Case history

CASE HISTORYCASE HISTORY
www.indiandentalacademy.com

Introduction
Case history is the compilation of information
gathered from patient, and parent/guardian to
aid in overall diagnosis of the case.
It is the first step in the assessment of an
orthodontic patient because orthodontic
diagnosis requires a broad overview of the
patient’s situation. A thorough case history
assures that other significant problems are
not overlooked.

Introduction
It helps us understand the development of
malocclusion by which we can eliminate the
causative factors at the earliest.
The prognosis will be more favourable as
compared to a purely symptomatic approach.

Personal Details
Name
Contact Address
Date of birth & Age
Sex
Class / School / College
Father’s Name & Occupation
Ethnic Origin
Diet

Name
The case sheet always begins with the patient
introduction.
Communication and identification
Friendly Patient – Doctor relationship.
Knowing and remembering patient name
makes patient more comfortable.
A young child may be addressed by a pet
name, if any, to aid in reducing the child
apprehensions about the dentist.

Contact Address
Correspondence and communication.
Patient coming from a far away place may
need a different appliance as he may not be
able to visit the dentist very frequently.
Intimate the patient about the scheduled
appointments and changes in the
appointments.

Date
It records the time the patient reported and can
be referred back to during follow ups.

Date of Birth & Age
Functional appliances are best given in an
adolescent and surgical treatment should be
planned only after the cessation of growth.
Likewise, what may appear, as malocclusion may
be normal for that age, as in ugly duckling stage.
It helps us calculate the chronological age of the
child and compare it with dental age.
It helps in growth prediction.
Treatment modalities can be planned keeping
the patient’s age in mind.
Example: -

Date of Birth & Age
Just before birth
1 year after birth
Mixed dentition stage
- Boys 8-11 years
- Girls 7-9 years
Prepubertal stage
- Boys 14-16 years
- Girls 11-13 years
Growth Spurts

Date of Birth & Age
During growth spurts, arch expansion and rapid
skeletal expansion can be undertaken.
Tooth movement can be achieved rapidly during
growth spurts.

Sex
The timing of growth spurts is different for males and
females.
Females precede males in the onset of growth spurts,
puberty and termination of growth.
The direction of facial growth is similar for both sexes, with a
tendency towards a more horizontal growth pattern in
females .
Females are likely to be more concerned about esthetics
while seeking treatment.
Angle 1993 No. 1, 47 - 56: Sexual dimorphism in normal
craniofacial growth Weber J.S. Ursi, Carroll-Ann Trotman, James
A. McNamara Jr., Rolf G

Class / School / College
These questions open up conversation.
It establishes an effective level of communication at the
child's IQ level.
Progress of the child in school should also be found
out. A slow progress may reveal learning disability in
the child. Such children have short attention spans,
thus needing modified approach. They should not
receive too detailed information at a stretch. Fixed
treatment is more preferable than a removable
appliance in such cases.

Father’s Name & Occupation
It helps us know the social economic
background of the patient and whether they can
afford expensive fixed treatment modalities.

Ethnic Origin
Class I bimaxillary protrusion is commonly
seen in natives of Kerala.
SNA & SNB are increased in Negro.
Racial differences bring variations in growth rate and onset of maturation indicators. Also, certain
races show certain peculiar malocclusion.
Example: -

Diet
Malnutrition causes delay in growth
Non-Vegetarians may need an extra word of
caution when treated with fixed appliances
Fibrous diet stimulates the muscles to work
more and increases the load of function on the
teeth. This produces less caries, greater mean
arch width, increases occlusion wear of teeth

Diet
Highly refined soft modern diet leads to lack of
function of muscles thus resulting in
- Contraction of dental arches,
- Insufficient occlusion wear,
- Absence of the kind of occlusal adjustment
normally seen in maturing dentition.
Children consuming more soft drinks containing
phosphoric acid poses a hazard during fixed
orthodontic treatment as it results in increased
demineralisation.
J. Michael Steffen.Angle Orthodontist,
1996 No. 6, 449 - 456: The effects of soft drinks on etched and
sealed enamel

Chief Complaints
Chief complaint should be recorded in patient’s own
words.
Improves medico legal documentation
Why the patient is seeking treatment?
Reasons for patients concern about teeth
alignment.
Importance of dental aesthetics to patient
Why the patient has come now as opposed to
some other time?
Patients expectation as treatment results and how
realistic these expectations are?

Factors for Patient Motivation
External (Parents, Spouse etc)
Internal
External motivation increased risk for
treatment, poor cooperation during treatment,
decreased treatment tolerance,increased
chances of being unhappy with treatment
results.

General History
Family History
History Of Orthodontic Treatment
Prenatal History
Natal History
Postnatal History
Habits
Medical history

Family History
Family environment
Position of child ,status of child in family and parental
attitudes can influence the child's behavior.only child
usually have over indulgent parents leading to difficulty
in controlling the child during treatment.
Internal family conflicts also affect the child's behavior.
Children from a broken home are a poor risk. The
dentists should first analyse the psychological state of
his mind.

Marriage
Consanguineous / Non Consanguineous
Consanguinity has been known to increase the chance
of the husband and wife carrying an identical gene
derived from a common ancestor. Children of such a
marriage, therefore, are at greater risk of being
homozygous for a harmful gene and consequently
suffer autosomal recessive genetic disorders.
Indian Journal of Community Medicine Vol. 29, No. 1 (2004-01 -
2004-03) Prevalence Of Consanguineous Marriages In A Rural
Community And Its effect On Pregnancy Outcome - A Nath, C.
Patil, V.A. Naik

Parents General & Dental Conditions
Various genetically transferred dentofacial
deformities and communicable diseases.
Example: -
Undiagnosed diabetes mellitus
Rheumatic heart diseases
Hemophilia
Tuberculosis
A parent’s dental condition is a good indicator of the
child’s susceptibility to periodontal disease / caries.

