Extra Oral
Examination

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INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Shape of Head
Cephalic index =
Maximum skull width / Maximum skull length

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Facial complex attaches to basicranium .thus
the cranial floor acts as a template and
establishes many of the dimensional ...
Dolicocephalic
-

-

-

-

Nose is thin ,vertically long and protrusive.there may be
(aqualine)convex nasal contour(Roman ...
Brachycephalic
-

-

-

Broad , less protrusive face
Euryprosopic type
Eyes are wide apart thus the nose is wide ,pug
like...
Dinaric
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
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








Named after dinaric mountains in Yugoslavia
Anterio-posterior short head like in brachycephal...
Shape of Head
Classification and index values according to Martin and
Saller,
Dolicocephalic (x – 75.9)
- Long and narrow ...
Shape of Head
Mesocephalic (76.0 – 80.9)
- Average shape of head
- They have normal dental arches

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Shape of Head
Brachycephalic (81.0 – 85.4)
- Broad and short head
-Anterior cranial fossa is broad and short thus
maxilla ...
Facial Form
Morphologic facial height  distance between
nasion & gnathion
Bizygomatic width  distance between the
zygoma...
Facial Form
Classification and index values according to Martin
and Saller,
Hyper Euryprosopic (x – 78.9).
-Wide base of j...
Facial Form
- Mesoprosopic – Average or normal face
(84.0 – 87.9)

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Facial Form
Leptoprosopic – Long & narrow face (88– 92.9)
- Apical base is narrow
- In cases of maxillary crowding, there ...
Facial Form


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

w...
Facial Form


Increased facial height is due to vertical maxillary
excess or excessive lower facial height.



Decreased...
Facial Form - Rule of Fifths


The face is divided sagittally into 5 equal parts
from helix to helix of outer ears, all m...
Facial Profile


It is determined by a line joining the nasion with
Point A & Point B. It helps in diagnosing gross
devia...
Facial Profile

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Facial Profile
Orthognathic – All the 3 points are in the same
plane
Convex – Point A is ahead. Seen in Class II jaw
relat...
Facial Divergence


It is the anterior or posterior inclination of
the lower face relative to the forehead.
Straight
Ante...
Facial Symmetry


Asymmetries that are gross and easily detectable
should be recorded.

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Facial Symmetry


a)

b)
c)

Etiology of asymmetry includes:
Genetic or congenital malformations e.g.
Hemifacial microsom...
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 m...
Lip line



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It is the relationship of the lower lip to upper
central incisor.
In class II div 1- lip line will be low...
Lip seal


Based on the lip seal the lips can be classified as
Competent – Lips are in slight contact when the
musculatur...
Lip seal


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Incompetent – They are morphologically short lips which do
not form a lip seal in relaxed state. Lip seal i...
Lip seal
Potentially Incompetent – Normal lips that fail to
form a lip seal due to protruding upper incisors.

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Lip seal



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

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Lip Projection


According to ideal E-Line relationship
(Ricketts – E esthetic line) lower lip should
coincide with a lin...






According to Reed Holdaways ,H
line(harmony line)is a tangent lip from the tip
of the upper lip.the depth of upp...
Lip Projection




Lip projection is affected by both dental and skeletal
protrusion or retrusion. Lip projection is an ...
Lip Projection
If the lip is forward to the line, it is prominent.
If it falls behind the line, it is retrusive.
 If bot...
Lips




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When the upper lip tubercle lies superior to the
adjacent vermilion or is entirely absent, it is called as
g...
Lip step
It gives us the relation of lower lip to upper lip.
 According to korkhaus
 Positive lip step-Protrusion of low...
Smile Evaluation
1.

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

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Smile Evaluation
2.

3.

Crown height and width – Height is normally
9 – 12 mm. With age, it increases due to
apical migra...
Smile Evaluation
4.

Smile arc – It is the relationship of the
curvature of the incisor edges of maxillary
incisors and ca...
Smile Evaluation
It can be,
 Consonant – It is the ideal smile arc with
maxillary incisal edge curvature parallel to
curv...
Smile Evaluation
5.

Buccal Corridor Width – It is measured from
mesial line angle of maxillary first premolars
to interio...
Smile Evaluation
6.

