Clinical examination of an Orthodontic patient www.indiandentalacademy.com
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The human faces around the world have not popped out of a clone machine. The shape, the colour , the size and the overall appearance differs based on the the environmental influences of that area. Though a topographic subjectivity exists some similarities are present which can add an objectivity to the study of the human face. The growth and development of the craniofacial complex follows a certain pattern in all the individuals across the globe. All the four concepts ,namely 1.cephalocaudal gradient 2.variability 3.predictability and 4.timing are aspects seen in all human beings leading to objectivity in examination www.indiandentalacademy.com
This aspect of objectivity brings about a certain level of acceptability in terms of aesthetics in a certain group. A deviation from the normal range affects the individual forcing him or her to seek help. So the equation is Abnormal facial proportions-----Socially undervalued aesthetics Psychosocially unacceptable----Forcing person to undergo orthodontic treatment------Orthodontist uses the facial proportions relevant to that population to evaluate patient clinically Thus the relationship between clinical examination and facial proportions www.indiandentalacademy.com
Study of facial proportions in anthropology to evaluate ethnic difference. Prior to the advent of cephalometric radiography,dentists and orthodontists often used anthropometric measurements to help establish facial proportions. Farkas – studies of Canadians of northern European origin. Facial measurements for anthropometric analysis are made with either bow calipers or straight calipers. www.indiandentalacademy.com
History: Indian iconometry – studies by Ruelius. Face height was used as the module of both the ‘Sariputra’ and ‘Alekyalakshana’ which reflected the natural relation of parts of the body to each other. Sariputra system –1200 AD – known for honoring sculptures of God Buddha. www.indiandentalacademy.com
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The Divine proportion: - 1509 – Fra Luca Pacioli The major part is 1.61803 times larger than the minor part. Drawing of the face is inscribed in a golden rectangle and triangle. Ratio of upper face height to maxillary alveolar height to mandibular facial height is 1:0.61:1 – the golden proportion. www.indiandentalacademy.com
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Leonardo da Vinci – 1459 to 1519 studied his drawings of facial proportions and the projection of a coordinate system on the face of a horseman.
Albrecht Durer – used strict geometric methods and provided a proportionate analysis of the leptoprosopic face and euryprosopic face in a coordinate system where the horizontal and vertical lines were drawn through some landmarks or facial features.
Petrus camper - 1722 to 1789 made extensive studies of crania. Campers horizontal extended from porius acousticus to a point below the nose and was guided by the zygomatic process.
Welcker – 1862 – demonstrated the descent and rotation of the mandible during ontogenesis by means of triangular configuration from basion to gnathion. www.indiandentalacademy.com
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The use of facial proportions in modern day orthodontics: Cryer had pointed out that angle showed the straight profile of Apollo belvedere as his ideal. Angle concenterated more on occlusion whereas Case said that Angles concept that an ideal occlusion would naturally have an ideal face was false. www.indiandentalacademy.com
Factors that played a major role in deciding the esthetics following orthodontic treatment. Angle concentrated on non extraction treatment and his idea was based on settling occlusion for the patient.His ideal needed to have a good occlusion. Cephalometric values by Steiner, Downs etc were based mainly on bringing about ideal occlusion.There wasn’t much emphasis on soft tissue corrections. www.indiandentalacademy.com
Tweed stressed on lower anterior positioning for retention and advised extraction for all cases. Theory of attritional occlusion put forth by Begg also denied much importance to the soft tissue. So, it was an era of structural discrepancies dominating the limitations of orthodontic treatment. www.indiandentalacademy.com
The importance of clinical examination With the resurgence of nonextraction treatment and the advent of orthognathic surgery evaluation of soft tissue drape preand post treatment started to gain importance. This interdisciplinary approach and various studies of the soft tissue changes following surgery swung the pendulum in favor of the soft tissue look before and after treatment. www.indiandentalacademy.com
The bending of the head at angle to the body during the process of evolution to focus vision on the path of movement for the bipod did in no way deter the shape of the head to be a part of the body(spinal chord) in shape and size. The face being a part of the head and the head being part of the body all of them will have to be in proportionate with one another. Hence the relationship between the body type to the head shape to facial form.