Family Malocclusion History
Examining parents and older siblings helps gain
information regarding treatment needs of the child.
According to Niswander, frequency of malocclusion is
decreased among siblings of index cases with normal
occlusion whereas the siblings of index cases with
malocclusion tend to have the same type of
malocclusion more often.
The genetic basis for the resemblance is mainly
polygenic..
Mills, L. F., Niswander, J. D., Mazaheri, M., Brunelle, J. A.. 1968:
Minor Oral and Facial Defects in Relatives of Oral Cleft Patients.
The Angle Orthodontist: Vol. 38, No. 3, pp. 199–204

Family Malocclusion History
Correlation coefficient for a parent and child in context
to skeletal dimension is 0.5 and for dental
characteristics it varies between 0.5 to 0.15 for each
feature. When these correlations are used to predict
facial growth, errors are considerably reduced.
However the current morphology of the patient is the
primary source of information about the future growth.
Orthodontics Current Principles and Techniques
Thomas Graber

History Of Orthodontic Treatment
Type of appliance: Fixed or Removable
Duration of treatment
Reasons for discontinuing,
- Unhappy with the progress
- Did not maintain follow ups
- Financial reasons
This information helps us plan the treatment to enable
patient satisfaction.
In cases of relapse the etiology of the problem should
be found out and the case be treated accordingly.

Concern About Treatment
Concerned parents help the orthodontist in
child cooperation and in bringing successful
outcome of treatment
Indifferent parents do not contribute much to
the treatment. The treatment results depends
on the child cooperation only
Opposed parents – such children may
discontinue the treatment mid way,or may
turn uncooperative

Prenatal History
Fetal damage due to any cause may lead to,
Maldevelopment of first and second brachial
arches
Micro gnathisn
Oligodontia
Anodontia

Narrator
It is important to record, from whom the information is
being gathered.

History Of Infectious Disease Of
Mother During Pregnancy
Bacterial infections
Osteomyelitis alters bone response to force.
Congenital syphilis
 Peg laterals,
 Mulberry molars,
 Enamel hypoplasia,
 Under developed and narrowed maxilla,
 Depressed nasal bridge etc.,
Tuberculosis leads to delayed eruption of teeth and
generalized stunted growth.

Viral Infections
Infections like mumps and maternal rubella
affect the oral structures. They cause,
Dental hypoplasia
Delayed eruption of teeth
Extensive caries
Rubella infection in the first trimester of
pregnancy may lead to cleft lip and palate.

Viral Infections
Cytomegalovirus infection may cause
microcephaly, hydrocephaly, microphtalmia.
Fungal infections like toxoplasmosis may result
in similar deformities.

Health during Pregnancy
Malnutrition and vitamin deficiency affects the
fetal growth and development deleteriously.

Type of Delivery
Forceps delivery may harm the area around TMJ
resulting in ankylosis of TMJ. Affected child had
severely impeded mandibular growth causing the
patient develop a vogelgesicht (poor chin grower)

Type of Delivery
Intra uterine moulding: -
Hypoplasia of mandible can occur due to intra uterine
pressure .Decreased volume of amniotic fluid may
result in fetus head being flexed against the chest
preventing normal mandibular growth.
Intra-uterine pressure during pregnancy and significant
pressure in the birth canal during parturition can have
observable effects on the bones of the fetal skull.
Moulding of the parietal and facial bones from these
pressures can result in facial asymmetry. These effects
are generally transient with rapid restoration of the
normal relationships of the skull within a few weeks to
several months

Type of Delivery
Fetal position may result in asymmetry. A knee or a leg
may press against the face in such a manner as to
promote asymmetry of facial growth or retardation of
mandibular development.
Difficult breech delivery may result in fracture of
mandibular condyle leading to facial asymmetry and
deviation of mandible to affected side
Boder, E. A Common Form of Facial Asymmetry in the Newborn Infant: Its
Etiology and orthodontic Significance. Am J Orthod 1953; 39:895.

Drugs Taken During Pregnancy
Agents that affect the developing embryo and
can produce defects if given at a critical time are
called teratogens.

Teratogens Effects
Aminopterin Anencephaly
Aspirin Cleft lip and palate
Dilatin Cleft lip and palate
6-Mercaptopurine Cleft palate
Iso-tretinion Retinoic acid syndrome
Thalidomide Mandibulo facial
syndrome
Valium Cleft lip and palate

In addition to these drugs,
cigarette smoking ->cleft lip and palate
Irradiation-> microcephaly
Alcohol-> fetal alcohol syndrome

Natal History
Rh compatibility
This leads to a condition called as
erythroblastosis fetalis.The sensitized
antibodies of the mother cross the placental
barrier and a immune reaction takes place.It
effects the dentition causing a hump on tooth
and causes a peculiar blue green discoloration

Premature Baby
Altered palatal morphology due to oral
intubations
No delay in dental development and eruption
Malocclusions from possible alterations of
palatal morphology such as asymmetry and
high arched palates
Paulsson I, Bondemark I, Soderfeldt b.Related articles,
A systematic review of the consequences of premature birth on
palatal morphology, dental occlusion, tooth-crown dimensions,
and tooth maturity and eruption.Angle Orthod. 2004 Apr;74(2):269-
79. Review.

Birth Weight
 Birth weight less than 1500 gms-> VLBW(very low
birth weight)
 Delay in dental maturation
 Higher percentage of enamel defects
 When birth weight is less than 1000gms, greatest
lag period in dental maturation
Pediatr Dent. 1996 Sep-Oct;18(5):379-84.
A study of the development of the permanent dentition in very
low birthweight children.
Seow WK

Post Natal History
Feeding
Duration
Weaning
Milestones in development
Childhood diseases
Habits
History of trauma
History of tonsillectomy and adenoidectomy

Feeding
The method of feeding is important with regard to
etiology of a retruded mandibular position.
The orthodontic advantage of breast-feeding is that
the infant must activate and protract the jaw
musculature much more to express milk out of the
mother’s breast.
This higher functional loading during the first few
months of life helps to move the mandible anteriorly
and thus compensates for the physiologic retruded
mandibular jaw relationship that exists at birth.

