orthodontics diagnosis

1. ORTHODONTIC
DIAGNOSIS
DR RITESH SHIWAKOTI

2. CASE HISTORY
 Case history involves eliciting and recording of
relevant information from the patient and parent
to aid in overall diagnosis of the case
PERSONAL DETAILS:
NAME :the patient’s name should be recorded for
the purpose of communication and identification.
BIRTHDATE : to assist growing age and for diagnosis
and treatment planning.

3.  AGE-the patients chronological age should be
recorded. Age consideration helps in diagnosis as
well as treatment planning.
 growth modification procedures using functional
and orthopaedic appliances are carried out
during growth period.
 SEX-patient’s sex should be recorded in case
history.
 This is important in planing treatment,as the timing
of growth events such as growth spurts is different
in males and females.

4.  ADDRESS AND OCCUPATION-recording of address
and occupation helps in evaluation of socio-economic
status of the patient and the parents.
 CHIEF COMPLIANT -the patient’s chief compliant
should be recorded in his/ her on words.
 This help the clinician in identifying the priorities
and the desires of the patient.

5. GENERAL EVALUTATION
 Height and weight-they provide clue to the
physical growth and maturation of the patient.
 Gait-(way a person walks) abnormalities of gait
are usually associated with neuromuscular
disorders that may have a dental correlation.
 Posture-(way a person stands)abnormal postures
can predispose to malocclusion due to alteration
in maxillo-mandibular relationship.

6. FACIAL STRUCTURE
 The patient’s facial symmetry is examined to
determine disproportions of the face in transverse
and vertical planes. Gross facial asymmetry can
occur as a result of:
A. Congenital defects
B. Hemi-facial atrophy/hypertrophy
C. Unilateral condylar ankylosis and hyperplasia

7. FACIAL PROFILE
 The facial profile is examined by viewing the
patient from the side. The facial profile helps in
diagnosing the gross deviation of maxillo-mandibular
relationship. the profile is assessed by
joining the following two reference lines.
1. A line joining the forehead and the soft tissue
point A(deepest point in curvature of upper lip)
2. A line joining point A and the soft tissue
pogonion(most anterior part of the chin)

8.  STRAIGHT PROFILE-the two lines form nearly
straight line.
 CONVEX PROFILE-the two lines form an angle with
concavity facing the tissue.
This kind of profile occurs as a result of prognathic
maxilla retrognathic mandible as seen in CLASS
11,DIVISON 1 MALOCCLUSION.
STRAIGHT PROFILE CONVEX PROFILE

9.  COCAVE PROFILE-the two reference lines form an
angle with convexity towards tissue.
 This type of profile is associated with a prognathic
mandible or retrognathic maxilla as in CLASS 111
MALOCCLUSION.

10. FUNCTIONAL ANALYSIS

11. TMJ
 Clicking ,popping or crepitus.
 Deviation or Deflection while opening.
 Pain or tenderness over joint or masticatory
muscles.
 Maximal inter Incisal opening ( 40-45 mm)
 Range of vertical & lateral movements.

12. PALPATION OF PRE TRAGUS AREA:
 The examiner can be positioned either in front of or behind the
patient.
 Patient is asked to slowly open and close the mouth.Palpation
with index finger,placed in the pre tragus depression is done.
INTRA AURICULAR PALPATION:
 Performed by inserting small finger into the ear canal and
pressing anteriorly.
 While palpating with this methods check whether condyle
moves symmetrically, with the rotation and translation phase.

13. INTER-OCCLUSAL CLEARANCE.
 The postural rest position of the mandible at which the
muscles that closes the jaw and those that open them
are, in state of minimal contraction to maintain the
posture of mandible.
 At postural rest position, a space exists between the
upper and lower jaws.
 This space is known as FREEWAY SPACE.
 FREEWAY SPACE is 3mm in canine region.

14.  VERNIER CALIPERS CAN BE USED DIRECTLY IN THE
PATIENT’S MOUTH IN THE CANINE OR INCISAL
REGION TO MEASURE FREEWAY SPACE.
 THIS IS DIRECT INTRA ORAL METHOD.

