CASE HISTORY AND

CLINICAL EXAMINATION

UNDER THE ABLE GUIDANCE

OF:
Dr. RAKESH KOUL (PROF) Presented by:
Sana Mahtab (JR 1)
Dr. RAM AUTAR (PROF & HOD) Department of Orthodontics
Dr. SHANTANU KHATTRI (PROF) and Dentofacial Orthopaedics

Dr. MADHVI BHARDWAJ (PROF)

Dr. VIJAYTA YADAV (READER)
 INTRODUCTION
Recognizing the problem

Formulating the problem

Carrying out the necessary examination

Interpretation of the results

Diagnosis
 DIAGNOSTIC AIDS
 ESSENTIAL  SUPPLEMENTAL
DIAGNOSTIC AIDS: DIAGNOSTIC AIDS:
1. Case history. 1. Specialized radiographs;
like
2. Clinical examination.
a. Occlusal views of maxilla
3. Study models. and/or mandible.
4. Certain radiographs: b. Selected lateral jaw
a. Periapical views, etc.
radiographs. 2. Electromyographic examination of
b. Lateral muscle activity.
radiographs. 3. Hand-wrist radiographs.
4. Computed axial tomography (CT
c. Orthopantomogra
scan).
ms.
5. Magnetic Resonance Imaging
d. Bite wing (MRI).
radiographs. 6. Endocrine tests and/or other blood
5. Facial photographs. tests.
7. Estimation of the basal metabolic
 CASE HISTORY
Case history is the information gathered from the patient and/or parent to
aid in the overall diagnosis of the case.
It includes:
Personal details:
• Name
• Age
• Sex
• Address & occupation
Chief complaint.
Medical history.
Dental history.
Prenatal history.
Postnatal history.
Family history.
 PERSONAL DETAILS

Name:
• Recorded For communication and identification.

Age and Date of Birth:

• The chronologic age of the patient helps in diagnosis,
treatment planning and growth prediction.

• Certain transient conditions, which might be perceived

as malocclusion by the patient and parents, can be
identified .

• The age of the patient also dictates the use of certain

treatment protocols.
Sex:
• Sex of the patient also helps in treatment
planning.

• Girls mature earlier than boys the timing of

growth related events including growth spurts,
eruption of teeth and onset of puberty are
different in males and females.

Address & occupation:

• Important for records, communication,
assessing the socioeconomic status.
 CHIEF COMPLAINT:
• The patient's chief complaint should be recorded in his
or her own words.

• It should mention the conditions the patient

feels
he/she is suffering from.

• This helps in identifying the priorities and desires of the

patients.

• The parent's perception of the malocclusion should also

be noted. This will help in setting the treatment
objectives and satisfying the patient in general.

• There are three major reasons for patient concern about

the alignment and occlusion of the teeth: ( esthetics ,
 MEDICAL HISTORY:

• Knowledge of a patient's general health is essential and

should be obtained prior to examination.

• It is best obtained by a questionnaire.

• In most cases orthodontic treatment can be undertaken

but precautions may be required prior to extractions.

• For example: Antibiotic coverage may be required in

patients with rheumatic fever or cardiac anomalies even
for molar band placement/removal, if the adjacent gums
are inflamed or bleeding is anticipated.

• Mentally or physically challenged patients may require

special management.
 DENTAL HISTORY:

• The patient's dental history should include

information on the age of eruption and exfoliation of
deciduous and permanent teeth.

• Reason for exfoliation will also hint at the oral hygiene

maintenance capabilities of the patient.

• The past dental history will also help in assessing the

patients and parents attitude towards dental health.
 PRENATAL HISTORY:

• Prenatal history should concentrate on the

condition of the mother during pregnancy and
the type of delivery.

• Her nutritional state and any infections that she

might have will affect the developing teeth of the
child.

• The use of certain drugs or even excess use of

certain vitamins can result in congenital
deformities of the child
 POSTNATAL HISTORY:

• The postnatal history should concentrate on the type

of feeding, presence of habits like digit/thumb
sucking.
 FAMILY HISTORY:

• Skeletal malocclusions especially skeletal Class III

malocclusions and congenital conditions such as
cleft lip and palate are inherited.
 CLINICAL EXAMINATION
General examination:
1. Body build.
2. Cephalic and facial examination.
3. Assessment of facial symmetry.
4. Facial profile.
5. Facial divergence.
Assessment of anteroposterior jaw relationship.
Assessment of vertical skeletal relationship.
Examination of the soft tissues.
6. Extraoral
7. Intraoral
Clinical examination of the dentition.
Functional examination:
8. Assessment of postural rest position and maximum intercuspation.
9. Examination of the temporomandibular joint.
10. Examination of orofacial dysfunctions.
 GENERAL EXAMINATION

• The clinician should observe the gait, posture and physique

of the patient.