Feeding
According to Anderson,
Breast fed babies are better adjusted, have less
abnormal perioral muscle habits & less retained
infantile mechanisms.
Breast-feeding leads to development of fewer
sucking habits and a stronger buccinator
activity.

Frequency
If sucking reflects is fulfilled, there will be
fewer sucking habits.
Normal frequency is 8 to 12 times a day,
once every two to three hours.
Typically, breast-fed babies eat more
frequently than formula-fed babies do
Nighttime feeding pre-disposes to rampant
caries

Weaning
For normal development of deciduous dentition
the child should be given solid foods as soon as
the deciduous molar erupt.
If the child is not weaned at this stage he will
become a temporalis chewer (will perform only
chopping movements) instead of a masseter
chewer (performs complete grinding cycles
during mastication).

Weaning

Deciduous Dentition
Massetric chewers Temporalis chewers
Abraded deciduous
teeth
Minimal abrasion
Position of mandible
is normal
Mandible is retro
gnathic
Position of first
molar-favorable
Unstable
Overbite-decreased Excessive

Type of Nipple - Conventional
Nipple contacts only
mucous membrane of lips
Mouth is propped open
Lip seal is difficult
Chances of air intake
with milk is likely.
Abnormal muscle pressures are exerted to
compensate for excessive mouth opening
Suckling becomes sucking as there is enlarged hole
at the end of nipple
Orthodontics Current Principles and Technique
Thomas Graber www.indiandentalacademy.com

Type of Nipple
Requirements of ideal nipple
Base should clear the nose area to permit
breathing.
Length and flexibility must allow baby to adapt it
with the tongue against the roof of his/her
mouth.
Hole in nipple adjusts flow of liquid and should
not be enlarged so cheek and lip muscles
develop properly

Type of Nipple- Physiologic
Nipple adapts to the contours of lips
Entire perioral area comes in contact with the
warm nipple base
It has a short nipple shank and broad
adaptive rubber base

Medical History
A complete medical history has to be obtained
from the patient, as a definite relationship exists
between overall health and dental development.
It is important to know the last time the patient
saw a physician, any hospitalisation and any
current medications.
Although there are not many medical
conditions, which preclude orthodontic
treatment, it may be necessary to postpone or
take precautions in certain cases.

Medical History
Allergy to latex or nickel or acrylic resin – latex
gloves, elastics and wire and brackets containing
nickel should be avoided. Patient may be given a
fixed treatment in case of allergy to resin.
History of blood transmission – increased risk of
hepatises or HIV exposure.
Heart problems such as rheumatic fever are mitral
valve prolapse – anti biotic prophylaxis is needed
before extractions, placement of orthodontic bands,
periodontal surgeries and placement of implants.

Medical History
Any procedure leading to injury to soft tissues or bone
resulting in bleeding can produce transient bacteremia
even in normal persons. However in patients with
following conditions, it can result in bacteremia.
Prosthetic cardiac valves
Previous history of bacterial endocarditis
Surgically constructed systemic pulmonary shunts
Congenital cardiac malformations
Rheumatic and other acquired valvular dysfunction
Hypertrophic cardiomyopathy
Mitral valve prolapse with regurgitation

Prophylaxis
Adults :- Amoxicillin 3 gms orally 1 hour before
procedure and 1.5 gms 6 hours after initial dose.
Children:- Amoxicillin 50 mg/kg orally 1 hour before and
½ the initial dose 6 hours later.
Allergic to Penicillin:-
Adults:- Erythromycin ethyl succinate 800 mg or
Erythromycin steareate 1 gm orally 2 hours before
procedure and ½ the dose 6 hours later.
Children:- Erythromycin 20 mg/kg1 hour before
procedure and ½ the dose 6 hours later.

Prophylaxis
Allergic to Penicillin & Erythromycin:-
Adults:- Clindamycin 300 mg 1 hour before
procedure and 150 mg 6 hours after the initial
dose
Children:- Clindamycin 10 mg/kg 1 hour before
procedure and ½ the dose, 6 hours after the
initial dose

Habits
Habits are learned patterns of muscle contraction of a very
complex nature. They serve as a stimuli for a normal growth
of Jaws. They are part of normal sequence of maturation in
children. They become bad habits when,
1. Activity continues for longer than typical
2. It becomes severe to cause physical damage
3. When it is engaged so frequently so as to interfere
with physical, social and cognitive development.
Subtelny J;Oral habits-studies in form ,function and therapy .Angle
Orthod 43;347-383, 1973

Thumb / Digit Sucking
It is one of the most common oral habits. 89% of infants show
hand sucking within 2 hours of birth and virtually 100% of
children within first year of life. The activity decreases with age
and seizes by 3.5 – 4 years.
Effects of thumb sucking depend more on duration (in
hours/day) rather than intensity of habit (amount of force).
Angle Orthod. 2006 May;76(3):441-5. Dental arch diameters and
relationships to oral habits.Aznar T, Galan AF, Marin I, Dominguez A.www.indiandentalacademy.com

Thumb / Digit Sucking
Flared maxillary incisors
Lingually inclined lower incisors
Anterior open bite
Posterior cross bite
Increased risk for distortion of dentoalveolar
Deep palate
Upward rotation of anterior maxilla
Development of class II malocclusion

Dummy Sucking
The use of pacifiers causes anterior open bites
and maxillary constrictions. Posterior cross bites
are more common and develop at an early age.
Angle Orthod. 2006 May;76(3):441-5.
Dental arch diameters and relationships to oral habits.
Aznar T, Galan AF, Marin I, Dominguez A.

Bruxism
It involves titanic like contraction of
masticatory muscles and rhythmic
side to side grinding and gnashing
of teeth.
Susan E. Menapace, Donald J. Rinchuse, Thomas Zullo, Calvin
the Angle Orthodontist 1994 No. 1, 43 - 52: The dentofacial
morphology of bruxers versus non-bruxers
Bruxism causes muscle pain, TMJ clicking, gingival
recession, loose or sensitive teeth, tooth fracture,
attrition, dental intrusion or extrusion, and pupal
pathology. Prevalence of Bruxism varies, ranging
from 5% to 96% of the population.