15. PATH OF CLOSURE
The path of closure is the movement of mandible from
the rest position to habitual occlusion .
 Forward path of closure: a forward path of closure
occurs in patients with mild skeletal and
prenormalcy or edge to edge incisor contact. In
such patients ,the mandible is guided to a more
forward position to allow the mandibular incisors to
go labial to the upper incisors.
 Backward path of closure: class 11 ,division 2 exhibit
premature incisor contact due to retroclined
maxillary incisors. Thus the mandible is guided
posteriorly to establish occlusion
 Lateral path of closure : lateral deviation of
mandible to left or right side is associated with
occlusal prematurities and a narrow maxillary arch

16. ASSESSMENT OF ANTERO-POSTERIOR
JAW RELATIONSHIP
 It can be assessed clinically.
 Ideally maxillary skeletal base is 2-3 mm ahead of
the mandibular skeletal base when the teeth are
in occlusion.
 Estimation is done by placement of index and
middle fingers at the soft tissue point A and point
B respectively.

17.  In skeletal CLASS1 PATIENTS, the index finger is
anterior to middle finger or the hand points
upwards.

18.  In a skeletal CLASS 11 patient, the middle finger is
ahead of the forefinger or the hand points
downwards.

19.  In a patient with CLASS 111 skeletal pattern the
hand is at an even level.

20. ASSESSMENT OF VERTICAL
SKELETAL RELATIONSHIP
 The vertical skeletal relationship assessed by studying
the angle formed between the lower border of the
mandible and the Frankfort horizontal plane(a line
between the most superior point of external auditory
meatus and inferior border of orbit)
 Normally the two planes intersects at the occipital
region.
 In case the two planes meets beyond the occipital
region, it indicates a low angle case or a horizontal
growing face.
 If two planes meet anterior to occipital region it
indicates a high angle case or a vertical growing
face.

21. Assessment of vertical facial height

22. EVALUATION OF FACIAL
PROPORTIONS
 A WELL PROPORTIONED FACE CAN BE DIVIDED
INTO THREE EQUAL VERTICAL THIRDS USING FOUR
HORIZONTAL PLANES AT THE LEVEL OF THE
HAIRLINE,THE SUPRA ORBITAL RIDGE, THE BASE OF
THE NOSE AND THE INFERIOR BORDER OF CHIN
 WITHIN THE LOWER FACE, THE UPPER LIP OCCUPIES
A THIRD OF THE DISTANCE WHILE CHIN OCCUPIES
THE REST OF THE SPACE.

23. EXAMINATION OF LIPS
 The upper lip covers the entire labial surface of
upper anteriors except the incisal 2-3 mm during
rest position.
 The lower lip covers the entire labial surface of
lower anteriors and 2-3 mm of incisal edge of
upper anteriors during rest position.

24. CLASSIFICATION OF LIPS
 COMPETENT LIP-THE LIPS ARE IN SLIGHT CONTACT
WHEN MUSCULATURE IS RELAXED.

25.  INCOMPETENT LIPS-they are morphologically short
lips which do not form a lip seal in a relaxed state.
 The lip seal can only be achieved by active
contraction of perioral and mentalis muscle.

26.  POTENTIALLY INCOMPETENT LIP-they are normal
lips that fails to form a lip seal due to proclaimed
upper incisor.
 EVERTED LIP-they are hypertrophied lips with weak
muscular tonicity.
 Lip are seperated at rest by more than 3-4 mm .
 Measured by vernier caliper

27. An imaginary line is drawn from the tip of the nose to
the tip of the chin called as E line.
If the lip is significantly forward from this line it can be
judged to be prominent, if the lip fall behind this
line it is retrusive.
Lower lip to E line measures = -2 mm

28. Gingival display
Ideal = 2.3 mm tooth coverage
Maximum = 0.8 mm tooth coverage
Minimum = 4.5 mm tooth coverage
Incisal display at rest = 2-3 mm