Body Types: Ectomorphic Mesomorphic
Endomorphic www.indiandentalacademy.com
Height and weight:
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Shape of the head: Clinical examination should begin by adjusting the position of the patient in such a way that Frankfurt horizontal plane is parallel to the floor. Stand behind the patient, lower the chair and observe the shape of the head. Mesocephalic
- average head shape
Dolichocephalic
- long and narrow head shape
Brachycephalic
- broad and short head shape. www.indiandentalacademy.com
Cranial index: Cephalic index : I= maximum skull width Maximum skull length CLASSIFICATION: Dolichocephalic(long skull) x – 75.9 Mesocephalic 76 – 80.9 Brachycephalic (short skull) 81 – 85.4 Hyperbrachycephalic 85.5 – x www.indiandentalacademy.com
Maximum cranial breadth is measured wherever it is found between the two most prominent points on either side of the cranium. Maximum cranial length is the distance between the glabella and the opisthocranion ( the most prominent point of the occipital bone in the midline ) . www.indiandentalacademy.com
Facial Form: Stand in front of the patient and examine the face form of the patient. Mesoprosopic – average face form Euryprosopic - broad and short face Dolicoprosopic – long and narrow face
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Frontal facial analysis: Vertical relationship: The ideal face is divided into equal thirds by horizontal lines adjacent to the hairline ,the nasal base and menton. The lower third of the face is further divided into upper one thirds from the upper lip and the lower lip to the chin comprise the lower two thirds. www.indiandentalacademy.com
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Facial height: Upper facial height is clinically measured from the bridge of the nose to the lower border of the nose. Lower facial height is clinically measured from the lower border of nose to the lower border of chin. Ideal proportion of UFH is 45% of total facial height.Ideal proportion of LFH is 55% of the total facial height. www.indiandentalacademy.com
Treatment options for vertical facial proportions: Long upper face – camouflage with hairstyle Excessive nasal height- increase lower facial height to camouflage nasal proportions Rhinoplastic modification of the alar width to affect proportions. Excessive lower facial height – orthognathic maxillary impaction to shorten facial height. Excessive chin height – vertical wedge reduction genioplasty. Short lower facial height – vertical maxillary deficiency – orthognathic maxillary downgraft to increase lower facial www.indiandentalacademy.com height.
Transverse facial and dental proportions.
The rule of fifths is a method used to describe the ideal transverse relationships of the face. The face is divided sagitally into five equal segments from helix to helix of the outer ears.Each of the segment should be one eye distance in width. www.indiandentalacademy.com
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The middle fifth of the face – delineated by inner canthus of the eye.A line from the inner canhus should be coincident with the ala of the base of the nose. The medial two fifths of the face – A line from the outer canthus of the eye should be coincident with the gonial angle of the mandible. The outer two fifths of the face – measured from the base of the ear to the helix of the ear,which represents the width of the ears. www.indiandentalacademy.com
Normative values for facial dimensions. Interpupillary – 65 mm Intercanthal – 35 mm ( adult ) 30.3 mm ( age 9 ) 31.6 mm ( age 16 ) Outercanthal – 9.8 cm
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Facial profile: The patients facial profile is examined by standing on the side of the patient. The profile is evaluated in the natural head position which is determined by the visual axis – the patient is asked to look straight forwards. Three soft tissue points are taken into consideration – most prominent point on the forehead,base of the upper lip and pogonion. www.indiandentalacademy.com
Depending on the alignment of the three points , the profile can be straight, convex or concave.
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Facial Divergence: Divergence of the face is defined as an anterior or posterior inclination of the lower face relative to the forehead. Divergence of the face ( term coined by the eminent orthodontist – anthropologist Milo Hellman ) is influenced by the patient’s racial and ethnic background. The facial angle,which is the angle formed by the nasion pogonion sot tissue line and the frankfurt horizontal line is used to define the facial divergence.It can be orthognathic, anterior divergent and posterior divergent. www.indiandentalacademy.com
Orthognathic face – facial angle approximately 90 degrees. Posterior divergent face – the facial angle is low Anterior divergent face – the facial angle is high.
