Clinical Examination.

Extra oral : Profile / Frontal view

The profile is an important aspect of the patient's external appearance and give an indication of the underlying orthodontic situation. The examination should be done with the Frankfort Horizontal Plane parallel to the floor. If the chin slopes back or the maxilla and the nose are set forward, the profile is convex. If all of the middle of the face retreats, then the profile is concave. In between convex and concave, the profile becomes straight. There are no set measurement that can be used when assessing the profile - experience is the key.
The profile view allows a lateral evaluation to be made which corresponds to the lateral cephalogram. The following aspects of the face should be viewed and noted in the treatment chart.


1.The lip posture : This is viewed with the patient seated upright in a relaxed position with the lips parted. If the teeth are exposed this reflects that the dentition are positioned forward in the jaws.This could possibly mean need for retraction of the anterior dentition, with an indication for bicuspid extraction. It is also important to note the extent to which the lips are separated when they are relaxed and whether the patient must strain to bring the lips together. When the lips are protrusive and separated at rest by more than 3 to 4 mm, it can be concluded that the lip protrusion results from protrusion of incisors, and that both lip function and facial esthetics would improve if the protruding teeth were retracted. If the lips are protrusive but close over the teeth without strain, on the other hand, retraction of the incisor teeth will result in minimal changes in lip prominence.
Detecting protrusion of incisors (which is relatively common) or retrusion of incisors (which is rare) is important because of the effect of this on space within the dental arches. If the incisors protrude, they align themselves on the arc of a larger circle as they lean forward, whereas if the incisors are retrusive, less space is available to accommodate the canines and premolars. In extreme cases, incisor protrusion in what might have been a patient with severe crowding can produce ideal alignment of the dental arches, at the expense of lips that protrude and are difficult to bring into function over the protruding incisor teeth. This condition can be termed bimaxillary dentoalveolar protrusion, meaning simply that in both jaws the teeth protrude. The condition is often referred to as just bimaxillary protrusion, a simpler term but a misnomer since it is not the jaws but the teeth that protrude.


2. Lip thickness: In patients with very thin lips, the orbicularis oris muscle contract and pull the lips together. In such patients caution must be applied if the anterior teeth are to be retracted. Retraction of the anterior teeth in such cases will cause the lips to retract at approximately a one to one ratio with the dentition. This could result in excessive flattening of the profile, creating a "dished - in" look.
Excessive advancement of the anterior dentition in a tight-lipped should also be handled with caution. In such patients change will initially make the profile more aesthetically pleasing. But , the tight musculature will often cause these teeth to relapse to their original position. In such situation it is wiser to warn the patient prior to the treatment and indicate that lenghty retention procedure will be essential.
When anterior teeth are retracted in the thick lipped patient, for every two millimeters of dental retraction, the lips move distally only one millimeter. Hence, it is more difficult to alter this type of profile dramatically. These patients will usually exhibit tittle lips strain. and the orbicularis oris muscles are more flaccid. Advancement of the incisors in these patients is quite easy, because there is less muscle strain. This also minimizes the chances of relapse.


3. Shape of nose and the naso - labial angle : The naso labial angle is too actue, the upper lip should be retracted. If the angle is too obtuse, the upper lip may need to be advanced.


4. Upper lip lower lip relationship: The anteroposterior relationship between the most anterior surfaces of the upper and lower lip have a great effect on facial esthetics. The relationship of the lips could reflect the skeletal pattern of the patient. When the upper lip is advanced the patient could be a skeletal class II. Retruded upper lip could mean a skeletal class III.This could be confirmed by looking at the cephalomatric readings.


5. Soft tissue pogonion: This indicates whether the lower face is protruded, retruded or in normal relationship to the other facial bones.



6. Facial type: The shape of the face indicates whether the patient has a round , long , short or balanced face.


7. Facial heights: Here it is noted whether the face is equally balanced or unbalanced. Vertical proportions can be seen more clearly in profile. The face is divided into vertical thirds. The inclination of the mandibular plane to a true horizontal line is visualized readily by placing a ruler along the lower border of the mandible. A steep mandibular plane angle correlates with long anterior facial vertical dimensions. A flat mandibular plane angle correlates with short anterior facial height.
There is also an interaction between face height and the anteroposterior position of the mandible. A long face predisposes the patient to Class ll malocclusion, a short face to Class lll.


8. Smile line: The smile line reveals whether the patient has a gummy smile or much more of the mandibular teeth is seen than that should be.With a relatively short upper lip and/or long maxillary alveolar process, a disfiguring amount of gingival tissue is exposed in laughing. This feature can influence the type of treatment and its prognosis. The height of the visible gingivae when laughing is measured from the cervical margin of the maxillary incisors to the inferior margin
of the upper lips .
Intra oral examination:

The routine intra oral examination is conducted with a through examination of the hard and soft tissues of the oral cavity. The presence of caries, hypocalcified teeth , fractured or discoloured teeth are noted. Presence of anomalies and non vital teeth are also looked for.
The soft tissues are examined , the periodontal condition should be evaluated and also look for the presence of abnormal labial , buccal and lingual frenal attachments. The health of the soft tissue and the presence of any soft tissue lesions must be checked
At this juncture it is good to evaluate the various habits such as tongue thrust, lip sucking , thumb sucking or any other oral habits.

Finally the general oral hygiene of the patient is evaluated. The need for oral prophylysis and oral hygiene instructions is noted. Care in oral hygiene, wearing of appliance and keeping to the treatment regime all call for strong motivation, and so it is wise to assess patient cooperation before starting active treatment, particularly when a long-lasting treatment is anticipated.