Tongue Thrusting
It is also called as deviated swallow, visceral
swallow, and reverse swallow, retained infantile
swallow.
Tongue thrust is actually a misnomer as it
implies forced forward placement of tongue.
However, swallowing is not a learned behaviour
but, is integrated and controlled physiologically
at subconscious levels.

Normal Tongue Position

Tongue Thrusting
According to Proffit and Mason, it is the
combination of one or all of the 3 conditions,
1. Forward placement of tongue during swallowing
so that tip of tongue contacts the lower lip
2. Inappropriate placement of tongue between or
against anterior dentition during speech
3. Forward positioning of tongue at rest so that the
tip is against or between the anterior teeth

Tongue Thrusting Types (Moyers)
Simple
 A tongue thrust with the teeth together
 Associated with digital habit.
Complex
 Tongue thrust with teeth apart
Retained Infantile

Visceral Swallowing
Normal swallowing in infancy is marked by
protrusion of tongue between the alveolar pads,
placement of tongue against lower lip, strong lip
activity associated with nursing and deglutition
with lips apart.

Visceral Swallowing
There are 4 phases of swallowing,
 Oral preparatory - Voluntary
 Oral - Voluntary
 Pharyngeal
 Esophageal

Pharyngeal Phase
Pharyngeal phase is of longer duration during
infancy and the forward movement of posterior
pharyngeal wall is exaggerated.
Transition to mature swallowing pattern is
marked by relaxation of lips, placement of tip of
tongue on anterior palate and deglutition with
posterior teeth in contact. This transition may
occur between 2- 12 years.

Tongue Thrusting
Tongue thrusting results in
Proffit W, Mason R Myofunctional Therapy for tongue thrusting.
Background and recommendations
J AM Dent. Association 90:403 – 411, 1975
 Contraction of the circumoral musculature,
 Separation of the mandibular and maxillary posteriors ,
 Protrusion of tongue between incisors.

History of Tonsillectomy &
Adenoidectomy
Adenoids are lymphatic tissues located behind the
nose where the nose and throat come together.
they help to fight infections that enter the body
through the nose and mouth.

History of Tonsillectomy &
Adenoidectomy
Patients with chronically enlarged tonsils and adenoids can
have symptoms of snoring, difficulty swallowing, painful
swallowing, bad breath, ear infections, or chronic nasal
drainage. Some children can have so much obstruction of
the nasal passage that they breathe through the mouth only.

History of Tonsillectomy & Adenoidectomy
Orthodontic therapy one month after
adenoidectomy may be necessary for solving
the orthodontic problems caused by adenoidal
enlargement .
Patients with adenoidal enlargement and oral
respiration, may show maxillary width reduction
as opposed to mandibular width.
Vojnosanit Pregl. 2005 Feb;62(2):119-24
[Effects of adenoidectomy and immediate orthodontic treatment on
jaw relations and naso-respiratory rehabilitation]
Milic JD, Nikolic P, Novakovic S

Trauma
Accidents are significant factor in malocclusion. As the
child learns to crawl and walk, the face and the dental
regions may receive trauma, which results in idiopathic
eruptive abnormalities.
There may be trauma to the,
- Jaws
- Teeth
Fracture of jaws may cause,
Trauma to deciduous teeth makes them non-vital, thus
resulting in abnormal resorption patterns and
consequently affect the successor.

Trauma
Trauma to the edentulous jaw results in
retained, displaced teeth and malformation of
roots.
Trauma after 4 years of age results in damage
to permanent tooth bud and impeded root
formation.

Clinical Examination
Physical status
Extra oral examination
Functional examination
Intraoral examination
Gnathic examination

Built
According to Sheldon built can be,
Ectomorphic, I-e tall and thin physique
Mesomorphic, I-e Average physique
Endomorphic, I-e Short and obese physique

Present Health
Weak and sick child may have delayed growth
as compared to a healthy child.
A sick child will be more uncooperative during
treatment.

Posture
Persons with faulty posture may demonstrate
undesirable mandibular posture positioning. Clinical
observations of oral postures examined maxillary
protrusion and open bite, anterior cross bite and facial
asymmetry.
The unstable forces induced by abnormal posture were
correlated with the varieties of malocclusion.
Morphology, function, and posture were shown to be
closely interrelated and to influence each other.
Bull Tokyo Dent Coll. 2003 May;44(2):43-54.
Malocclusion associated with abnormal posture.
Yamaguchi H, Sueishi K.

Extra Oral
Examination

Shape of Head
Cephalic index =
Maximum skull width / Maximum skull length

Facial complex attaches to basicranium
.thus the cranial floor acts as a template and
establishes many of the dimensional
,angular and topographic features of face.
Dolichocephalic
- narrow ,long protrusive face
leptoproscopic face
Eyes are closely set

Dolicocephalic
Nose is thin ,vertically long and protrusive.there may be
(aqualine)convex nasal contour(Roman nose/Dick Tracy
nose). Tip may point point down.
In some cases,there may be a S-shaped configuration
where the middle part is protrusive relative to the upper
part.
Forehead is more sloping.
Glabella and upper orbital rims are prominent
Face is more angular with deep set eyes.
Long midface and obtuse cranial base downward and
backward rotation of mandibleretrusive mandible and
lower lip, retrognathic (convex ) facial profile
Slumped head posture

Brachycephalic
Broad , less protrusive face
Euryprosopic type
Eyes are wide apart thus the nose is wide ,pug
like,short with rounded tip
Straight forehead with thin frontal sinus
Face is less angular and more flat
Cheekbones are prominent
Eyes are exopthalmic
Lower jaw is protrusive
Profile may be straight or concave
Erect head posture

Dinaric
Named after dinaric mountains in Yugoslavia
Anterio-posterior short head like in brachycephalics.
Wide and / flat occipital/ lamboidal regions
Bossing of parietal region
Skull appears triangular from above
Anterior part is narrow like in dolicocephalic
Face is leptoproscopic,long protrusive
Ear is characteristically closer to head due to occipital
flattening .
Large and aquiline nose.