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Assessment of vertical skeletal relationship: Evaluated by measuring the frankfurt mandibular plane angle ( FMA) depending upon the point where the two planes – “Frankfurt horizontal plane and the mandibular plane” meet to form the FMA angle. Average FMA angle cases – the two planes meet at the occipital region. Low angle cases – The two planes meet beyond the occipital region. High angle cases – the two planes meet in the www.indiandentalacademy.com mastoid region in front of the ear.
Assessment of the nose: Nasal anatomy: Transverse nasal proportions. Osseous components of the nose include the nasal bones and the frontal bone.The nasal bones are paired and average 25mm in length.
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Fomon and Bell described three major categories of nasal features according to racial background. 1. Leptorrhine – Usually found in whites and characterized by a long,high,narrow nose and nostrils. 2. Mesorrhine – Usually found in Asians and characterized by lack of dorsal height and collumellar suport. 3. Platyrrhine – Usually found in blacks and characterized by a flat broad nose and wide nostrils.
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Alar base width: - The width of the alar base should be approximately the same as intercanthal distance,which should be the same as the width of an eye. Collumella :- between nasal tip and base of the nose.Divide into anterior lobular,intermediate and basal portions.All segments – equal. Nasal tip: - On frontal view, nasal tip should have four defining points. •
Nares barely visible in natural head position.
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‘Gull in flight’ contour of the base of the nose.
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Columella slightly lower than and parallel to the ala when viewed in any direction.
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Cartilages shouldbe well defined to form a scroll.
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Nasal dorsum:- The nasal dorsum should be outlined by two slightly curved divergent lines extending from the medial superciliary ridges to the nasal tip defining points. The external nose resembles a pyramid, with the upper half comprised of bone and the lower half of cartilage.
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Naso labial angle. It is the angle between the lower border of the nose to the upper lip. Average naso labial angle is 90 degrees to 110 degrees.it is reduced in cases of proclined maxillary anterior teeth,maxillary prognathism etc.Increased in cases of retrusive maxilla,retroclined maxillary anterior teeth etc. www.indiandentalacademy.com
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Examination of Lips: If the teeth protrude excessively the lips are prominent and everted and the lips are separated at rest by more than 3 to 4 mm which is sometimes termed lip incompetence. Lip posture – should be evaluated by viewing the profile with the patient’s lips relaxed.This is done by relating the upper lip to a true vertical line passing through the concavity at the base of the upper lip (soft tissue point A) and by relating the lower lip to a similar true vertical line through the concavity between the lower lip and chin( soft tissue point B ). If the lip is significantly forward from this line – it can be judged to be prominent. www.indiandentalacademy.com
If the lip falls behind the line, it is retrusive.
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Lip length: - The length of the lips can be examined by gently parting the lips.Usually the upper lip covers the entire labial surface of upper anteriors except the incisal third or 2 to 3 mm and the lower lip extends on to the incisal one third of the upper anterior teeth. Texture and color:- usually both the lips are of same color.When one lips is of a color or texture different from that of the other , it should be examined further. Less active or hypoactive upper lip is chapped and lighter in color. Tonicity: - Feel the lip for consistency,Normal lip – minimal tonicity,Hypertonic lip – tend to be firm and redder, www.indiandentalacademy.com Hypotonic lip is flaccid.
Mento labial sulcus:- The region between the lower lip and the mentalis muscle is called mento labial sulcus. It is affected by lower incisor position and by the vertical height of the lower face.Upright lower incisors tend to result in a shallow mentolabial sulcus. Excessive lower incisor proclination deepens the mentolabial sulcus. www.indiandentalacademy.com
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Throat form: Lip chin throat angle:-The angle between the lower lip,chin and R point ( the deepest point along the chin neck contour) should be approximately 90 degrees. An obtuse angle which is unaesthetic reflects the following: •Chin deficiency •Lower lip procumbency •Excessive sub mental fat •Retropositioned mandible www.indiandentalacademy.com
•Low hyoid bone position.
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Chin neck angle: It is also termed cervicomental angle.Vistness and Souther stressed that the normal cervico mental angle is approximately 90 degrees. Soft tissue sag due to ageing is one of the contributors for less than ideal sub mental form. Weight gain also plays an important role. www.indiandentalacademy.com
Facial Symmetry. Potential etiologies of asymmetry. 1. Genetic or congenital malformations 2. Environmental factors such as habits and trauma 3. Functional deviations 4. Tumors of hard and soft tissue 5. Condylar hypoplasia or hyperplasia including unilateral condylar resorption resulting from local or systemic factors. 6. Assymetric mandibular growth – condylar fracture. www.indiandentalacademy.com 7. Massetric hypertrophy.
