Clinical examination of an orthodontic patient

Clinical
examination of an
Orthodontic
patient
www.indiandentalacademy.com

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

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

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.

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.

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.

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.
The use of facial proportions in modern day
orthodontics:

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.

The importance of clinical examination
With the resurgence of nonextraction
treatment and the advent of orthognathic
surgery evaluation of soft tissue drape pre-
and 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 Endomorphic
Mesomorphic www.indiandentalacademy.com

Height and weight:

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.

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

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 ) .

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

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.

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.

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
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.

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.

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

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.

Depending on the alignment of the three points ,
the profile can be straight, convex or concave.

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.

Orthognathic face – facial angle approximately
90 degrees.
Posterior divergent face – the facial angle is low
Anterior divergent face – the facial angle is high.

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
mastoid region in front of the ear.

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.
Assessment of the nose:

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.

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.
• ‘Gull in flight’ contour of the base of the nose.
• Columella slightly lower than and parallel to the ala when
viewed in any direction.
• Cartilages shouldbe well defined to form a scroll.

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.

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.

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.
If the lip falls behind the line, it is retrusive.

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,
Hypotonic lip is flaccid.www.indiandentalacademy.com

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.

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
•Low hyoid bone position.

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.

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.
7. Massetric hypertrophy.www.indiandentalacademy.com

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
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.
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.

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

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.

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.

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.

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.

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.

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 be an option if it is a skeletal
deformity.

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

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.

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

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.

•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
classification.

Arch forms
Tapered
Ovoid
Square
Arch symmetry

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

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 %.

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.

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.

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.

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.

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…………”www.indiandentalacademy.com

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.

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 lip-
tooth – 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

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.

.- 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
noting assymetric muscle activities.
Study lip function during speech

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
function properly eg. Maxillary lip in extreme CL II DIV

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.

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.

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 mm may be normal.www.indiandentalacademy.com

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.

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.

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
•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
getting stabilized into occlusion.

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 extremes of adaptive swallowing behavior.www.indiandentalacademy.com

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.

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 disorders of the region.www.indiandentalacademy.com

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.

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 unobserved-
Nasal 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.

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 moisture during breathing. A cotton
butterfly may also be used.

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.

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.

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.

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.
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.

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.

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.

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.
CONCLUSION:

Clinical examination of an orthodontic patient

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Clinical examination of an orthodontic patient