Shape of Head
Classification and index values according to Martin
and Saller,
Dolicocephalic (x – 75.9)
- Long and narrow head
- anterior cranial fossa is narrow and long thus
maxilla is narrow and palate is deep.
- They have narrow dental arches

Shape of Head
Mesocephalic (76.0 – 80.9)
- Average shape of head
- They have normal dental arches

Shape of Head
Brachycephalic (81.0 – 85.4)
- Broad and short head
-Anterior cranial fossa is broad and short
thus maxilla is wide and palate is shallow
- They have broad dental arches
Hyper Brachycephalic (85.5 – x)

Facial Form
Morphologic facial height  distance
between nasion & gnathion
Bizygomatic width  distance between the
zygoma points.
Morphologic facial index =
Morphologic facial height /
Bizygomatic width

Facial Form
Classification and index values according to
Martin and Saller,
Hyper Euryprosopic (x – 78.9).
-Wide base of jaw
-In case of dental crowding,it is
usually coronal crowding.
-Transverse expansion is indicated.
Euryprosopic – Broad and short face (79.0 –
83.9)

Facial Form
- Mesoprosopic – Average or normal
face (84.0 – 87.9)

Facial Form
Leptoprosopic – Long & narrow face (88– 92.9)
- Apical base is narrow
- In cases of maxillary crowding, there is
not only coronal crowding but also apical.
- Extraction is indicated.
- Mandibular plane and gonial angles are
usually quite obtuse, with appearance of
a longer lower face height
Hyper Leptoprosopic (93.0 - x)

Facial Form
Face can be divided into 3 equal parts. By
horizontal lines adjacent to hairline, Nasal base
and Menton.

Facial Form
Increased facial height is due to vertical maxillary
excess or excessive lower facial height.
Decreased face height is due to vertical maxillary
deficiency, mandibular deficiency with diminished
mandibular body or ramus height or short chin height.

Facial Form - Rule of Fifths
The face is divided sagittally into 5 equal parts from
helix to helix of outer ears, all measuring the width
of one eye.
Alar width should coincide
with inter canthal distance
and commissural width
should coincide with
medial limbus of eyes.

Facial Profile
It is determined by a line joining the nasion with
Point A & Point B. It helps in diagnosing gross
deviations in maxillo mandibular relationship. It
also evaluates the lip posture ,incisor prominence,
vertical facial proportions and mandibular plain
angle.

Facial Profile

Facial Profile
Orthognathic – All the 3 points are in the same
plane
Convex – Point A is ahead. Seen in Class II jaw
relationship
Concave – Point B is ahead. Seen in Class III jaw
relationship

Facial Divergence
It is the anterior or posterior inclination of
the lower face relative to the forehead.
Straight
Anterior divergence
Posterior divergence

Facial Symmetry
Asymmetries that are gross and easily detectable
should be recorded.

Facial Symmetry
Etiology of asymmetry includes:
Genetic or congenital malformations e.g.
Hemifacial microsomia and unilateral clefts of
the lip and palate;
Environmental factors, e.g. habits and trauma
Functional deviations, e.g. mandibular shifts as
a result of tooth interferences.

Lips
Normally upper and lower lip touch each other
when the jaws are at rest to form a lip seal. The
upper lip is 2-3 mm above the incisal edge of
the upper central incisor. The lower lip extends
up to the incisal third of labial surface of upper
anteriors.

Lip line
It is the relationship of the lower lip to upper
central incisor.
In class II div 1- lip line will be lower
In class II div 2 – lip line will be higher

Lip seal
Based on the lip seal the lips can be classified as
Competent – Lips are in slight contact when the
musculature is relaxed

Lip seal
Incompetent – They are morphologically short lips which do
not form a lip seal in relaxed state. Lip seal is achieved
only by active contraction of orbicularis oris and circumoral
muscles.
(a) Short Upper Lip
(b) Short Lower Lip

Lip seal
Potentially Incompetent – Normal lips that fail to form a
lip seal due to protruding upper incisors.

Lip seal
Everted / Curled – They are hypertrophic lips
with redundant tissue but weak muscular
tonicity.

Lip Projection
According to ideal E-Line relationship (Ricketts
– E esthetic line) lower lip should coincide with a
line from the nasal tip to anterior chin and upper
lip should be 1 mm behind it.

According to Reed Holdaways ,H line(harmony
line)is a tangent lip from the tip of the upper
lip.the depth of upper lip sulcus is measured
from this point.normal value- 2.5 mm
It varies with thickness of lips(+/- 1.5 mm)
Lip strain decreased depth
Lip redundancy or jaw overclosure increased
depth

Lip Projection
Lip projection is affected by both dental and skeletal
protrusion or retrusion. Lip projection is an important
factor in facial esthetics and it decreases with ageing.
Lip prominence can also be evaluated by relating the
upper lip to a true vertical line passing through the
concavity at the base of upper lip and relating the lower
lip to a similar true vertical line passing through a point
in the concavity between the lower lip and chin.

Lip Projection
If the lip is forward to the line, it is prominent.
If it falls behind the line, it is retrusive.
If both the lips are prominent and are separated by
more than 3-4 mm, it indicates dento alveolar
protrusion.

Lips
When the upper lip tubercle lies superior to the
adjacent vermilion or is entirely absent, it is called as
gull wing deformity.
Vertical maxillary excessexcessive tooth exposure
from embrasure to embrasure
Gull wing deformity excessive exposure of central
incisors with progressively less tooth exposure laterally.
Dentofacial deformity volume I Epker and Stella

Lip step
It gives us the relation of lower lip to upper lip.
According to korkhaus
Positive lip step-Protrusion of lower lip in relation to
upper lip
Negative lip step- Protrusion of upper lip in relation to
lower lip
Normal- slightly negative
Orthodontic diagnosis – Thomas Rakosi

Smile Evaluation
1. Amount of incisor display - It may be the entire or only
a percentage of upper incisor.

Smile Evaluation
Crown height and width – Height is normally 9 –
12 mm. With age, it increases due to apical
migration. Width-height ratio for central
incisors is 8:10
Gingival Display – A gummy smile is considered
more esthetic than a smile with diminished
tooth display.

