Clinical Examination

Prof. Dr. Ahmed El-bialy

Head of orthodontics department
Mansoura University
INTRODUCTION

► Orthodontic diagnosis deals with recognition of the various characteristics of the

malocclusion.

► Orthodontic diagnosis should be based on scientific knowledge combined at times with

clinical experience and common sense.

▸ diagnosis include case history, clinical examination and other diagnostic aids such as study
casts, radiographs and photographs.

► Comprehensive orthodontic diagnosis is established by clinical implementation called

diagnostic aids.

► Orthodontic diagnostic aids are of two types namely':

1. Essential diagnostic aids

2. Supplemental diagnostic aids

ESSENTIAL DIAGNOSTIC AIDS

They are clinical aids that are considered very important for all cases.

The following are essential diagnostic aids:

1. Case history

2. Clinical examination

3. Study models

4. Certain radiographs:

► Periapical

Bitewing

4 Panoramic

5. Facial photographs
Supplemental diagnostic aids

► They are certain aids that are not essential in all cases. They may require specialized
equipments that an average dentist may not possess.

► The supplemental diagnostic aids include:

1-Specialized radiographs ex;

a-cephlometric radiographs

b-occlusal intra-oral films

c-selected lateral jaw views

d-cone shift technique

2.Electromyographic examination of muscle activity

DIAGNOSTIC AIDS

• 1. Case history
• 2. Clinical examination
• 3. Study models

• 4. Certain radiographs:
• a. Periapical radiographs
• b. Lateral radiographs
• c. Orthopantomograms
• d. Bite wing radiographs.

• 5. Facial photographs.
CASE HISTORY

Case history involves eliciting and recording of relevant

information from the patient and parent to aid in overall
diagnosis of the case

-personal details,

-the chief complaint,

-Past and present dental and medical history and any associated
family history
PERSONAL DETAILS
• NAME : the patient's name should be recorded for the purpose of
communication and identification.

• AGE : -the patients chronological age should be recorded.

• Age consideration helps in diagnosis as well as treatment planning.
• ► growth modification procedures using functional and orthopaedic
appliances are carried out during growth period.

• SEX : patient's sex should be recorded in case history.

• ► This is important in planing treatment, as the timing of growth events

such as growth spurts is different in males and females

• ADDRESS AND OCCUPATION : recording of address and occupation helps

in evaluation of socio-economic status of the patient and the parents.
CHIEF COMPLIANT
• the patient’s chief compliant should be recorded in his/ her
own words.

• This help the clinician in identifying the priorities and the

desires of the patient.
MEDICAL HISTORY
full medical history is recorded before orthodontic treatment.

• Few medical conditions contraindicate the use of orthodontic

appliances such as;
• • Epilepsy
• • History of blood dyscrasias
• • Diabetic patient
• • Rheumatic fever
• • Cardiac anomalies
• • Physically and mentally handicapped children

• ► The medical history should include information on drug usage.

• The use of certain drugs like aspirin may impede orthodontic tooth
movement
DENTAL HISTORY
• information on the age of eruption of the deciduous and
permanent teeth , decay , history of extraction , restoration
and trauma to dentition.

• Past dental history helps in evaluation of patient and parent’s

attitude towards treatment.
 PRENATAL HISTORY
-it include information on the condition of the mother during
pregnancy and the type of delivery.

• Forceps delivery predispose to TMJ injuries that can result

mandibular growth retardation

• Drugs like thalidomide or affectation with some infection

during pregnancy like german measles can results in
congenital deformities of child.
 POST NATAL HISTORY
-it includes information on

• type of feeding

• presence of habits

• themilestones of normal development

FAMILY HISTORY
• class II ,class III malocclusions and congenital conditions such
as clefts of lip & palate are inherited.
• Family history should record details of malocclusion existing in
other members of the family.
CLINICAL EXAMINATION

GENERAL EXAMINATION
Body Build
Cephalic and Facial Examination
Facial Profile
ASSESSMENT OF ANTEROPOSTERIOR
JAW RELATIONSHIP
ASSESSMENT OF VERTICAL SKELETAL RELATIONSHIP
EXAMINATION OF THE SOFT TISSUES

Extraoral Examination
Forehead
Nose Size
Lips Lip length
NASOLABIAL ANGLE
Nose Size
CHIN
INTRAORAL EXAMINATION

• Tongue
Lip and Cheek Frena
EXAMINATION OF THE
PALATE
• 1. Dolicofacial patients have deep palate.
• 2. Presence of swellings in the palate
• 3. Mucosal ulcerations and indentations are a feature of
traumatic deep bite.
• 4. Presence of cleft in the palate.
• 5. The third rugae is usually in line with canines.
This is useful in the assessment of maxillary anterior
proclination.
Gingiva
Tonsils and Adenoids
Adenoid facies
Clinical Examination of the Dentition