Nasal asymmetry:- Can result from •Previous traumatic injury to the nose •Deviation of the nasal septal cartilage,sometimes including vomer •Unfortunate stigmata of nasal plastic surgery •Congenital nasal stenosis •Nasal deformities that occur in cleft lip. Rhinoplastic correction techniques include camouflage of the asymmetry through grafting of cartilage,injectable grafts such as fat cell or porcine collagen fiber.More complex correction of the septum and external nasal bones may also be a key to correction of nasal www.indiandentalacademy.com asymmetry.
Dental asymmetry:Maxillary dental midline discrepancy :- Look for a unilaterally missing tooth. Usually associated with a congenitally missing lateral incisor or in cases in which a crowded maxillary canine has been removed during adolescence in an effort to decrease crowding of teeth without comprehensive orthodontic treatment.
Maxillary rotation – Rarely seen , usually in association with post traumatic maxillary reconstruction.
Functional shift of the mandible laterally from mid symphysis may be a result of the following: Dental crowding with a shift of lower incisors. Congenitally missing teeth or missing lower incisors. www.indiandentalacademy.com
Asymmetry due to condylar fractures.
Chin asymmetry: If the systematic evaluation of dental and skeletal midlines and vertical relations of the maxilla is normal and lower facial asymmetry is noted,the asymmetry may be isolated to the chin. Measurement of the mid symphysis to the mid sagittal plane is a local indicator of chin asymmetry. www.indiandentalacademy.com
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Condylar resorption in asymmetry problems:A number of systemic diseases can lead to condylar resorption. 1. Rheumatoid or juvenile rheumatoid arthritis 2. Systemic Lupus erythematosus 3. Familial mediterranean fever 4. Sjogren syndrome 5. Marfan syndrome 6. Psoriatic arthritis www.indiandentalacademy.com
Hemimandibular hypertrophy. Characterized by: •Facial asymmetry with the midsymphysis to the opposite of the affected condyle. •The head of the condyle is enlarged compared with opposite condyle. •A frontal cant of the occlusal plane is demonstrated on AP cephalograms. •Open bite develops to the affected side. www.indiandentalacademy.com
Incisor to lip relationship: The philtrum height is measured in millimeters from sub spinale ( base of the nose at the midline) to the most inferior portion of the upper lip on the vermilion tip of the cuspids bow. In the adolescent,the philtrum height is commonly shorter than the commisure height. A short philtrum in an adult results in an unesthetic reverse resting maxillary lip line which resembles a frown. www.indiandentalacademy.com
Commissure height: The commissure height is measured from a line constructed from the alar bases through sub spinale and then from the commissures perpendicular to the line. The commissure height is normally 2 to 3 mm greater than the philtrum height in adults,but in adoloscents the philtrum height may often be several millimeters shorter than the commissure height.Correction of commissure height is brought about by rhytidectomy.
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Excessive maxillary incisor show: In the adult patient the amount of upper incisor display at rest decreases with age,whereas the amount of lower incisor display increases. In general,males show less of upper incisor and more of lower incisor at rest. Excessive incisor show results from a number of hard and soft tissue factors: Short upper lip philtrum height,VME.excessive crown height,detorqued maxillary incisors. www.indiandentalacademy.com
Inadequate incisor display: Results from a number of hard tissue and soft tissue factors; •Excessive upper lip philtrum height •VMD •Inadequate crown height •Flared maxillary incisors. www.indiandentalacademy.com
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The gummy smile: The vertical height of the maxillary central incisors in the adult is measured in millimeters and is normally between 9 and 12 mm,with an average of 10.6mm in males and 9.5mm in females. The child with incomplete permanent incisor eruption may also present a short clinical crown height. If there is excessive gingival display during smile,the first step is to probe the gingival sulci of the maxillary anterior teeth.The sulcular depth should ideally be 1mm.If there is an increase of about 3 to 4 mm,gingival surgery can be performed to improve esthetics.Surgical procedures can also www.indiandentalacademy.com be an option if it is a skeletal deformity.
