Unlike medicine, orthodontic diagnosis involves identifying malocclusion, assessing its severity and developing a plan to correct it based on various patient factors, such as age, sex, oral health, chief concern and ethnic origin. Orthodontic diagnosis and treatment planning are often closely linked and influenced by many factors beyond the nature of the malocclusion. Some of these factors may include social and financial limitations, as well as psychological concerns of the individual.

Diagnosing and treatment planning are closely intertwined in orthodontics and essential for a successful outcome. A thorough diagnosis is crucial in any treatment plan. ‘Eyes cannot see what the brain does not know’ truly implies to orthodontics, highlighting the importance of a deep understanding of the body’s stomatognathic system to identify abnormalities in both function and anatomy.

The diagnostic process is divided into two parts: (1) clinical examination and evaluation and (2) interpretation of diagnostic records and investigations.

Patient’s history, a detailed social, personal, medical and dental history, should precede any clinical examination. It is important to know the developmental milestones of a young child. The physical development of the child vis-à-vis his/her chronological age, dental maturation and skeletal age are of great importance. The child’s social and personal history aims to elicit concern for the dental and orthodontic care, number of siblings in the family, any history of orthodontic treatment of parents or siblings, socioeconomic status and attitude. Information is gathered with respect to:

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  Height, weight and obesity

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  Any sickness/or any medication

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  Juvenile diabetes

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  Performance in school

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  Any adjustment problems or psychological issues

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  Family: single/divorced/happy family and not so happy family

During an orthodontic evaluation, obtaining a thorough medical history is essential to identify any underlying health conditions that may negatively impact the growth of the skeletal system, craniofacial structures, muscles, teeth and occlusion. The medical history is also helpful in identifying environmental factors related to nutrition, growth status, dental/oral health, cavities, breathing patterns and harmful habits that may affect the development of occlusion. This information can help determine whether orthodontic treatment is appropriate and what treatment plan would be best for the patient.

The family history of orthodontic treatment and evaluation of parents, siblings for their facial forms, occlusion and malocclusion may give clues on the child’s facial form at adulthood. It is important to ask about any family history of a disease that can affect the development of the face, teeth and jaws.

Facial forms and malocclusions that have a strong familial tendency are:

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  Severe deep bite

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  Class II division 2 pattern

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  Skeletal open bite

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  Mandibular prognathism

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  Bimaxillary protrusion

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  Mandibular retrognathism

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  Severe crowding/spacing

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  Median diastema

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  Cleft lip and/or palate

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  Ectodermal dysplasia

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  Cherubism

Common problems of familial/genetic origin affecting dentition:

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  Peg-shaped or missing lateral incisors.

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  Hypodontia, Anodontia, Oligodontia

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  Supernumerary teeth

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  Macro or microdontia

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  Amelogenesis imperfecta/dentinogenesis imperfacta

History of orthodontic treatment in either of the parents should warrant a watch for possible malocclusion in the offspring under examination.

An orthodontist may often be encountered with a standard question by the parents, ‘Is my baby going to have braces when he/she grows up?’

In a clinical setting, parents often ask a seemingly simple question about their child’s occlusion (bite). However, even the most experienced clinician may find it difficult to provide a precise answer without obtaining a detailed history and conducting a clinical examination of the child. It is crucial to supplement the findings from the history and clinical examination with diagnostic investigations to arrive at a definitive conclusion. However, in some cases where the child is still growing, and their occlusion is not yet fully established, it may not be possible to give a definitive answer.

Orthodontic evaluation at any stage of a child’s growth involves:

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  Physical development and skeletal growth

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  Development of face and jaws

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  Development of dentition and occlusion

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  Occlusal relationships in centric occlusion and function

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  Normal/altered functions of the stomatognathic system

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  Examination of tongue

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  Recurrent throat infections

A newborn child’s face appears flat at birth, with the head occupying a considerably larger dimension compared to the face and a receding chin. By three years, the child’s head is closer to that of adult size, and after that, the changes in the head size are minimal. In contrast, the face grows rapidly in all three dimensions, that is in width (transverse), length (sagittal) and height (vertical) between the ages of 3 and 6 years. The facial convexity is reduced while the chin is trying to catch up with the maxilla. The condylar growth exceeds that of the vertical descent of the maxilla, and therefore, the mandibular plane angle remains nearly unchanged. A cephalogram will show a rather large ANB (close to 5 degrees) compared to adults (2 degrees), and therefore, some facial convexity is acceptable.