Smile Evaluation
Smile arc – It is the relationship of the curvature
of the incisor edges of maxillary incisors and
canines to the curvature of lower lip in posed
social smile.

Smile Evaluation
It can be,
Consonant – It is the ideal smile arc with
maxillary incisal edge curvature parallel to
curvature of lower lip on smile
Non Consonant – It is flat smile arc
characterized by maxillary incisal edge
curvature being flatter than the curvature of
lower lip.
Reversed

Smile Evaluation
Buccal Corridor Width – It is measured from
mesial line angle of maxillary first premolars
to interior portion of commissure of lips.
Buccal corridor width= inter commissure
width / distance from 1st
premolar to 1st
premolar.
Excessive width is referred to as negative
space.

Smile Evaluation
Amount of incisor Proclination
It has dramatic effects on incisor display.
Flared maxillary incisor reduces incisor
display and upright maxillary incisors
increases incisor display.

Mentolabial Sulcus
It is the concavity below the lower lip. It is deep
in Class II Division I malocclusions and shallow
in bimaxillary protrusions.
It is a feature of hyperactivity of mentalis
muscle.

Nasolabial Angle
It is the angle formed between lower border of
nose and the line connecting the intersection of
nose and upper lip with the tip of lip.
Normal value is 110°.
Increased value is seen in
retroclined maxillary anteriors.
Decreased value is seen in
proclined maxillary anteriors
or prognathic maxilla.

Chin
Projection of chin depends on bony projection of
anterio-inferior border of mandible and amount
of soft tissue over lying that bony projection.
Prominent chin is seen in Class III
malocclusions.
Recessive chin is seen in Class II malocclusions

Clinical FMA
Clinical examination of mandibular plane to the true
horizontal plane should be noted.
Steep Mandibular Plane Angle:-
Long anterior facial vertical dimensions
Open bite
Flat Mandibular Plane Angle:-
Short anterior facial height
Deep bite

Clinical FMA
It is visualized by placing a finger or a mirror
handle along the lower border of mandible.

Visualized Treatment Objective
This examination helps us decide whether any
functional appliance that postures the mandible
forward will improve the facial profile and
appearance.
Patient is instructed to swallow,lick the lips and
then relax.His profile with teeth in habitual
occlusion is observed.He is then asked to bring
the mandible forward into a correct sagittal
relationship reducing the over jet.

Profile does not improve when
-Excessive anterior facial height
-Procumbency of lower incisors
-Deficient symphyseal development
-Steep mandibular plane
Improved profile is seen in
-Anteriorly rotating growth patterns
-Functional retrusion
-Deep overbites
-Excessive interocclusal clearances with
normally positioned maxilla

Visualized Treatment Objective
It helps in predicting treatment changes that
would occur in the future for the patient.
The accuracy of prediction is a combination of
the effect of treatment procedures and accuracy
of predicting future growth.
They are not very accurate but may act as
rough estimate of actual outcome.

Functional examination
Respiration
Mirror test – A double-sided mirror is held
between the nose and the mouth. Fogging on
nasal side of mirror indicates nasal breathing
and fogging on oral side indicates oral
breathing.
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

Respiration
Water Test – Patient fills the mouth with water
and retains it for some time. Oral breathers fail
to perform this test.
Observation of external nares – The external
nares dilate during inspiration for nasal
breathers. No change is observed in oral
breathers

Path of closure
During closure of mandible, it can undergo both
rotational + sliding movements.
Types of movements during closure,
Pure rotational
Rotational movement with an anterior sliding
component
Rotational movement with posterior sliding
component.

Path of closure
Class II Malocclusion

Path of closure
Class III Malocclusion

Postural Rest Position
It is 2-3 mm below & behind the centric
occlusion (recorded at canine). This position
depends on head posture, thus patient should
be completely relaxed, sitting upright and
looking straight ahead.
Phonetic Method
Pronounce consonant like M or words like Ram,
Mississippi
Command Method
Command patient to swallow salivawww.indiandentalacademy.com

Non Command Method
Distract the patient + note the mandibular
position when patient relaxes.
Combined
Palpate the sub mental region to ascertain that
the muscles are relaxed.

Influences
1. Inconsistency in
muscle tonicity
2. Respiration
3. Body Posture
4. Stress
5. TMS dysfunction
Short Term Long Term
1. Attrition
2. Premature loss of
teeth
3. Diseases of neuro
muscular system

Interocclusal clearance
It is the distance between the upper and lower
canines when they mandible is at the postural
rest position.
It is usually 2-3mm.
It is increased in cases with decreased vertical
development of buccal segments.

Temporo Mandibular Joint
Auscultation: -
Initial Clicking- Retruded condyle in relation to
articular disc
Intermediate Clicking- Uneven condylar surface
+ articular disc surface
Terminal Clicking- Most Common – Condyle is
moved too far anteriorly in relation to disc on
max. jaw opening
Reciprocal Clicking-Displaced condyle + disc
occurs during opening & closing

Temporo Mandibular Joint
Pain on Palpation – Lateral pterygoid muscle
palpatory pain is common in children.
Masseter muscle pain is also seen in children
- Check for coordinated condylar movements

Range of motion
Maximum mouth opening - It is measured as the
distance between the upper and lower incisal
edges.it is usually 4-4.5 cm. It is measured
using a bole gauge.in case of overbite,the
amount of overbite is added to inter incisal
distance.
In case of open bite,its value is subtracted from
inter incisal distance.
Protrusion-The patient is asked to protrude the
mandible forward to the maximum.

Range of motion
Lateral excursions - The patient is asked to
move the mandible laterally and the distance
between the midline of upper and lower
dentition is measured.
It should be same on both the right and the left
sides

Intra Oral Examination

Soft Tissues
ORAL HYGIENE STATUS & BRUSHING
HABITS
Rapid Orthodontic treatment requires the patient
to maintain a good Oral Hygiene. Poor Oral
Hygiene causes debonding of the bracket,
delayed tooth movement, increased pre-
disposition to caries and gingival diseases.

