nasal passages.the obstruction may be temporary and recurrent.while more often it is partial than complete.The airway resistence may be enough to force the subject breath through mouth. Causes of obstruction to nasal passage are----> Allergenic rhinitis. > Enlarged tonsils or adenoids. > Deviated nasal septum. > Nasal polyps. > Enlarged nasal turbinates. A majority of the mouth breather patients develop class ii malocclusion.some patients may develop class iii occlusion due to anterior displacement of the tongue to tonsillar hypertrophy.

Clinical feature of mouth breathing: altered respiratory pattern,such as breathing through the mouth rather than the nose,could change the posture of the head,jaw,and tongue.this in turn could alter the equilibrium of pressures on the jaws and teeth and affect both jaw growth and tooth position. The clinical features often include---------1. Excessive lower anterior face height.(classic adenoid facies). 2. Incompetent lip posture. 3. Excessive appearance of maxillary anterior teeth.GUMMY SMILE. 4. A nose that appears to be flattened,nostrils that are small and poorly developed. 5. Steep mandibular plane. 6. Posterior crossbite. 7. Open mouth posture. 8. A short upper lip and a fuller lower lip. 9. A narrow V-shaped upper jaw with a high narrow palatal vault. 1o. A class ii skeletal relationship. 11.Anterior open bite and increasing overjet. 12.gingivitis of upper anterior teeth.

Clinical feature of mouth breathing

b

fig: a classic adenoid facies characterised by mouth breathing,associated with incompetent lip,short upper lip.procline maxillary teeth.

fig: patient with mouth breathing habit exibiting upper anterior marginal gingivitis

Clinical feature of mouth breathing

fig:patient with mouth breathing habit,tendency for crossbite.

Method of examination of mouth breathing pattern:

Water holding test: patient is to hold water in his mouth.Inability to

keep the mouth closed for >2 minute confirms nasal obstructions and therefore mouth breathing habit.
Mirror condensation test: A two surface mirror is placed in between

the nose and mouth if the upper surface condenses,then breathing is through the nose,but if the condensation occurs on the lower surface then the breathing is through the mouth.
Cotton wisp test: A small wisp of cotton is placed below the nostrils

and look for the movement of the cotton.if no movement of cotton then patient is mouth breather.if cotton moves then breathing through the nose.

18.DEGLUTITION OR SWALLOWING PATTERN: Normally tongue rests at the occlusal level within the arches,dorsum touching the palate & the tip of the tongue rests against the lingual surface of the anteriors. >differential diagnosis of tongue posture: the tongue can havea. abnormal posture b. abnormal function a. abnormal posture 1.Retracted posture is seen in less than 10% of the children.It is frequently present in edentulous patient. 2.Protracted tongue posture-endogenous-this is a retention of the infantile postural pattern. 3.protracted tongue posture-acquired:this is due to tonsillitis or pharyngitis. b.Abnormal function: Abnormal function of lips & facial muscle is seen in the cases of tongue thrust swallowing.

>Differential diagnosis of swallowing pattern:

a. Normal infantile swallowing pattern: seen only prior to the eruption of the buccal teeth in the primary dentition.Here tongue lies between gum pads and the mandible is stabilized by strong contraction of the facial muscles. b. Normal mature swallowing pattern: it is characterised by1.Maxillary and mandibular teeth in contact. 2.Mandible stabilized by muscle of mastication. 3.The tip of tongue is held against the palate above and behind the incisors

c.Simple tongue thrust swallow(teeth together swallow): This is characterized by1.contraction of the lips,mentalis muscle & mandibular elevators. 2.open bite is well defined.it has a definite beginning & ending. 3.usually seen in nasal breathers with a history of digital sucking or thumb sucking. 4.good occlusion of the posterior teeth is present. d.Complex tongue thrust swallow:(teeth apart swallow) This is characterized by1.strong contraction of lip,facial & mentalis muscle are present in the absence of contraction of mandibular elevators. 2.open bite is more diffused & difficult to define. 3.poor inter-cuspation & instability of occlusion is present. 4.patients are likely to be mouth breathers.frequently giving history of chronic naso-respiratory disease or allergies.

e. Retained infantile swallowing: it is defined as predominent persistence of the infantile swallowing reflex even after the eruption of the permanent teeth.This is characterised by---1. Very strong and total contraction of lips and the facial musculature. 2. Tongue thrust violently between the teeth in the front and laterally on both sides.
3. Patients will have expressionless face and give massive effort of

stabilizing the mandible during the swallowing. 4. Patients have difficulty in mastication due to the presence of poor occlusal stability. 5. The retained infantile swallowing behaviour is a rare occurrence.

Methods of examinations of swallowing pattern: 1.observe the position of the tongue while the mandible is in its postural rest position. >In normal swallowing pattern,the mandible rises as the teeth are brought together & the lips touch lightly without any contraction of facial musculature. 2.place fingers over the temporalis & masseter,give a little water to the patient.ask him to swallow. >Normal swallowing pattern-contraction of the muscles can be felt. >Tongue thrust swallowing-no contraction or mild contraction can be felt.

Fig:examination of tongue during swallowing

3.retract the lower lip using a tongue depressor or a mouth mirror & ask the patient to swallow. >Normal swallowing pattern-the patient can complete the act of swallowing without the lip support. >Tongue thrust swallowers-patient can not complete the act of swallowing,because the mandibular stabilization of such patients which takes place by the contraction of mentalis muscle is inhibited by the depression of the lower lip.

Fig: examination of tongue during swallowing

4.other indicators of the presence of tongue thrusting type of swallowing are: a.incompetent lips b.incomplete over-bite c.lisping d.circumoral muscle contraction.

REFERENCE BOOK:
1.CONTEMPORARY ORTHODONTIC 4TH EDITION BY WILLIAM R PROFFIT. 2.OM.P.KHARBANDA-1ST EDITION. 3.M.S.RANI-3RD EDITION. 4.THE ART AND SCIENCE OF ORTHODONTICS BY-BHALAJI. 5.CLINICAL DENTAL PROSTHODONTICS BY-FENN. 6.ESSENTIAL OF ORTHODONTICS BY-MD.EMADUL HAQUE.

THE END

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