In general, by 36 months, all deciduous teeth have erupted, and deciduous occlusion is fully established. The deciduous incisors are more upright compared to their permanent successors, and their crowns appear rather wide due to the relatively short crown height. Overjet and overbite are minimal. The deciduous molars show a mesial step or a flush terminal plane. Often, spaces of about 2–3 mm are seen mesial to the deciduous canines in the maxilla and distal to the deciduous canines in the mandible. These spaces are known as primate spaces ( Fig. 18.1 ).

Primate spaces: These are often found distal to deciduous lateral incisors in the maxilla and deciduous canines in the mandible. First described by Baume in 1950.

Pierre robin sequence

This anomaly includes severe micrognathia, glossoptosis and cleft palate or an arched palate ( Fig. 18.2 ). The cleft of the soft palate, along with a low-postured and backwards-positioned tongue, may cause difficulty in breathing and cyanosis in a newborn. If cyanosis or respiratory problems persist in a newborn, tracheostomy or surgery to fix the tongue in a forward position may be required. The growth of the mandible usually catches up as the child grows.

Severe retrognathia: A child with severe retrognathic lower jaw.

Such a situation warrants detailed medical examination by the paediatrician. Pierre Robin sequence is a common cause of such a clinical presentation. Pierre Robin sequence is associated with cleft palate, mandibular retrognathia and glossoptosis. This condition may occur as an isolated malformation complex or part of a broader pattern of systemic abnormalities.

It may affect the whole face or the lower face, which may show up in the form of a deviated chin. Facial asymmetry can be seen in many congenital disorders affecting the face and jaws. These include congenital defects such as the unilateral absence of a condyle, agnathia, cleft lip and palate and developmental abnormalities such as the underdevelopment of one side of the mandible due to trauma to the temporomandibular joint ( Fig. 18.3 ).

Facial asymmetry.

A girl reported with the chief complaint of gradually increasing asymmetry of the face (A–C) . She had unilateral condylar hyperplasia of the left condyle that gradually caused a shift of the lower dentition and the midline to the right side (D–F) .

Humans have dental arches with tight contacts in the adult dentition. In about half of the children, however, there are diastemas in the deciduous dentition. These correspond in location to the Ape diastema. In the dental literature, these spaces are called ‘primate spaces’. In other words, primate spaces are naturally occurring spaces in the ‘normal’, primary dentition, existing distal to the primary mandibular canines and mesial to the primary maxillary canines. These were first described in detail by Baume and later by Foster and others. Facal-García recorded primate spaces in 3-year-old Caucasians and found that the prevalence of spacing was more frequent in males than in females. The presence or absence of spacing was not directly related to occlusion except in cases of posterior cross-bite, where it was less frequent, and open bites, in which spaces appeared more often than usual. Ohno et al. ^, recorded primate spaces and interdental spaces in the primary dentition based on jaw and gender in Indian children in Delhi aged 5–7 years. He also investigated the relationship of these spaces with the morphological characteristics of the deciduous dental arches.

Ohno et al. reported a wide variation in the interdental spacing pattern, with the most common site being mesial to the maxillary primary canine (primate spaces) and distal to the mandibular primary canine for the studied age group. The maxillary primate spaces had a higher frequency than mandibular spaces.

A lack of primate spacing can be one of the indicators of insufficient growth in the dental alveolar arches and, hence, an indicator of the tendency for crowded dentition ( Fig. 18.4 ).

Early signs of deep bite. A young girl, 3 years old, with deciduous dentition and occlusion.

(A–C) She has poor oral hygiene, presence of visible plaque, and signs of cervical caries in the lower left canine. She has a deep bite and a lack of spacing in the dentition. Such an occlusion has greater potential for developing a malocclusion. High caries susceptibility, if not controlled, will lead to carious teeth.

Attrition of the deciduous dentition allows forward posturing of the mandible in near edge-to-edge bite and freedom in jaw movements. It thereby enhances the growth of the mandible ( Fig. 18.5 ). Such a normal pattern of incisor relationship should be differentiated from a reverse overjet tendency and arrived at a decision of its habitual, functional or anatomic nature. Such an incisor relationship warrants a detailed clinical examination to rule out a true mandibular excess. It also necessitates the consideration of the morphology of the mandible and chin for any signs of skeletal mandibular prognathism. Such a case of class III malocclusion should also be examined for deficiency of mid-face, which is not an uncommon finding.