• Abnormal gait may be present due to an underlying

neuromuscular disorder.

• Abnormal posture also may lead to malocclusions.

• Height and weight are recorded to assess for the physical

growth and development of the patient.
 1. BODY BUILD

a. Ectomorphic: Tall and thin physique

b. Mesomorphic: Average physique
c. Endomorphic: Short and obese physique .
 2. CEPHALIC AND FACIAL EXAMINATION:
• Martin and Saller (1957) formulated cephalic index & facial
index which concluded that:

• The shape of the head may be:

a. Mesocephalic
(average skull proportions)

b. Dolicocephalic
(long, narrow skull)

c. Brachycephalic
(short, broad skull)

d. Hyper brachycephalic
• The shape of the face may be:
a. Hyper Euryprosopic
b. Euryprosopic (low facial Skeleton)
c. Mesoprosopic (average facial skeleton)
d. Leptoprosopic (high facial skeleton)
e. Hyper Leptoprosopic
3. ASSESSMENT OF FACIAL SYMMETRY:
• A certain degree of asymmetry between the right and left sides of the
face is seen in most individuals.
• The face should be examined in the transverse and vertical planes to
determine a greater degree of asymmetry than is considered normal.
• Gross facial asymmetries may be seen in patients with:
i. Hemifacial hypertrophy / atrophy.
ii. Congenital defects.
iii. Unilateral condylar hyperplasia.
iv. Unilateral Ankylosis.

A 3-year-old girl with unilateral condylar

ankylosis following trauma at birth
 4. FACIAL PROFILE:

• The profile is examined from the side by

making the patient view at a distant object,
with the FH plane parallel to the floor.

• Clinically or in extraoral photographs, the

profile can be obtained by joining two
reference lines:
a. Line joining forehead and soft tissue point A .
b. Line joining point A and soft tissue pogonion.
• Three types of profiles are seen:

a. Straight / orthognathic profile :

• The two lines form an almost straight line.

b. Convex profile :
• The two lines form an acute angle with the concavity facing
the tissues.
• This type of profile is seen in Class II div 1 patients due to
either a protruded maxilla or a retruded mandible.

c. Concave profile:
• The two lines form an obtuse angle with the convexity
facing the tissues.
• This type of profile is seen in Class III patients due to either
a protruded mandible or a retruded maxilla.
 5. FACIAL DIVERGENCE:
• The inclination of the lower face is termed as the facial divergence,
which may be influenced by the patient's ethnic or racial background.

• A line is drawn from the forehead to the chin to determine whether

the
face is:
a. Anterior divergent (line inclined anteriorly)
b. Posterior divergent (line inclined posteriorly)
c. Straight/orthognathic (straight line, no slant seen)
 ASSESSMENT OF VERTICAL
SKELETAL RELATIONSHIP

• A normal vertical relationship is one where the distance

between the glabella and subnasale is equal to the
distance from the subnasale to the under side of the chin.

• Reduced lower facial height

usually associated with deep
bites while increased lower
facial height is seen in anterior
open bites.
 EXAMINATION OF THE SOFT
TISSUES

A.Extraoral examination:

• The esthetic prognosis of an

orthodontic case is determined by
its profile, which in turn is
influenced by the shape of the
forehead and the nose.
1. Forehead
• For a face to be harmonious, the
height of the forehead (distance
from hairline to glabella) should
be as long as the mid-third
(glabella-to-subnasale) and the
lower third (subnasale-to-
menton), i.e. each of these is one-
third the total face height.

• Dental bases are more

prognathic in cases with a steep
forehead, than with a flat
forehead
2. Nose
• Size, shape and position of the nose determines the
esthetic appearance of the face and is therefore important
in the prognosis of a case.

3. Lips
• Lip length, width and curvature should be assessed.

• In a balanced face, the length of the upper lip measures one-

third, the lower lip and chin two thirds of the lower face
height.

• The upper incisal edge exposure with the upper lip at rest
should be normally 2 mm.
 • Lips can be classified into:
a. Competent lips:
• Slight contact of lips when musculature is
relaxed

b. Incompetent lips:
• Anatomically short lips, which do not contact
when musculature is relaxed.
• Lip seal achieved only by active contraction
of the orbicularis oris and mentalis muscles.

c. Potentially competent lips:

• Lip seal is prevented due to the protruding
maxillary incisors despite normally
developed lips.

d. Everted lips:
• These are hypertrophied lips with redundant
tissue but weak muscular tonicity
4. Chin
The configuration of the chin is
determined by bone structure, the
thickness and tone of the mentalis
muscle.

• Mentalis activity:
A normal mentalis muscle becomes
hyperactive in certain malocclusions
like Class II div 1 cases, where
puckering of the chin may be seen.