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Negative space: Frush and Fisher defined the buccal corridor as the space created between the buccal surface of posterior teeth and the commissures of the lip when the patient smiles. The teeth should fill the corners of the smile. In prosthodontics,the esthetic concept is termed buccal corridors. www.indiandentalacademy.com
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Intra Oral examination: Intraoral examination should begin by examining the following details: •Oral hygeine status •Frenum – In an infant,upper labial frenum extends from the upper lip to the incisive papilla. As the incisors erupt,the frenum usually migrates and gets attached to the labial surface of the alveolar process. www.indiandentalacademy.com
Occasionally,the frenum will persist and this may be associated with midline diastema.In these cases,the palatine papilla will blanch,is the lip is pulled forward.- Blanch test. Lower lingual frenum is examines by asking the patient to protrude the tongue.if the patient is not able to protrude the tongue- abnormal lingual frenum also called as tongue tie or ankyloglossia. •Tongue: - Look for the presence or absence of indentations or tooth impression on the sides of the tongue.If present – due to large tongue or macroglossia. www.indiandentalacademy.com
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Gingiva – The amount of attached gingiva is the keratinized tissue between the depth of periodontal probing and the beginning of alveolar mucosa. In young healthy patients 2 –3 mm of attached gingiva is apparent. In adults ,where recession is apparent, gingival grafting should be taken into consideration. Periodontal status may also be checked by tooth movement with the help of mouth mirror and the fingers. There should be no pockets above 5 mm for the patients planning to undergo orthodontic treatment. www.indiandentalacademy.com
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•Palate: - Look for the depth and width of the palate and any other developmental abnormalities like torus palatinus. •Teeth present •Teeth missing Condition of teeth present: Vitality,carious,fractured,discolored,hypoplastic, wearfacets,malformed teeth etc .
Angles classification: The patient should be made to occlude the teeth in centric occlusion and the relationship of molars,canine and the incisors should be examined to classify it according to Angle’s www.indiandentalacademy.com classification.
Arch forms Tapered Ovoid Square Arch symmetry www.indiandentalacademy.com
Overjet: Horizontal overlapping of upper and lower teeth is called as overjet. It is measured from the labial surface of lower anteriors to incisal edges of upper anteriors.(most proclined tooth). Normal overjet is 2 to 3 mm. Variations of overjet – decreased,increased,reverse overjet or cross bite and edge to edge bite. www.indiandentalacademy.com
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Over bite: The vertical overlapping of anterior teeth is called as overbite.Normally,it is 2 to 3 mm. To measure overbite – a mark of the incisal edges of upper anterior teeth are made on the labial aspect of the lower anterior teeth.The distance between the incisal edge of lower incisor to the mark gives overbite in mms. Overbite percentage – overbite/ clinical length of the tooth x 100. Normal value – 33 1/3 %. www.indiandentalacademy.com
Variations of overbite: Deep bite – where the overbite is more than 2 to 3 mm. Complete deep bite – where the lower anteriors contact either the upper anteriors or the palatal mucosa. Closed bite – where the upper anteriors overlap the lower anteriors completely – class II div 2 malocclusion. Open bite – lack of vertical overlapping of teeth. www.indiandentalacademy.com
Transverse tooth malpositions – Cross Bite or Scissors bite. Individual tooth irregularities – Rotations etc. Curve of spee – Measured by placing a flat surface touching the incisors and posteriorly up to the second molar. Flat curve of spee – all teeth touch the flat surface Deep curve of spee – The occlusal surfaces of posterior teeth form a curve which is more than a mm in depth. www.indiandentalacademy.com
Midline: Normally the upper and lower midlines coincide Nose tip to mid sagittal plane Mid sagittal plane to midline of upper arch. Upper arch midline to lower arch midline. Lower arch midline to mid symphyseal plane. Mid symphyseal plane to mid sagittal plane. www.indiandentalacademy.com
Functional examination:Evaluation of sensory and motor abilities. Sensory evaluation of the mouth: Several familiar geometric forms of identical size are presented to the patient to observe. An unknown form from a duplicate set is slipped unseen into the patient’s mouth and he or she is asked to identify it with the tongue. www.indiandentalacademy.com
Patients whose lingual tactile discriminatory abilities are limited have trouble discerning even simple differences in shape and size. There is evidence that individuals with such sensory limitations have difficulty learning new oral muscular skills such as those involving speech or an intra oral orthodontic appliance or orofacial myotherapy. Another test – the patient is asked to count the number of teeth with the tip of the tongue. www.indiandentalacademy.com