29. Overjet refers to the extent of horizontal (anterior-posterior)
overlap of the maxillary central incisors
over the mandibular central incisors
Normal 1mm – 2mm
Mild 3mm- 4mm
Moderate 5 – 6 mm
Severe - more than 7 mm

30. Overbite refers to the extent of vertical (superior-inferior)
overlap of the maxillary central incisors
over the mandibular central incisors, measured
relative to the incisal ridges.
0-2 mm = normal
3-4 mm = slightly deep
5-7 mm = moderately deep
>7 mm = significantly deep

31. Abnormal occlusion in the transverse plane. It is a
condition where one or more teeth may be
abnormally malposed bucally or lingually or
labially with reference to opposing tooth or teeth
Anterior crossbite
Single tooth
Segmental
Posterior crossbite
Unilateral
Bilateral

32. Upper and lower crowing: discrepancy between the
tooth size and the arch width leads to crowding
0-1 mm = Normal
2-3 mm = Mild crowding
4-6 mm = Moderate crowing
>7 mm = Severe

33. Angle’s classification of malocclusion:
Canine relationship:
Class I relation: It means, mesial inclination of the
cusp of the upper canine which overlaps the
distal incline of the cusp of lower canine.
Class II relation: Distal incline of cusp of upper canine
overlaps the mesial incline of the cusp of the
lower canine.
Class III relation: lower canine is forwardly placed
compared to upper canine.

34. Class I molar relation: Mesiobuccal cusp of the
permanent maxillary first molar occludes in
mesiobuccal groove of first permanent
mandibular molar.
Class II relation: distobuccal cusp of the permanent
maxillary first molar occlude in mesiobuccal
groove of first permanent mandibular molar.
Division I : class II molar relation on either side with
proclined maxillary anteriors.

35. Division II : class II molar relation with retroclined
maxillary anterior.
Class III : mesiobuccal cusp of maxillary first
permanent molar occludes interdentally between
first and second mandibular molar.
End to End relation: the cusp of upper and lower first
permanent molar are in same plane.
Flush terminal plane: A relationship between primary
teeth in which the buccal(distal) surfaces of the
opposing second molars are aligned when
occlusion is centric.

36. Arch length :
Overall ratio = sum of mand 12* 100/sum of max 12
Overall ratio = 91.3%
If < 91.3 max excess
If > 91.3 mand excess

37. Curve of spee
Normal = 2-4 mm
Flat = 0-2 mm
Deep = >/= 2 mm

38. Palate contour:
High ( V shaped )
Normal ( U shaped )
Low ( Flat )

39. Arch width:
Wide : increase inter canine width and increased
inter molar width
Narrow : decreased inter canine and inter molar
width
Normal

40. Arch form:
Symmetrical
Asymmetrical
Caries :
High
Moderate
Low

41. Tongue
Normal : Tongue lies in the floor of the mouth with
the tip forward & slightly below the incisal edges
of the mandibular anterior teeth.
Large : The tongue is flattened &broadened but the
tip is in a normal position.
Small :the tongue is retracted & depressed into the
floor of the mouth ,with the tip curled upward,
downward or assimilated into the body of
tongue.•.

42.  Lingual frenum.
Normal : lingual frenum is loosely attached to the
floor of the mouth.
Short : lingual frenum is short and leads to tongue
tie.
Broad : fan shaped.

43.  Tonsils and adenoid
Enlarged
Inflamed
Moderate
Small
Not visible
Removed

44. Gingiva :
Healthy
Marginal irritation
Inflamed
Bleeding
Hypertrophic
Recessed

45. Hygiene :
Good
Fair
Poor
Habits:
None , thumb , finger

46. Cephalometric reading :
Study of area maxillary to cranial base and
mandible to cranial base and maxillo-mandibular
relationship gives us idea that malocclusion is of
skeletal origin.
Vertical height is used to denote if a person has
vertical or horizontal growing face.
Maxillary mandibular incisor position : denotes
malocclusion is of dental origin
Normal soft tissue line = -2mm