Amount of incisor Proclination
It has dramatic effects on incisor display.
Flared maxillary incisor r...
Mentolabial Sulcus




It is the concavity below the lower lip. It is
deep in Class II Division I malocclusions and
shal...
Nasolabial Angle
It is the angle formed between lower border of nose
and the line connecting the intersection of nose and
...
Chin


Projection of chin depends on bony projection
of anterio-inferior border of mandible and
amount of soft tissue ove...
Clinical FMA


Clinical examination of mandibular plane to the true
horizontal plane should be noted.

Steep Mandibular P...
Clinical FMA


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

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Visualized Treatment
Objective




This examination helps us decide whether
any functional appliance that postures the
m...
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Profile does not improve when
-Excessive anterior facial height
-Procumbency of lower incisors
-Deficient symphyseal devel...
Visualized Treatment
Objective
It helps in predicting treatment changes that
would occur in the future for the patient.

...
Functional examination
Respiration
Mirror test – A double-sided mirror is held
between the nose and the mouth. Fogging on
...
Respiration




Water Test – Patient fills the mouth with water
and retains it for some time. Oral breathers
fail to per...
Path of closure


During closure of mandible, it can undergo
both rotational + sliding movements.



Types of movements ...
Path of closure


Class II Malocclusion

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Path of closure


Class III Malocclusion

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Postural Rest Position
It is 2-3 mm below & behind the centric occlusion
(recorded at canine). This position depends on
he...
Postural Rest Position
-

-

-

Non Command Method
Distract the patient + note the mandibular
position when patient relaxe...
Postural Rest Position


Influences

Short Term

Long Term

1. Inconsistency in
muscle tonicity
2. Respiration
3. Body Po...
Interocclusal clearance


It is the distance between the upper and
lower canines when they mandible is at the
postural re...
Temporo Mandibular Joint


Auscultation: -

 Initial Clicking- Retruded condyle in relation to
articular disc
 Intermed...
Temporo Mandibular Joint
 Pain on Palpation – Lateral pterygoid muscle
palpatory pain is common in children.
 Masseter m...
Range of motion


Maximum mouth opening - It is measured as the
distance between the upper and lower incisal
edges.it is ...
Range of motion


Lateral excursions - The patient is asked to
move the mandible laterally and the distance
between the m...
Intra Oral Examination

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Soft Tissues


ORAL HYGIENE STATUS & BRUSHING
HABITS



Rapid Orthodontic treatment requires the
patient to maintain a g...
Gingiva


Localised gingival lesions may suggest,

Traumatic occlusion
Poor oral hygiene
Delayed eruption of permanent te...
Gingiva
The texture and colour of gingival tissue is an index of
periodontal health.
Gingival diseases and periodontal di...
Frenal Attachment
A thick, fibrous, low maxillary frenum may lead to malocclusion
by leading to a midline diastema. The ma...
Tongue
Size: The tongue can be small, long or broad. A long
tongue can usually reach the tip of the nose.
Macroglossia imp...
Tongue





Movements:
They may be restricted due to ankyloglossia.
Proffit has stated that the resting pressure of
the...
Palatal Contour








The palate may be,
- Shallow
- Normal
- Deep

Shallow palate may be seen in broad arch forms...
Circumoral muscle tone


Abnormal circumoral muscle tone tends to
accentuate the developing malocclusions.So,
during trea...
Hard Tissues
Teeth present
Number of teeth present,number of deciduous
teeth,number of permanent teeth,teeth which are
mi...
Caries


It is one of the local causes of malocclusion.

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Caries


It results in premature loss of tooth leading to
drifting of adjacent tooth, abnormal axial
inclination, over er...
Teeth size shape form
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
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Variations in size of teeth are seen due to
- sex, males have larger teeth than females
...
Teeth size shape form
Shape
Variations in shape occurs most commonly iin
maxillary lateral incisors.


According to Garn...
Key Ridge


The key ridge is the prominence below
the molar process which divides the
canine from the infra temporal foss...
Gnathic examination - Arch
Shape: It can be average,V shaped,U shaped or
square.


Symmetry: Etiology of asymmetry includ...
Crowding


It can be classified according to amount of
space deficiency (Mixed Dentition)

 First Degree
- Slight malali...
Crowding
 Third Degree
- Severe malalignment of anterior teeth
- Adjacent permanent teeth undermines the
deciduous teeth ...
Crowding
Classification according to etiology.
 Primary - Hereditary
- Disproportion between size of jaws
- Persistence o...
Crowding
Tertiary
- Primarily lower anterior crowding
- Occurs in 18-20 year olds
- Causes:- Eruption of third molars, Di...