• 1. NUMBER OF Teeth present in the oral cavity

• 2. Teeth unerupted
• 3. Teeth missing
• 4. Teeth erupted and not erupted
• 5. Presence of caries, restorations, malocclusions, hypoplasia,
wear and dislocation.
• 6. Check for the occlusion based on ANGLES CLASS I, II, III
• 7. Record overbite, overjet
• 8. Check for crossbite
• 9. Individual tooth irregularities such as rotation,
displacement,intrusion and extrusion are noted.
• 10. Check arch form
NUMBER OF Teeth
ANGLE CLASS I
ANGLE CLASS II
OVERJET
OVERBITE
CROSS BITE
ROTATION
FUNCTIONAL EXAMINATION
• 1. Assessment of postural rest position and interocclusal
space.
• 2. Path of closure
• 3. Assessment of respiration
• 4. Assessment of TMJ
• 5. Examination of swallowing
• 6. Examination of speech
ASSESSMENT OF POSTURAL RESTPOSITION
AND INTER-OCCLUSALCLEARANCE
• The postural rest position of the mandible at which the
muscles that closes the jaw and those that open them are,
instate of minimal contraction to maintain the posture of
mandible.
• At postural rest position, a space exists between the upper
and lower jaws.
• This space is known as FREEWAY SPACE.
• FREEWAY SPACE is 3mm in canine region.
Methods used to record the postural rest position
PHONETIC METHOD

• the patient is asked to repeat some consonants “m or c’’ or

repeat a word like Mississippi.
• The mandible returns to postural rest position 1-2seconds
after the exercise.
• The patient is told not to change the jaw, lip or tongue
position after phonation, as the dentist parts the lips to study
interocclusal space.
COMMAND METHOD
• THE PATIENT IS ASKED TO PERFOM CERTAIN FUNCTIONS SUCH
AS SWALLOWING.
• THE MANDIBLE TENDS TO RETURN TO REST POSITION
FOLLOWING THIS ACT.
Non command method
• The patient is observed as he speaks or swallows.
• The patient is no aware that he is being examined.
• This is usually being carried out by talking about topics
unrelated to the patient while carefully observing him or not
Methods to measure inter-occlusal clearance

• VERNIER CALIPERS CAN BE USED DIRECTLY INTHE PATIENT’S

MOUTH IN THE CANINE ORINCISAL REGION TO MEASURE
FREEWAY SPACE.
• THIS IS DIRECT INTRA ORAL METHOD.
EVALUVATION OF PATH OF CLOSURE
• The path of closure is the movement of mandible from the rest
position to habitual occlusion .
• Forward path of closure: a forward path of closure occurs
inpatients with mild skeletal and prenormalcy or edge to edge
incisor contact.
• In such patients ,the mandible is guided to amore forward
position to allow the mandibular incisors to go labial to the
upper incisors.
• Backward path of closure: class 11 ,division 2 exhibit premature
incisor contact due to retroclined maxillary incisors. Thus the
mandible is guided posteriorly to establish occlusion
• Lateral path of closure : lateral deviation of mandible to left or
right side is associated with occlusal prematurities and an arrow
maxillary arch
ASSESSMENT OF RESPIRATION
• Humans may exhibit three types of breathing: nasal ,oral and oro-
nasal
• Test to diagnose the mode of respiration:
• Mirror test : a double sided mirror is held between the nose and
the mouth .fogging on the nasal side of the mirror indicates nasal
breathing while fogging towards oral side indicates oral breathing
• Cotton test : a butterfly shaped cotton piece is placed over the
upper lip below the the nostrils . if the cotton flutters down
indicates nasal breathing .this test is used to determine the
unilateral nasal blockage
• Water test: the patient is asked to fill his mouth with water and
retain it for a long period of time .while nasal breathers
accomplish this with ease , mouth breathers find it difficult task.
• Observation : in nasal breathers the external nares dilate
during inspiration .in mouth breathers ,there is either no
change in the external nares or they may constrict during
inspiration
EXAMINATION OF T.M.J
• The functional examination should routinely include
auscultation and palpation of temporomandibular joint and
musculature associated with mandibular opening .
• The patient should be examined for the symptoms of
temperomandibular joint problems like clicking, crepitus ,pain
of masticatory muscles ,limitation of jaw movement ,hyper-
mobility and morphological abnormalities.
• The maximum mouth opening is determined by measuring the
distance between the maxillary and mandibular incisal edges
with mouth wide open .
• The normal inter incisal distance is 40- 45 mm
EVALUVATION OF SWALLOWING
• In a new born, tongue is relatively large and protrudes
between the gum pads and takes part in establishing the lip
seal .this kind of swallow is called infantile swallow and is
seen till one and half to two years of age .
• Infantile swallow is replaced by mature swallow as the buccal
teeth start erupting.
• The persistence of infantile swallowing can cause malocclusion
.thus the swallowing pattern of the individual should be
examined. The persistence of the infantile swallow is indicated
by the presence of the following features :
• a. Protrusion of the tip of tongue
• b. Contraction of perioral muscles during swallowing
• c. No contact at the molar region during swallowing
SPEECH
• Certain malocclusions may cause defects in speech due to
interference with the movement of tongue and lips .
• this should be observed while talking with the patient .The
patient can be asked to readout from a book or asked to count
from 1-20 while observing the speech .
• Patients having tongue thrust habit tend to lisp while cleft
palate patients may have a nasal tone
THANK YOU