Evaluation of oro facial motor skills: Bloomer suggested diadochokinetic performance as a test of oral motor skills.The child repeats each of the following sounds.first slowly to achieve perfect formation and then gradually increased speed until he or she is repeating them as rapidly as possible. 1. “puh,puh,puh……….” 2. “tah,tah,tah…………”
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3. “Kuh,kuh,kuh…………” 4. “ puh- tah- kuh,” “puh tah kuh” Age affects diadachokinetic performance.Children whose oral movements are below the normal range for their age are defective speakers,often shoe patterns of swallowing abnormalities and give evidence of dysdiadochokinesia.The child who has defective speech and swallowing abnormalities without dysdiadochokinesia has a better prognosis for speech therapy and oral myotherapy. www.indiandentalacademy.com
Muscle groups: Muscles of the face and lips: Morphologic examination:The morphologic relationships of the lips are determined to an extent by the skeletal profile. When the mandible is in postural rest position – the lips normally touch lightly effecting an oral seal. www.indiandentalacademy.com
In mouth breathers and a few nasal breathers, the lips will be parted at rest . Some competent lips will have adapted to malocclusion- thus although a seal is present ,it is not a lip - lip seal but a liptooth – lip arrangement. Differences in color,texture and size of lips are often related to lip malfunction.Hyperactive lips may be larger and more red and moist than hypoactive or normal lips. www.indiandentalacademy.com
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Functional examination: Observe the lip and facial muscle contractions during the various swallows. Observe lip function during mastication.- bite size dry breakfast food may be used to study mastication.During normal mastication,the lips are held lightly together.Strong contractions of the mentalis and circum oral muscles will be seen in teeth apart swallowers.The same muscles also contract strongly in cases of large overjet and overbite. www.indiandentalacademy.com
Study lip function during speech .- most abnormal lip function during speech of children with malocclusions is an adaptation or accomodation to tooth positions and not an etiologic factor for malocclusions. Palpate the jaw elevators – ( eg the masseters ). Masseters sometimes enlarge remarkably with chronic hyperactivity.It is a good way to identify assymetric muscle function and tonicity.palpating both right and left muscles during simple jaw functions such as jaw opening,tapping of teeth provides means of www.indiandentalacademy.com noting assymetric muscle activities.
Differential diagnosis of lips:Morphologically inadequate lips - on
rare occasions the upper lip is short
- lips originally diagnosed as morphologically inadequate might be found satisfactory later because the tooth movements allow normal lip function to return
Functionally inadequate lips – - sometimes lips are adequate in size and but fail to www.indiandentalacademy.com function properly eg. Maxillary lip in extreme CL II DIV
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Functionally abnormal lips – • One of the most frequent of abnormal lip functions is associated with tongue thrust swallowing • The mentalis muscle and the inferior orbicularis muscle is enlarged • Gingivitis in the mandibular incisor region in the absence of maxillary gingivitis is indicative of hyperactive mentalis function • Gingivitis of both maxillary and mandibular incisor region indicates mouth breathing. www.indiandentalacademy.com
Determination of postural rest position : .The rest position of the mandible depends on head and body posture as they are influenced by gravity.The patient is seated upright preferably with back unsupported. Several methods are available to determine the postural rest position of the mandible. Phonetic exercises: Patient assumes relaxed upright body posture and is looking straight ahead. The letter m is generally used to start and is repeated 5 to 10 times. Repeating or spelling the word Mississipi also is a good exercise.After the phonetic exercise the mandible usually returns to postural rest. www.indiandentalacademy.com
Non command method: The patient has no idea of the parameter being examined.Careful observations are made as the patient talks,swallows and turns the head while being questioned on a number of unrelated subjects.
Combined method: The combined method usually provides the best reproduction of the postural rest position in the mixed dentition.The patient performs a prescribed function ( eg swallowing) and then relaxes. After instructing the patient not to move,the clinician gently palpates the submental muscles to assess whether they are relaxed. Normally the lower canine should be 3mm below the upper in comparison with the occlusal position.An inter occlusal space of 4 mmwww.indiandentalacademy.com may be normal.