• Mentolabial sulcus:
It is the concavity present below the lower
lip.

Deep sulcus is seen in Class II cases whereas

a shallow sulcus is seen usually in
bimaxillary protrusion cases.
o Along with the chin width, development
of chin height is important. Chin height is
the distance from the Mentolabial sulcus
to menton.
o Over development of chin height alters
the lower lip position and interferes with
lip closure.

o Prominent chin is usually associated with

Class III malocclusions.
o Whereas recessive chin is seen in Class II
malocclusion.
B. INTRAORAL EXAMINATION:
1. Tongue
• Tongue is for shape, color and
examined
configuration.
• Tongue size can be roughly estimated with the help
of a lateral cephalogram.

• An excessively large tongue

(macroglossia) usually shows
imprints on its lateral margins,
which gives the tongue a
scalloped appearance.
• The lingual frenum should be
examined for tongue tie.

• Tongue tie can lead to

impaired tongue movements.

• Abnormalities of the tongue

can upset muscle balance
equilibrium leading and
malocclusion. to
 2. LIP AND CHEEK
FRENUM
• Maxillary labial frenum is most
commonly the cause of a
malocclusion.

• A thick, fibrous, low labial

frenum prevents upper central
incisors from approximating
each other leading to a midline
diastema.
• Frenectomy is indicated when the frenum is
inserted deeply with fiber extensions into the
interdental papilla.

• A Periapical x-ray of the area may show a

bony fissure between the roots of the upper
central incisors.
• Blanch test can be done to confirm diagnosis wherein
the upper lip is stretched upward and outwards.
• Presence of blanching in the papilla region indicates an
abnormal attachment.
• The mandibular labial frenum is less often
associated with a diastema. However, it can exert a
strong pull on the free and attached gingiva leading
to recession in the lower anterior region.
 3. GINGIVA
• The gingiva should be examined for the type (thick fibrous or thin
fragile), inflammation and mucogingival lesions.

• In children, most commonly generalized marginal gingivitis occurs

due to plaque accumulation and can be resolved by improving the
oral hygiene.

• In adults, scaling followed by curettage and

sometimes mucogingival surgery is usually required.

• Local gingival lesions may occur due to occlusal

trauma, abnormal
functional loadings or medication (e.g. Dilantin).
• In mouth breathers, open lip posture causes dryness
of the mouth leading to anterior marginal gingivitis.
• Gingivitis is considered a contraindication
for orthodontic treatment.
• Treatment should be started only when the gingival
condition improves.
 4. PALATE
• The palatal mucosa is examined for:
a. Pathologic palatal swelling: Indicative of
displaced/ impacted tooth germ, cysts, etc.
b. A traumatic deep bite can lead to mucosal
ulcerations and
indentations.
c. Palatal depth and shape varies in accordance with the
facial form, e.g. Brachyfacial patients have broad and
shallower palates as compared to dolicofacial patients.
d. Presence of clefts of varying degree may be seen. Scar tissue
following palatal surgery prevents normal development of
the maxillary arch
e. Rugae can be used as a diagnostic criterion for anterior
proclination. Third rugae is normally in line with the
canines.
 5. TONSILS AND ADENOIDS
• The size and presence of inflammation in the tonsils,
if present, should be examined.
• Prolonged inflammation of the tonsils causes
alteration of the tongue and jaw posture, upsets the
orofacial balance and can result in "Adenoid facies".
 CLINICAL EXAMINATION OF THE
DENTITION

The dentition is examined for:

1. The dental status, i.e. of teeth present,

number
unerupted or missing.
2. Dental and occlusal anomalies should be recorded in
detail. Carious teeth should be treated before
beginning orthodontic treatment. Dentition should be
examined for other malformation, hypoplasia,
restorations, wear and discoloration.
3. Assessment of the apical bases
• Sagittal plane Check whether molar relation is Class I, II
or III.
• Vertical plane Overjet and overbite are
recorded and
variations like deep bite, open bite should be recorded.
• Transverse plane Should be examined for lateral shift and
cross-bite

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

midline should be examined.

5. Individual tooth irregularities, e.g.

rotations, displacements, fractured tooth

6. Shape and symmetry of upper and lower arches.

 FUNCTIONAL
EXAMINATION

• A functional analysis includes:

1. Assessment of postural rest position and
maximum intercuspation
2. Examination of the TMJ.
3. Examination of orofacial dysfunctions.
1. ASSESSMENT OF POSTURAL REST POSITION:

Postural rest position is the usual position of the mandible

when the patient is resting comfortably in the upright position
and the condyles are in a neutral unstrained position in the
glenoid fossae.