Features of deciduous dentition at the age of 6 years.

(A–C) Spacing in the anterior dentition, edge-to-edge bite and attrition of the deciduous teeth are indicators of good alveolar growth and sagittal forward repositioning of the mandible. Such a clinical situation often leads to eruption of normal alignment of permanent teeth and possibly a class I molar relation.

In suspected class III, evaluation of the parents and siblings is required for any signs of class III skeletal/dental relationship. to diagnose or rule out the familial class III occlusion.

A posterior cross-bite of a single tooth should not be viewed with suspicion towards incipient malocclusion. A unilateral posterior cross-bite of two or more teeth may be associated with some deviation of the lower jaw to the opposite side and may show some degree of midline shift. Unilateral posterior cross-bite may be the outcome of a narrow maxilla associated with prolonged thumb or finger sucking. Mouth breathing can also cause a narrow maxilla and, thereby, premature contact with the mandibular teeth. The lower jaw tends to avoid prematurity, resulting in a convenient swing of the mandible occluding in unilateral cross-bite.

Active growth of jaws coupled with the attrition of deciduous teeth brings about the following alterations in occlusion. The crowns of the deciduous incisors may further shorten, thereby worsening the width-to-height ratio of deciduous crowns. The deciduous incisor crowns may appear broad and short. There may be an edge-to-edge bite of incisors and lack of overjet, which also brings about a mesial step relationship of the deciduous molars ( Fig. 18.6 ). The anterior dentition is spaced. Lack of spacing in the deciduous dentition and the presence of an overjet and a straight terminal plane are indicators of incipient malocclusion. Children with such an occlusion need to be kept under observation for the potential development of class II malocclusion.

Deciduous dentition and occlusion at 6 years.

(A–C) The dentition has attrition and edge-to-edge bite. Note the mandibular central incisors have erupted without any crowding or rotations. The molars are in class I occlusion relation, a sign of early mesial shift, which in this case seems to be facilitated due to the forward shift of mandible.

Several factors are associated with the transition to normal occlusion in permanent dentition from an existing primary dentition. Some naturally occurring indicators which must be clinically evaluated are spacing in dentition, primate spaces and the terminal plane relationship of the deciduous molars (i.e. straight/mesial step/distal step), leeway space and incisor liability. According to Baume, type 1 primary dentitions with wide spacing between the teeth lead to a normal alignment of permanent dentition more frequently than type 2 dentitions with closed contacts between the teeth.

It has been reported in a long-term study that a straight terminal plane relationship may change into a class I molar relation in favourable growth pattern cases or class II in children with unfavourable growth. A mesial step terminal plane is the most beneficial for developing a dental class I relationship in permanent dentition. The distal step relationship is an indicator of future class II molar relationship.

Leeway space is described as an excess arch length available consequent to combining smaller mesiodistal widths of canines and premolars with their deciduous counterparts. Leeway space amounts to 0.9 mm per side in the maxilla and 1.7 mm per side in the mandible. Leeway of space contributes to the development of class I molar relations. Additional space is needed to accommodate large permanent incisors compared to small primary incisors, and this is termed incisor liability. It averages 7.6 mm for the maxilla and 6 mm for the mandible.

By the age of 9–10 years, the growth of the skull and maxilla is nearly complete. However, the mandible continues to grow in a downward and forward direction till the completion of puberty. The maxillary dentition accordingly descends to catch up with the mandible while the mandibular teeth erupt to maintain an occlusal relationship.

The face should be evaluated at the frontal and lateral profile. The lateral aspect reveals the pattern in a sagittal plane (convex/straight/concave), whereas the frontal view indicates the facial form (broad/average/narrow or square/oval/tapered) and symmetry. The vertical proportions of the face should also be assessed by measuring the anterior and posterior facial heights and their relative proportions to each other. An increase in the anterior lower face height should be reconfirmed with the associated steepness of the mandibular plane. Accordingly, the face may be categorised into normal, vertical or horizontal.

The frontal examination should include an assessment of the shape of the nose, the size of the nostrils, nose tip and nasal bridge. Lips are examined at rest and during smiling. The child should be carefully observed for any deviations and midline shifts during jaw closure and at rest.

Rapid changes take place in the face and dentition with the eruption of permanent first molars and incisors. The orchestrated events of shedding of deciduous dentition, the eruption of permanent teeth, the growth of the underlying skeletal bases, maturation, and function of overlying soft tissue integument, and functional growth of the organs of respiration, mastication, deglutition and speech are all under strong genetic control, more so before birth.