Registration of postural rest position: Extra oral method: Direct caliper measurements can be made on the patients profile by measuring the distance from soft tissue nasion to menton. This measurement is done in both postural rest and habitual occlusion. The difference between the two measurements constitutes the inter occlusal clearance.
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Direct intra oral method: In addition to visual observation,the clinician can perform a direct intra oral procedure by using a plaster core registration similar to that sometimes used in prosthodontics. Indirect extra oral method – does not come under clinical examination – various adjuncts such as cephalometry,kinesiography,electromyography are all used.
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Tongue: • Morphologic examination • Size and shape. • Ask the patient to protrude the tongue and note the symmetry of its position.Then ask the patient to relax the tongue,allowing it to drape over the lower lip. • Functional asymmetries of tongue change from one position to the other.Morphologic asymmetries will persist in the draped position. www.indiandentalacademy.com
Functional examination: •Observe the posture of the tongue while the mandible is in its postural position.During mandibular posture,the dorsum touches the palate lightly. •Observe the tongue during various swallows… The unconscious swallow,The command swallow of saliva,the command swallow of water and the unconscious swallow during mastication.The tongue tip during normal mature swallow touches the curvature of the palate just behind the maxillary incisors. •Observe role of tongue during mastication www.indiandentalacademy.com •Observe role of tongue during speech.
Normal infantile swallow: The tongue lies between the gum pads and the mandible is stabilized by obvious contractions of the facial muscles.Buccinator muscle is particularly strong in the infantile swallow. Normal infantile swallow as seen in neonates gradually disappears with the eruption of the buccal teeth in primary dentition. As teeth erupt,the swallow follows a transitional pattern towards the mature swallow and this is called as transitional swallow – occurs during early mixed dentition. Appearance of contractions of the mandibular elevators is a strong indicator of transitional period as the teeth are www.indiandentalacademy.com getting stabilized into occlusion.
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Normal mature swallow: Characterized by very little lip and cheek activity. There is contraction of the mandibular elevators bringing the teeth into occlusion. The swallow which is most apt to be occasionally observed with tongue thrust is the swallow during mastication. Simple tongue thrust swallow: Typically displays contractions of the lips,mentalis muscle and mandibular elevators. The teeth are in occlusion as the tongue protrudes into an open bite.The most primary etiologic factor for open bite due to tongue thrust is because of thumb sucking. www.indiandentalacademy.com
Complex tongue thrust swallow: Defined as tongue thrust with teeth apart swallow.patients with this type of swallow combine contractions of the lip,facial and mentalis muscles,lack of contraction of mandibular elevators,a tongue thrust between the teeth and a teeth apart swallow. The open bite associated with complex tongue thrust is diffuse and often difficult to define than that seen with a simple tongue thrust. Patients with complex tongue thrust usually demonstrate occlusal interferences in the retruded contact position. www.indiandentalacademy.com
Retained infantile swallow: Defined as predominant persistance of infantile swallowing pattern after the arrival of permanent teeth. Patients demonstrate a very strong contraction of the lips and facial musculature. The tongue thrusts strongly between the teeth in front and on both sides. Patients have contact only between one molar in each quadrant. Retained infantile swallow may be associated with skeletal craniofacial development syndromes or neural deficits. Excessive anterior facial height often produces severe frontal open bites and extremeswww.indiandentalacademy.com of adaptive swallowing behavior.
Muscles of mastication: Morphologic Examination: Palpation of each jaw muscle at rest and in function is often useful to reveal asymmetries of muscle size and placement. Functional Examination: Functional analysis of the jaw musculature is best carried out with each particular synchronized function in mind. www.indiandentalacademy.com
Muscles of neck and head support: Morphology – Only on rare occasions does one encounter atypical morphologies of the neck and head support muscles. Function:- - The role of these muscles in head posture is often revealed even in a casual glance at patients as they walk into the examination room and seat themselves. Pain and tenderness:Myalgia of the neck muscles may be associated with tempero mandibular dysfunction, spondylitis or other functional disorderswww.indiandentalacademy.com of the region.