The space which exists between the

upper and lower jaws at the postural rest
position is the interocclusal clearance or
freeway space which is normally 3 mm in
the canine region.
 THE REST POSITION SHOULD BE DETERMINED
WHILE:
• The patient relaxed and seated upright with the back
unsupported.
• The head is oriented by making the patient look straight
ahead
• Frankfurt horizontal parallel to the floor.

 Methods for recording the postural

rest position:
1. Phonetic method
2. Command method
3. Non command method
4. Combined methods

• The "Tapping test" can also be carried out to

relax the musculature.
• Relaxation confirmed by palpating the submental
muscles.
EVALUATION OF THE PATH OF CLOSURE:
• The path of closure is the movement of the mandible from rest position
to full articulation.
• The amount of rotation and sliding during mandibular closure is
analyzed.

Vertical Plane:
It is important to differentiate between two types of
overbites.
a. The true deep overbite is caused by infraocclusion of the
molars and can be diagnosed by the presence of a large
freeway space.
 The prognosis with functional therapy is favorable.

b. Pseudo-deep bite is caused due to over-eruption of the

incisors and is characterized by a small freeway space.
 Prognosis with functional therapy is unfavorable.
 SAGITTAL PLANE:
In Class II malocclusions, 3 types of movements can be
seen:
a. Pure rotational movement without a sliding
component
• seen in functional true Class II malocclusion.

b. Forward path of closure

• i.e. rotational movement with anterior sliding movement.
The mandible slides into a more forward position,
therefore, Class II malocclusion is more pronounced in
habitual occlusion.

c. Backward path of closure

• i.e. rotational movement with posterior sliding movement.
In Class II div 2 cases, the mandible slides backward into
a posterior occlusal position because of premature contact
with retroclined maxillary incisors.
 TRANSVERSE PLANE:
During mandibular closure, the midline of the mandible is
observed.

• In case of unilateral crossbite, this analysis is relevant to

differentiate between laterognathy and laterocclusion:
a. Laterognathy or true crossbite :
The center of the mandible and the facial midline don't
coincide in rest and in occlusion.

b. Laterocclusion:
The center of the mandible and facial midline coincide in
rest position but in occlusion the mandible deviates due
to tooth interference leading to non-coinciding midlines.
 Rest position

Interference

Laterognathy due to Osteochondroma of

the right condyle

Laterocclusion due to
functional shift
2. Temporomandibular joint (TMJ):

• The clinical examination of the TMJ should include

auscultation and palpation of the TMJ and the
musculature associated with mandibular movements as
well as the functional analysis of the mandibular
movements.

• The main objective of this examination is to look for

symptoms of TMJ dysfunction such as crepitus, clicking,
pain, hypermobility, deviation, dislocation, limitation of
jaw movements and other morphological abnormalities.

• Adolescents with Class II div 1 malocclusions and lip

dysfunction are most frequently affected by TMJ
disorders.
3. Examination of orofacial dysfunctions:

Includes evaluation of:

• Swallowing
• Tongue
• Speech
• Lips
• Respiration
 Swallowing:
• At birth the tongue protrudes anteriorly
between the gum pads to establish lip
seal.
• Therefore the infant swallows viscerally
for the first 1.5 to 2 years of age.

• This infantile swallow is gradually

replaced by the mature
swallow as the deciduous dentition is
• completed.
If infantile swallow
beyond fourth
persistsyear, it is
the as an orofacial
considered
dysfunction.
Tongue
• Tongue thrust is one of the
most common dysfunction of
the tongue.

• Cephalograms can help to evaluate the position

and size of the tongue in relation to the available
space. However, in orthodontics diagnostic
registration of tongue position is usually more
important than its size.
• Palatography involved applying a thin layer of
contrasting impression material to the patients tongue
for registration of tongue position relative to the
palate and teeth during rest and during swallowing.
 PHOTOGRAPHS IN
ORTHODONTICS

EXTRA-ORAL PHOTOGRAPHS

1. Face-Frontal (lips relaxed).

2. Face-Frontal (Smiling).
3. Profile (Right side preferably - Lips relaxed).
4. (45 °) Profile (also known as 3/4 Profile -
Smiling).
INTRA-ORAL PHOTOGRAPHS
1. Frontal
2. Right Buccal
3. Left Buccal
4. Upper Occlusal
5. Lower Occlusal
FRONTAL AT REST
FRONTAL DYNAMIC
(SMILE)
OBLIQUE AT REST
PROFILE (RIGHT SIDE – LIPS
RELAXED)
AN OPTIONAL SUBMENTAL VIEW

Such a view may be taken

to document mandibular
asymmetry.
In patients with
asymmetries, submental
views can be particularly
revealing.
POSITION OF RETRACTORS FOR
UPPER OCCLUSAL SHOT
 POSITION OF RETRACTORS
FOR LOWER OCCLUSAL SHOT