-

-

According to inclination,
Coronal crowding
There is this harmony between width of apical
base and dental arch d...
Crowding


-

-

Apical crowding
There is disharmony in width of apical base &
maxillary dental arch. Upper posteriors ar...
Spacing






Spacing in deciduous dentition is normal.
However in permanent dentition, it is
unesthetic.
It is a resul...
Rotations


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

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Curve of Spee
Curve of spee in normal occlusion is not deeper than
1.5 mm. There is good intercuspation around premolars
a...
Curve of Spee


Reverse curve of spee creates excessive
space in the upper jaw and insufficient space
in the lower jaw. T...
Curve of Spee
Excessive curve of spee restricts the space available
for upper teeth, thus they move towards the mesial
and...
Angles classification


Dr. Edward Angle described three (3) classes
of malocclusion based on the occlusal
relationship o...
Class I Malocclusion
Mesio buccal cusp of maxillary first permanent molar
occludes in buccal grew of mandibular first perm...
Class II Malocclusion
Disto- buccal cusp of maxillary first permanent molar
occludes in the buccal grew of mandible.


Di...
Class II Malocclusion
Division 2: Retroclined upper central incisors
Overlapping of lateral incisors on central
Deep overb...
Class III Malocclusion



Mesio buccal cusp of maxillary first permanent
molar occludes in the inter dental space between...
TRUE Class III
True Class III: It is a skeletal malocclusion showing,
v Edge to edge relationship or anterior cross bite
v...
Pseudo Class III









(Postural or Habitual Class III): It involves the forward movement of the
mandible during ...
Canine relationship
Class I canine relation-this is a normal relation
where the upper canine overlaps the distal
incline o...
Incisor relationship
It is based on relationship of lower incisal edge to the
cingulum of upper central incisors.
 Class ...
Incisor relationship
Class II
Mandibular incisal edges lie posterior to the
cingulum of maxillary central incisors
Divisio...
Over Jet


Over jet is the horizontal over lap of the incisors.
Normally the incisors are in contact with the upper
incis...
Over Jet




Open bite can classified on the basis of
localization of malocclusion
Anterior open bite
-Caused by tongue ...
Over Jet
Lateral open bite
-Tongue thrusts between the teeth laterally
-There is also a disturbance in physiologic growth
...
Over Jet





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

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Over Bite




It is the vertical over lap of the incisors.
Normally the lower incisal edges contact the
lingual surface ...
Deep Bite
Deep bite can be,
Dentally supported
Gingivally supported


In deciduous dentition, incisal overlap of more
t...
Over Bite
Closed Bite:It it caused by increased forward and upward rotation
of mandible occurring due to lack of posterio...
Over Bite
Classification according to Hotz and Muhlemann,
True deep over bite
-Large free ray space
-Infra occlusion of m...
Vertical Malposition



-

-

-

It is the malocclusion in relation to occlusion
plane. It usually occurs along with irr...
Cross Bite





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-

-

When the lower incisors are in front of the
upper incisors, the condition is called as
reverse ...
Cross Bite
Posterior cross bite exists when maxillary posterior
teeth are lingually positioned relative to mandibular
teet...
Midline Deviation
It can be,
 Dento
alveolar
 Skeletal
 Combined
OR
 Maxillary
 Mandibular
 Combined
www.indiandenta...
References
Orthodontics Current Principles and Techniques
Thomas Graber , Robert Vanarsdall, Katherine Vig

Orthodontic di...
Thank you
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Extra oral examination /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Extra oral examination /certified fixed orthodontic courses by Indian dental academy