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Inquire about pain in the region and palpate thoroughly all of neck muscles, particularly those originating at the occiput and the sterno cleidomastoid . It may be necessary to refer the patient to an attending physician before beginning orthodontic treatment.
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Examination of specific neuro muscular functions: Posture:
General body posture and head posture are of diagnostic significance.Note asymmetries of shoulder position,spinal curvature and the natural placement of the head atop the vertebral column. Sollow and Tallgren showed that head and chin up posture is more associated with disproportionate anterior facial height while posturing the head back and the chin down is more associated with shorter anterior facial height. www.indiandentalacademy.com
Respiration: Methods of examination: 1. Study the patients breathing unobservedNasal breathers usually show the lips touching lightly during relaxed breathing,whereas mouth breathers must keep the lips parted. 2. Ask the patient to take a deep breath 3. Ask the patients to close the lips and take a deep breath through the nose. www.indiandentalacademy.com
Nasal breathers normally demonstrate good reflex control of the alar muscles,which control the size and shape of the external nares.Therefore they dilate the external nares on inspiration. Mouth breathers, even though they are capable of breathing through the nose,do not change the size or shape of the external nares and occasionally actually contract the nasal orifices while inspiring. Unilateral nasal function may be diagnosed by placing a small,two surfaced steel mirror on the patients upper lip.The mirror will cloud with condensed moisturewww.indiandentalacademy.com during breathing. A cotton butterfly may also be used.
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Speech: A simple test the dentist may use to evaluate the relationship between speech and malocclusion. The dentist watches closely how the tongue and lips adapt to the structures with which they are supposed to articulate. Listens to how the consonants sound. ( th,r,f,s,l,k) Patients are asked to form sentences with these consonants. www.indiandentalacademy.com
Oral sensory defects or lack of orofacial motor skills may be common to both swallowing and speech disorders. In observing patients speech the dentist should pay importance to articulatory errors as stops,fricatives,nasals etc. www.indiandentalacademy.com
Examination of tempero mandibular joint: The objective of this aspect of functional examination is to assess whether incipient syptoms of TMJ dysfunction are present. Early symptoms of TMJ problems include: •Clicking and crepitus •Sensitivity in the condylar region and masticatory muscles •Functional disturbances •Radiographic evidence of morphologic and positional abnormalities. www.indiandentalacademy.com
Clinical functional examination of the tempero mandibular joint area includes three steps: Auscultation:A stethoscope is used to check for signs of clicking and crepitus.A stereostethoscope is better because it allows the operator to determine the magnitude and timing of abnormal sounds for each joint simultaneously. The examination is performed by having the patient open and close the jaw into full occlusion. If clicking or crepitus is noted,the patient is asked to bite forward into incision and then repeat the opening and closing movements. www.indiandentalacademy.com
Most often sounds disappear in the protruded position.
Palpation:The condyle and fossa are palpated with index finger during opening and closing maneuvers.The posterior surface can be palpated by inserting the little finger in the external auditory meatus. The condyles can thus be checked for tenderness, synchrony of action and coordination of relative position in the fossae. Palpation of the lateral Pterygoid muscle area is done by placing the forefinger behind the maxillary tuberosity right above the occlusal plane and the palmar surface of the finger directed medially towards the pterygoid hamulus. www.indiandentalacademy.com
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Functional analysis: Dislocation of the condyles and discoordination of movements are early symptoms of functional disturbance. The extent of maximum opening is measured with a Boley guage. In over bite cases this amount should be added to the maesurement whereas in open bite cases the distance seperating the incisors on full occlusion must be subtracted.
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Several specific measures can be employed to prevent functional TMD’s. 1. Early care of deciduous teeth for caries and interferences. 2. Elimination of tooth guidance cross bites and an unwanted translatory condylar movement in the deciduous dentition. 3. Elimination of neuro muscular dysfunctions and habits that force the mouth open. www.indiandentalacademy.com
CONCLUSION:
Clinical examination is a part of diagnostic interpretation.It is important for the orthodontist to pay much emphasis on it as it aids in diagnosis. An appreciation of the various aspects discussed helps put the dynamic intrinsic forces into therapeutic use to achieve a balanced functional occlusion. www.indiandentalacademy.com
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