Gingiva
Localised gingival lesions may suggest,
Traumatic occlusion
Poor oral hygiene
Delayed eruption of permanent teeth
Hyper activity of mentalis muscle
Mouth breathing

Gingiva
The texture and colour of gingival tissue is an index
of periodontal health.
Gingival diseases and periodontal diseases have a
direct and highly localized effect on the teeth. They
may cause loss of teeth, changes in closure pattern
of mandible, teeth ankylosis

Frenal Attachment
A thick, fibrous, low maxillary frenum may lead to
malocclusion by leading to a midline diastema. The
mandibular labial frenum can exert a strong pull on
gingival leading to recession.
Blanch test can confirm the diagnosis of high frenal
attachment. The upper lip is pulled in an upward and
Outward direction. Presence of
blanching in the papilla
indicates abnormal frenal
attachment.

Tongue
Size: The tongue can be small, long or broad. A long
tongue can usually reach the tip of the nose.
Macroglossia implies a large tongue.
Position:
It may be affected by enlarged tonsils/adenoids
In class III cases, the tongue is broad and low lying and
extends over the dental arches. In such cases, the size
of the dental arch should not be decreased by further
Orthodontic treatment (Eg:- Extractions)

Tongue
Movements:
They may be restricted due to ankyloglossia.
Proffit has stated that the resting pressure of the
tongue is one of the primary factors in the
maintenance of dental equilibrium

Palatal Contour
The palate may be,
- Shallow
- Normal
- Deep
Shallow palate may be seen in broad arch forms
Deep palate is common in class II cases and in
children with oral habits.

Circumoral muscle tone
Abnormal circumoral muscle tone tends to
accentuate the developing malocclusions.So,
during treatment such conditions should be
eliminated first to achieve stable results.

Hard Tissues
Teeth present
Number of teeth present,number of deciduous
teeth,number of permanent teeth,teeth which
are missing,teeth which are erupting should be
determined.
This helps us in calculating the dental age of the
patient. A difference of +/- 2.5 years between
dental and skeletal age is considered normal.
Helps us to find over retained
teeth,supernumerary teeth, congenitally absent
teeth which may contribute to malocclusion.

Caries
It is one of the local causes of malocclusion.

Caries
It results in premature loss of tooth leading to
drifting of adjacent tooth, abnormal axial
inclination, over eruption & bone loss. They
should be restored to prevent further infection or
loss of teeth.
Series of proximal carious lesions, if unrepaired
leads to loss of arch length which may be more
than actual tooth loss.

Teeth size shape form
Variations in size of teeth are seen due to
- sex, males have larger teeth than females
- size and shape of face and head
- racial variations
The incisors may appear large sized in a child ,
but it must be remembered that there will be
further facial growth.

Teeth size shape form
Shape
Variations in shape occurs most commonly iin maxillary
lateral incisors.
According to Garn,Lewis and Kerewsky,
The more distal a tooth in each morphologic class is ,
the more likely it is to be subject to greater numerical
variations than the tooth nearer to midline.
All these variations affect the alignment and occlusion
of teeth

Key Ridge
The key ridge is the prominence below
the molar process which divides the
canine from the infra temporal fossa on
the lateral surface of maxillary bone.
Eur J Orthod. 2001 Jun;23(3):263-73.
Location of the centre of resistance of the upper
dentition and the nasomaxillary complex. An
experimental study.
Billiet T, de Pauw G, Dermaut

Gnathic examination - Arch
Shape: It can be average,V shaped,U shaped or
square.
Symmetry: Etiology of asymmetry includes: a) Genetic
or congenital malformations e.g. hemifacial microsomia
and unilateral clefts of the lip and palate; b)
Environmental factors, e.g. habits and trauma; c)
Functional deviations, e.g. mandibular shifts as a result
of tooth interferences
Alignment- crowding,spacing,rotation

Crowding
It can be classified according to amount of
space deficiency (Mixed Dentition)
First Degree
- Slight malalignment of anterior teeth
- No abnormality of supporting zone
Second Degree
- Pronounced malalignment of anterior teeth
- No abnormality of supporting zone

Crowding
Third Degree
- Severe malalignment of anterior teeth
- Adjacent permanent teeth undermines the
deciduous teeth due to unusual root resorption.
Crowding in conjunction with reduced supporting
zones is difficult to treat.
Supporting zones in mixed dentition should be
maintained to provide space for eruption of
permanent teeth.

Crowding
Classification according to etiology.
Primary - Hereditary
- Disproportion between size of jaws
- Persistence of tooth germ position in
anteriors
- Lingually blocked out lateral incisors
Secondary - Acquired anomaly
- Prematured loss of deciduous molars
- Mesial drift of posteriors

Crowding
Tertiary
- Primarily lower anterior crowding
- Occurs in 18-20 year olds
Causes:- Eruption of third molars, Differential
growth termination of upper and lower arches

According to inclination,
Coronal crowding
There is this harmony between width of apical
base and dental arch due to broad apical base.
Thus the posteriors are tipped Lingually. There
is inter dental spacing in the posteriors and
crowding anteriorly.
Treatment - Expansion

Crowding
Apical crowding
There is disharmony in width of apical base &
maxillary dental arch. Upper posteriors are tilted
buccaly in relation to their apical base. Upper
arch is constricted anteriorly.
Treatment - Extraction

Spacing
Spacing in deciduous dentition is normal.
However in permanent dentition, it is unesthetic.
It is a result of arch length and tooth width
discrepancy.

Rotations
It may be centric or eccentric.localization of axis
of rotation is important

Curve of Spee
Curve of spee in normal occlusion is not deeper than
1.5 mm. There is good intercuspation around
premolars and molars. The occlusal plane is flat.

Curve of Spee
Reverse curve of spee creates excessive space
in the upper jaw and insufficient space in the
lower jaw. There is open bite anteriorly.

Curve of Spee
Excessive curve of spee restricts the space available
for upper teeth, thus they move towards the mesial
and distal. There is inadequate space in lower arch.
The intercuspation is not normal. There is an
increased over bite.