  1. 1. Extra Oral Examination www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. Shape of Head Cephalic index = Maximum skull width / Maximum skull length www.indiandentalacademy.com
  4. 4. 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  www.indiandentalacademy.com
  5. 5. 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 www.indiandentalacademy.com
  6. 6. 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 www.indiandentalacademy.com
  7. 7. 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. www.indiandentalacademy.com
  8. 8. 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 www.indiandentalacademy.com
  9. 9. Shape of Head Mesocephalic (76.0 – 80.9) - Average shape of head - They have normal dental arches www.indiandentalacademy.com
  10. 10. 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) www.indiandentalacademy.com
  11. 11. Facial Form Morphologic facial height  distance between nasion & gnathion Bizygomatic width  distance between the zygoma points. Morphologic facial index = Morphologic facial height / Bizygomatic width www.indiandentalacademy.com
  12. 12. 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) www.indiandentalacademy.com
  13. 13. Facial Form - Mesoprosopic – Average or normal face (84.0 – 87.9) www.indiandentalacademy.com
  14. 14. 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) www.indiandentalacademy.com
  15. 15. Facial Form  Face can be divided into 3 equal parts. By horizontal lines adjacent to hairline, Nasal base and Menton. www.indiandentalacademy.com
  16. 16. 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. www.indiandentalacademy.com
  17. 17. 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. www.indiandentalacademy.com
  18. 18. 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. www.indiandentalacademy.com
  19. 19. Facial Profile www.indiandentalacademy.com
  20. 20. 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 www.indiandentalacademy.com
  21. 21. Facial Divergence  It is the anterior or posterior inclination of the lower face relative to the forehead. Straight Anterior divergence Posterior divergence www.indiandentalacademy.com
  22. 22. Facial Symmetry  Asymmetries that are gross and easily detectable should be recorded. www.indiandentalacademy.com
  23. 23. Facial Symmetry  a) b) c) 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. www.indiandentalacademy.com
  24. 24. 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. www.indiandentalacademy.com
  25. 25. 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 www.indiandentalacademy.com
  26. 26. Lip seal  Based on the lip seal the lips can be classified as Competent – Lips are in slight contact when the musculature is relaxed www.indiandentalacademy.com
  27. 27. 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 www.indiandentalacademy.com
  28. 28. Lip seal Potentially Incompetent – Normal lips that fail to form a lip seal due to protruding upper incisors. www.indiandentalacademy.com
  29. 29. Lip seal  Everted / Curled – They are hypertrophic lips with redundant tissue but weak muscular tonicity. www.indiandentalacademy.com
  30. 30. 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. www.indiandentalacademy.com
  31. 31.     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 www.indiandentalacademy.com
  32. 32. 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. www.indiandentalacademy.com
  33. 33. 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.  www.indiandentalacademy.com
  34. 34. 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 www.indiandentalacademy.com
  35. 35. 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 www.indiandentalacademy.com
  36. 36. Smile Evaluation 1. Amount of incisor display - It may be the entire or only a percentage of upper incisor. www.indiandentalacademy.com
  37. 37. Smile Evaluation 2. 3. 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. www.indiandentalacademy.com
  38. 38. Smile Evaluation 4. 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. www.indiandentalacademy.com
  39. 39. 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 www.indiandentalacademy.com
  40. 40. Smile Evaluation 5. 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. www.indiandentalacademy.com
  41. 41. Smile Evaluation 6. Amount of incisor Proclination It has dramatic effects on incisor display. Flared maxillary incisor reduces incisor display and upright maxillary incisors increases incisor display. www.indiandentalacademy.com
  42. 42. 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. www.indiandentalacademy.com
  43. 43. 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.  www.indiandentalacademy.com
  44. 44. 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  www.indiandentalacademy.com
  45. 45. 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  www.indiandentalacademy.com
  46. 46. Clinical FMA  It is visualized by placing a finger or a mirror handle along the lower border of mandible. www.indiandentalacademy.com
  47. 47. 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. www.indiandentalacademy.com
  48. 48. www.indiandentalacademy.com
  49. 49. 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  www.indiandentalacademy.com
  50. 50. 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.  www.indiandentalacademy.com
  51. 51. 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  www.indiandentalacademy.com
  52. 52. 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 www.indiandentalacademy.com
  53. 53. 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. www.indiandentalacademy.com
  54. 54. Path of closure  Class II Malocclusion www.indiandentalacademy.com
  55. 55. Path of closure  Class III Malocclusion www.indiandentalacademy.com
  56. 56. 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 saliva - www.indiandentalacademy.com
  57. 57. Postural Rest Position - - - 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. www.indiandentalacademy.com
  58. 58. Postural Rest Position  Influences Short Term Long Term 1. Inconsistency in muscle tonicity 2. Respiration 3. Body Posture 4. Stress 5. TMS dysfunction 1. Attrition 2. Premature loss of teeth 3. Diseases of neuro muscular system www.indiandentalacademy.com