After birth, the development of a normal occlusion is likely to be influenced by environmental factors, which affect the normal physical and skeletal growth of a child and the development of the dentition. Hence, a thorough understanding of physical growth, skeletal growth and their association with the developing face is fundamental to orthodontic diagnosis.

Another major contributor to the development of normal occlusion is the integrity of deciduous dentition, which can be taken as a full complement of deciduous dentition free from dental caries or one with proper restorations.

Premature extractions of deciduous teeth call for space maintenance protocol to avoid space loss by the erupting adjacent teeth. The conditions include the loss of a tooth due to trauma. The establishment of normal occlusion can only be facilitated by the presence of a full complement of permanent teeth with normal morphology and size. The permanent teeth should erupt and timely replace the shedding deciduous dentition. The other major factors that can influence the development of occlusion are the mode of respiration and the behaviour of the tongue.

First and foremost, the clinical assessment of a child begins with a look at his/her physical development and overall presentation in behaviour. A child who is normal in height according to his/her chronological age and not overly overweight or underweight is likely to be free from any endocrinal/skeletal disorder that may influence facial growth. Records of weight and height related to age are used for the evaluation of physical growth.

Extraoral examination per se begins with the face in the state of rest, occlusion and function. The child should be examined in an environment that is friendly (not threatening) and conducive to understanding and enhancing confidence in the dentist/orthodontist. It may be a good idea to spend a few minutes talking to parents and children in the waiting room or in the consultation room on a subject that might interest a child and indulge him in conversation. This would help elicit information on the socio-cultural aspects of the family. Conversations like ‘How are you doing?’, ‘Have you had to miss your work to make this appointment?’, ‘How far is the child’s school from the house?’, ‘How did you travel to reach the clinic?’ and similar conversations give multi-fold benefits. It gives you time to understand the child and his parents along with an opportunity to observe the child, his face, the action of lips, posture during smile and rest. It will give you information on their concern about malocclusion, their reason for visiting the office, their concern for the problem, their attitude and their awareness about orthodontic treatment and oral health. The number of siblings and the nature of the parents’ jobs provide some information on the parents’ possible motivation for an orthodontic consultation.

The overall shape of the face, including the skull, may fall into one of the three types:

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  Long and thin, often associated with the ectomorphic body type.

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  Broad and square could be associated with the endomorphic body type.

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  Ovoid face (between A and B) is usually seen in meso- or endomorphic body types.

Mongoloid’s faces are broad and flat, while Africans and Islanders may show thick lips and prominent cheekbones, with the Caucasians falling in between the two. The shape of the head can be objectively evaluated using the cephalic index.

Cephalic index

The cephalic index is a ratio (%) of the maximum breadth to the maximum length of the skull or head. The principle employed by Anders Retzius was to take the longer diameter of the head, the anteroposterior diameter, as length. If the shorter or transverse diameter (width) falls below 75%, the skull may be classified as long (dolichocephalic), while if it exceeds 80%, the head is broad (brachycephalic). There are population differences in head forms that influence the face type ( Fig. 18.7 ).

Cephalic index.

(A) Dolichocephalic. (B) Mesocephalic. (C) Brachycephalic.

The individuals who have a dolichocephalic head type also have a proportionately narrower and longer face than those with a brachycephalic head form. Their cranial base flexure is more open or flat, resulting in a protrusive upper face and a retrusive lower face. They have a tendency for class II malocclusion. These features are characteristic of Caucasians. The opposite, that is, a closed cranial flexure, usually characterises the brachycephalic head, which embodies a wider, flatter, more upright type of face. The face appears broad and flat with a tendency for class III type of malocclusion and a prognathic mandible or a bimaxillary protrusion. There are many combinations of dolichocephalic and brachycephalic head forms.

Some authors have used the terms ultra-dolichocephalic, hyper-dolichocephalic, hyper-brachycephalic and ultra-brachycephalic for extreme facial types ( Table 18.4 ).