Angles classification
Dr. Edward Angle described three (3) classes of
malocclusion based on the occlusal relationship
of the first molars

Class I Malocclusion
Mesio buccal cusp of maxillary first permanent molar
occludes in buccal grew of mandibular first permanent
molar. There may be intra arch dental irregularities like,
Crowding
Spacing
Rotations
Anterior-Posterior cross bite
Deep bite
Proclination
Retroclination
Bimaxillary protrusion

Disto- buccal cusp of maxillary first permanent molar
occludes in the buccal grew of mandible.
Division 1: -
Proclined upper incisors
Increased overjet
Convex profile
Short hypotonic upper lip with lip trap &
incompetent lips
Increased over bite
Excessive curve of Spee
Proclinated lower anteriors
Abnormal buccinator and mentalis activity

Retroclined upper central incisors
Overlapping of lateral incisors on central
Deep overbite
Backward path of closure of mandible
Deep mentolabial sulcus
Straight profile with no abnormal muscle activity
Sub Division: -
Class I relation on one side and Class II relation on the
other side.
Division 2: -

Class III Malocclusion
Mesio buccal cusp of maxillary first permanent molar
occludes in the inter dental space between the
mandibular first and second molars.

TRUE Class III
True Class III: -
It is a skeletal malocclusion showing,
      Edge to edge relationship or anterior cross bite
      Narrow upper arch and broad lower arch
      Crowding in upper teeth and spacing in the lowers
      Concave profile with prominent chin
      May show anterior open bite

Pseudo Class III
(Postural or Habitual Class III): -
It involves the forward movement of the
mandible during jaw closure.
Causes: -
Occlusal prematurities
Premature loss of deciduous posteriors
Enlarged adenoids in children

Canine relationship
Class I canine relation-this is a normal relation
where the upper canine overlaps the distal
incline of lower canine
Class II canine relationship- the upper canine is
placed forward. The distal incline of upper
canine inclines with mesial incline of lower
canine.
Class III canine relationship-the lower canine is
placed forward to the upper canine and there is
no overlapping

Incisor relationship
It is based on relationship of lower incisal edge to the
cingulum of upper central incisors.
Class I
Mandibular incisal edges
occludes with upper incisor
at a point just below the
cingulum

Incisor relationship
Class II
Mandibular incisal edges lie posterior to the
cingulum of maxillary central incisors
Division 1-- Maxillary central incisors are
normal or proclined with increased overjet
Division 2 -- Maxillary central are retroclined.
Overjet is usually normal but may be increased
in certain cases.
Class III
Mandibular incisal edges lie anterior to
cingulum. There is a reverse overjet

Over Jet
Over jet is the horizontal over lap of the incisors.
Normally the incisors are in contact with the upper
incisors ahead of the lower incisors by the thickness
of the upper edges of maxillary incisors. I-e 2-3
mm.When it is increased, it is called as open bite.,

Over Jet
Open bite can classified on the basis of
localization of malocclusion
Anterior open bite
-Caused by tongue dysfunction, digit
sucking habits
-The tongue thrusts forward anteriorly.

Over Jet
Lateral open bite
Tongue thrusts between the teeth laterally
There is also a disturbance in physiologic growth
processes around molar region

Over Jet
Complex open bite
-Severe vertical malocclusion
- Teeth occlude only on second molars

Over Bite
It is the vertical over lap of the incisors.
Normally the lower incisal edges contact the
lingual surface of the upper incisors at or above
the cingulum. I-e 1-2 mm.
If it is more than the normal value, it is called as
deep bite.

Deep Bite
Deep bite can be,
Dentally supported
Gingivally supported
In deciduous dentition, incisal overlap of more
than half is considered as deep bite. But, in
genuine deep bite lower anteriors are
completely covered due to increase in height of

Over Bite
Closed Bite:-
It it caused by increased forward and upward rotation of
mandible occurring due to lack of posterior dental
support.
It may be a result of premature extraction of teeth in
mixed dentition.
TROUTEN, JAMES C., ENLOW, DONALD H., RABINE, MILTON, PHELPS,
ARTHUR E., SWEDLOW, DAVID. 1983: Morphologic Factors in Open Bite
and Deep Bite. The Angle Orthodontist: Vol. 53, No. 3, pp. 192–211

Over Bite
Classification according to Hotz and Muhlemann,
True deep over bite
Large free ray space
Infra occlusion of molars
Treatment:- functional appliance
Pseudo deep over bite
-Small free ray space
Fully erupted molars
Over eruption of incisors

Vertical Malposition
It is the malocclusion in relation to occlusion
plane. It usually occurs along with irregular
vertical development of alveolar process.
Supra Version / Supra Occlusion: -
Teeth exceeds the level of occlusal plain
Increased over bite
Infra Version / Infra Occlusion: -
Teeth are below the level of occlusal plain
Anterior open bite

Cross Bite
When the lower incisors are in front of the upper
incisors, the condition is called as reverse over
jet or anterior cross bite.
Causes:-
Narrow upper jaw and/or
Broad lower jaw
Bilaterally symmetric
Bilaterally Asymmetric
Unilateral

Cross Bite
Posterior cross bite exists when maxillary posterior
teeth are lingually positioned relative to mandibular
teeth. It usually reflects a narrow maxillary dental arch.
Buccal malocclusion: -
- Upper posterior teeth occlude completely buccally of
lower teeth

Midline Deviation
It can be,
Dento alveolar
Skeletal
Combined
OR
Maxillary
Mandibular
Combined

References
Orthodontics Current Principles and Techniques
Thomas Graber , Robert Vanarsdall, Katherine Vig
Orthodontic diagnosis – Thomas Rakosi
Handbook of Orthodontics – Robert E. Moyers
Contemporary Treatment of Dentofacial Deformity
William R. Proffit
Contemporary Orthodontics - William R. Proffit
Orthodontics Principles and Practice - T.M.Graber
Enlow DH: Handbook of facial growth 2nd
Edition Philadelphia,
PA: WB Saunder 1982

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