  59. 59. 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. www.indiandentalacademy.com
  60. 60. 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 www.indiandentalacademy.com
  61. 61. 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 www.indiandentalacademy.com
  62. 62. 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. www.indiandentalacademy.com
  63. 63. 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 www.indiandentalacademy.com
  64. 64. Intra Oral Examination www.indiandentalacademy.com
  65. 65. 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. www.indiandentalacademy.com
  66. 66. Gingiva  Localised gingival lesions may suggest, Traumatic occlusion Poor oral hygiene Delayed eruption of permanent teeth Hyper activity of mentalis muscle Mouth breathing www.indiandentalacademy.com
  67. 67. 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  www.indiandentalacademy.com
  68. 68. 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.  www.indiandentalacademy.com
  69. 69. 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)  www.indiandentalacademy.com
  70. 70. 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 www.indiandentalacademy.com
  71. 71. 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. www.indiandentalacademy.com
  72. 72. 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. www.indiandentalacademy.com
  73. 73. 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.  www.indiandentalacademy.com
  74. 74. Caries  It is one of the local causes of malocclusion. www.indiandentalacademy.com
  75. 75. 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. www.indiandentalacademy.com
  76. 76. 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. www.indiandentalacademy.com
  77. 77. 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  www.indiandentalacademy.com
  78. 78. 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   www.indiandentalacademy.com
  79. 79. 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 www.indiandentalacademy.com
  80. 80. 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 www.indiandentalacademy.com
  81. 81. 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. www.indiandentalacademy.com
  82. 82. 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  www.indiandentalacademy.com
  83. 83. 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 www.indiandentalacademy.com
  84. 84.   - - 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 www.indiandentalacademy.com
  85. 85. 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 www.indiandentalacademy.com
  86. 86. 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. www.indiandentalacademy.com
  87. 87. Rotations  It may be centric or eccentric.localization of axis of rotation is important www.indiandentalacademy.com
  88. 88. 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.  www.indiandentalacademy.com
  89. 89. 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. www.indiandentalacademy.com
  90. 90. 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.  www.indiandentalacademy.com
  91. 91. Angles classification  Dr. Edward Angle described three (3) classes of malocclusion based on the occlusal relationship of the first molars www.indiandentalacademy.com
  92. 92. 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 www.indiandentalacademy.com
  93. 93. Class II Malocclusion 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 www.indiandentalacademy.com
  94. 94. Class II Malocclusion Division 2: 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. www.indiandentalacademy.com
  95. 95. Class III Malocclusion  Mesio buccal cusp of maxillary first permanent molar occludes in the inter dental space between the mandibular first and second molars. www.indiandentalacademy.com
  96. 96. TRUE Class III True Class III: It is a skeletal malocclusion showing, v Edge to edge relationship or anterior cross bite v Narrow upper arch and broad lower arch v Crowding in upper teeth and spacing in the lowers v Concave profile with prominent chin v May show anterior open bite www.indiandentalacademy.com
  97. 97. 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 www.indiandentalacademy.com
  98. 98. 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  www.indiandentalacademy.com
  99. 99. 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 www.indiandentalacademy.com
  100. 100. 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  www.indiandentalacademy.com
  101. 101. 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., www.indiandentalacademy.com
  102. 102. 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. www.indiandentalacademy.com
  103. 103. Over Jet Lateral open bite -Tongue thrusts between the teeth laterally -There is also a disturbance in physiologic growth processes around molar region  www.indiandentalacademy.com
  104. 104. Over Jet    Complex open bite -Severe vertical malocclusion - Teeth occlude only on second molars www.indiandentalacademy.com
  105. 105. 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. www.indiandentalacademy.com
  106. 106. 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 upper anterior alveolar process www.indiandentalacademy.com 
  107. 107. 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  www.indiandentalacademy.com
  108. 108. 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  www.indiandentalacademy.com
  109. 109. 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 www.indiandentalacademy.com
  110. 110. 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 www.indiandentalacademy.com
  111. 111. 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  www.indiandentalacademy.com
  112. 112. Midline Deviation It can be,  Dento alveolar  Skeletal  Combined OR  Maxillary  Mandibular  Combined www.indiandentalacademy.com
  113. 113. 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 www.indiandentalacademy.com
  114. 114. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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