TABLE 18.4

Classification according to the cephalic index

Ultradolichocephalic	x%–64.9%
Hyperdolichocephalic	65.0%–69.9%
Dolichocephalic	70.0%–74.9%
Mesocephalic	75.0%–79.9%
Brachycephalic	80.0%–84.9%
Hyperbrachycephalic	85.0%–89.9%
Ultrabrachycephalic	90.0–x%
Cephalic index	Maximum skull width × 100 Maximum skull length

Facial index

In anthropometry, facial proportions are described as an index of morphological facial height, measured from the nasion (N) to gnathion (Gn) anatomical landmarks, divided by the bizygomatic width, measured from the left to the right region (Zyl-Zyr). The Greek terms are used in the facial index, where a prosopon is used for the face. According to this classification system, numerical values given in the table describe the face as euryprosopic, mesoprosopic and leptoprosopic. Facial index is calculated as given in Figs 18.8 and 18.9 , and Table 18.5 .

Facial index: calculated as the ratio between the morphological face height (N-Gn) and bizygomatic width (Zyr-Zyl).

(A) Euryprosopic face; (B) mesoprosopic face and (C) leptoprosopic face.

Source: Reproduced with permission from Franco FC, de Araujo TM, Vogel CJ, Quintão CC. Brachycephalic, dolichocephalic and mesocephalic: Is it appropriate to describe the face using skull patterns? Dental Press J Orthod. 2013 May-Jun;18(3):159–63.

Skull classified as hyperleptoprosopic (facial index = 96.2%) in relation to its predominantly vertical facial morphology (A) and hyperbrachycephalic (cranial index = 87.3%) in terms of shape (B) .

Source: Reproduced with permission from Franco FC, de Araujo TM, Vogel CJ, Quintão CC. Brachycephalic, dolichocephalic and mesocephalic: Is it appropriate to describe the face using skull patterns? Dental Press J Orthod. 2013 May–Jun;18(3):159–63.

Examination of the face should include evaluation of the symmetry of the structures of the right and left sides of the face. Some forms of facial asymmetry are seen in nearly everybody and are considered normal since the right and left sides of the face are not exact mirror images of each other. It is important that facial symmetry should be examined both in the rest position of the mandible and in occlusion. The midline of the nose, lips, chin and face should be co-incident. Deviated nostrils and nose are frequently seen in operated cases of cleft lip and palate. If the deviation of the chin appears from rest to a centric position, it is indicative of premature contact with the functional closure of the mandible.

Facial asymmetry may be exhibited as a deviation of the chin to either side. The face usually appears smaller on one side or larger on the contralateral side. A deviated chin to either side, both in occlusion and rest position, should alert the consultant to look for either deficient growth of the lower jaw on one side, usually the side that appears normal, or excessive growth.

The size and distance of eyes from the midline of the face are significant. A decrease in the interorbital distance (hypotelorism) or an increased distance (hypertelorism) should be carefully noted. In healthy subjects, the base of the nose should measure approximately the same as the inter-inner-canthal distance, while the width of the mouth should approximate the distance between the irises.

One of the important parts of the facial examination is to note the relationship between skeletal and dental midline since this cannot be determined from the dental casts. The relationship of the dental midline of each arch to the skeletal midline of that jaw is evaluated; that is, the lower incisor midline is related to the midline of the mandible, and the upper incisor midline is related to the midline of the maxilla and all are related to each other.

Evaluation of symmetry is best performed by examining a face from under the chin while the head is tilted backward. Such a view is necessary for the assessment of facial asymmetry, particularly of the nostrils, zygoma and upper lip ( Fig. 18.3 C).

The examiner should stand at the side of the patient while the patient is asked to stand and look straight, preferably into a mirror. An imaginary line is drawn connecting the bridge of the nose, the base of the nose and the chin. The nose can be a big distractor; a smaller nose tends to mask a retrognathic face to look straighter, while a very prominent nose gives a false feeling of a convex profile in an otherwise normal profile.

The facial profile could fall into one of three types, that is convex, straight, concave and bimaxillary protrusion ( Table 18.6 ; Fig. 18.10 A–C).

Facial profiles (A) Convex profile. (B) Orthognathic profile. (C) Concave profile.

Bimaxillary protrusion

The facial profile among ethnic groups from the southern part of India (mostly Dravidians/Sytho-Dravidians), Negroid, certain races from Indonesia and Islanders is unique in many aspects. These ethnic groups have significant protrusion of the upper and lower dentition and, thereby, of the mid-face, upper and lower lips. The chin may be normal/retrusive ( Fig. 51.27 A). These population groups have otherwise a class I occlusion. The upper and lower dentition shows significant proclination, that is a Bidental protrusion. When associated with the protrusion of dento-alveolar bases, it is called bimaxillary protrusion, which is reflected as protrusive upper and lower lips.

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