The evaluation and management of severe malocclussion is difficult and expensive. Patients must demonstrate medical necessity for programs such as Medicaid or Champus to provide reimbursement. The Handicapping Labiolingual Deviation (HLD) Index was developed as means to identify patients with handicapping malocclusion. This was modified by a lawsuit in California as the HLD (CalMod) Index.



(1) The observer should use a Boley gauge or disposable rule and an HLD score sheet.

(2) The patient's teeth are positioned in centric occlusion.

(3) All measurements are recorded in the order given and rounded off to the nearest millimeter (mm).

(4) If a condition is absent, a 0 is entered.

(5) The use of an assistant to record the findings is recommended.






Cleft palate deformities

X, and score no further


deep impinging overbite, when lower incisors are destroying the soft tissue of the palate

X, and score no further


crossbite of individual anterior teeth, when destruction of soft tissue is present

X, and score no further


severe traumatic deviations (attach description of condition)

X, and score no further


Overjet greater than 9 mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory and speech difficulties.

X, and score no further


overjet in mm



overbite in mm



mandibular protrusion in mm

(mm) * 5


open bite in mm

(mm) * 4


ectopic eruption: Count each tooth, excluding third molars

(count) * 3, see note below


anterior crowding: Score one point for maxilla, and/or one point for mandible; two points maximum for anterior crowding

(0, 1 or 2) * 5, see note below


labiolingual spread in mm



posterior unilateral crossbite (must involve 2 or more adjacent teeth, one of which must be a molar)



NOTE: If both anterior crowding and ectopic eruption are present in the anterior portion of the mouth, score only the most severe condition. Do not score both conditions.


Additional scoring instruction (Figure 3, page 139):

• 5B: This is recorded with the patient's teeth in centric occlusion and measured from the labial portion of the lower incisors to the labial portion of the upper incisors. The measurement may apply to protruding single tooth as well as to the whole arch.

• 6: A pencil mark on the tooth indicating the extent of overjet facilitates this measurement. "Reverse" overbite may exist in certain conditions and should be measured and recorded.

• 7: Score exactly as measured from the labial of the lower incisor to the labial of the upper incisor. A reverse overbite, if present, should be shown under 6 (above).

• 8: This condition is defined as the absence of occlusal contact in the anterior region. It is measured from edge to edge in millimeters. In cases of pronounced protrusion associated with open bite, measurement of the open bite is not always possible; in these cases, a close approximation can be estimated.

• 10: Arch length insufficiency must exceed 3.5 mm. Mild rotations that may react favorably to stripping or mild expansion procedures are not to be scored as crowded.

• 11: A Boley Gauge or disposable ruler is used to determine the extent of deviation from a normal arch. Where there is only a protruded or lingually displaced anterior tooth, the measurement should be made from the incisal edge of that tooth to the normal arch line. Otherwise, the total distance between the most protruded tooth and the lingually displaced anterior tooth is measured. The labiolingual spread probably comes close to a measurement of overall deviation from what would have been a normal arch. In the event that multiple anterior crowding of the teeth is observed, some deviation from the normal arch should be measured for the labiolingual spread, but only the most severe individual measurement should be entered on the index.

• 12: The crossbite must be one in which the mandibular posterior teeth involved may either be both palatal or both completely buccal in relation to the mandibular posterior teeth.



(1) If conditions 1 through 5A are present, then further scoring is not needed.

(2) If conditions 1 through 5A are not present, then


total score = SUM(all the conditions present)



• "X" is scored in conditions 1 through 5A: these are considered to be handicapping malocclusion

• scores >= 26: this is considered handicapping

• If a person does not score an "X" or has a total score less than 26, then s/he may be eligible under the EPSDT exception if medical necessity is documented.


EPSDT Exception - All of the following must be provided:

(a) principal diagnosis

(b) prognosis

(c) date of onset of the illness or condition, and etiology if known

(d) clinical significance or functional impairment caused by the illness or condition

(e) specific types of services to be rendered by each discipline associated with the total treatment plan

(f) the therapeutic goals to be achieved by each discipline and anticipated time for achievement of goals

(g) the extent to which health care services have been previously provided to address the illness or condition, and results demonstrated by prior care

(h) any other documentation available which may assist in making the required determination


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