CLINICAL EXAMINATION

General Examination

 It comprises of general assessment of patient.

Height & Weight

 They provide a clue to the

physical growth &
maturation of patient.

Somatogram
Body Built (Physique)

Classification of dental arches according to body

built is advocated by Berger

1 Long and slender (asthenic)—Tall thin person,

narrow shoulders, slim arms and hands, face is
high and narrow, mandible is underdeveloped.

2 Short and squat (Pyknic)—person with short

stature, with a short neck and trunk. Face is broad.

3 Muscular type (athletic)—Person with strong well

developed muscles, broad shoulders. Mandible is
square and well developed.
Body Type

 Sheldon has classified general body type into 3 types:

a) Endomorphic
physique with quantitatively endodermally derived
tissue. Tendency to obesity is present. Slow growers

b) Mesomorphic
characterized by quantitatively mesodermally derived
tissue.

c) Ectomorphic
characterized by linearity of structure with presence of
ectodermally derived tissue. Fast growers
 EXTRA ORAL EXAMINATION

 Shape of head—
Cephalic index-It provides a highly significant
test of genetic variability.

Cephalic index= Maximum head

breadth×100
Maximum head length
Head length-
maximum occipital glabella diameter
measured with spreading calipers.

Head breadth-
Greatest transverse diameter measured in
horizontal plane above supramastoid and
zygomatic crest
 Maximum
head length

Maximum
head breadth
 Above 80—Brachycephalic (broad arch form)

 75-80—Mesocephalic (average)

 below75—Dolicocephalic (long and narrow

arch form)
Facial form—Determined by morphological facial
index given by Martin and Seller 1957

Morphological facial height (N-Gn)

Bizygomatic width

Euryproscopic—79-83.9 (low facial skeleton)

Mesoproscopic—84—87.9(average facial skeleton)
Leptoproscopic—88-92.9 (high facial skeleton)

It is used for anthropometric measurements and to

assess genetic variability.
 Facial Profile
 The facial profile is examined by viewing
patient from side.

 Helps to establish whether jaws are

proportionally positioned in anteroposterior
plane of space or not.

The profile is assessed by joining the following

reference lines:
1. A line joining forehead & soft tissues point A
subnasal
2. A line joining subnasal & soft tissue pogonion
a) Straight Profile:

b) Convex

c) Concave Profile:
Straight profile convex profile convcave
profile
 Facial Divergence

It is defined as anterior or posterior inclination of lower face

relative to forehead.

It can be of 3 types.

1. Anterior Divergence: A line drawn b/w forehead & chin is

inclined anteriorly towards chin.

2. Posterior diveregence : Line draw b/w forehead & chin

slants posteriorly towards chin.

3. Straight or Orthognathic: Line is straight or

perpendicular to floor.

Facial divergence to large extent is influenced by patient’s

ethnic and racial background.
straight Posterior divergent Anterior divergent
EVALUATION OF FACIAL PROPORTIONS

 A well proportioned face can be divided into 3 equal vertical

thirds using four horizontal planes at the level of hair line,
supra orbital ridge, base of the nose and inferior border of
chin.

 Within the lower face, upper lip occupies 1/3 rd of distance

while chin occupies rest of 2/3rd.
RULE OF
THIRDS

1/3

1/3

1/3
Lip Posture and Tonicity-

 Competent
 Incompetent

 Potentially competent

 Everted

Feel for lip consistency

 Hypertonic lip—firm and red

 Hypotonic lip—flaccid
Competent lips Potentially Everted lips
Competent lips
 Interlabial Gap:- when lips are relaxed the
space between upper lip & lower lip is 1- 4
mm. Increase in the gap is seen with short
lip, vertical maxillary excess, mandibular
prognathism & open bite.

Decrease in the gap is found with vertical

maxillary deficiency long upper lip,
mandibular retrusion with deep bite.
FUNCTIONAL EXAMINATION
EXAMINATION OF RESPIRATION

 Patient must be assessed either he is nose-breather or mouth-

breather.

 Various methods to examine mouth breathing:

- Mirror test
- Cotton test
- Water holding test
- Nostril observation

Causes of Mouth Breathing

▪ Nasal Polyps
▪ Chronic inflammation of nasal mucosa
▪ Short upper lip
▪ Deviated nasal septum
Size and shape
of external nares
in patient with
nasal
respiration.

Size and shape

of external nares
in patient with
oral respiration.
▪ During oral respiration 3 changes seen in the
posture:

1. Lowering of mandible.
2. Positioning of tongue downwards and forward.
3. Tipping back of the head

Clinical Features
▪ Long face ‘Adenoid facies’
▪ Contracted upper arch with possibility of posterior
cross-bite
▪ Short upper lip
▪ Anterior open bite can occur
MASTICATION
 Mastication in any type of malocclusion with
maximum intercuspation is considered with no
problem. Ask patient whether they use one / both
side to chew food.

 If patient chews unilaterally then marked calculas

deposit can be observed on the side which is not
used for mastication.

 Patient with improper mastication have problem

with cheek and lip biting , they avoid eating hard
food.
 Postural Rest Position

 The position of the mandible at which the muscles

that open and close the mandible are in a state of
minimal tonic contraction sufficient to maintain
posture against gravity.
 Alters with the position of the head.
 Determination Postural Rest Position
 Phonetic method— patient is asked to pronounce
certain consonants e.g.m/g or words like missisipi.
Mandible returns to normal resting position 1-2
seconds after the exercise.

 Command method— patient is asked to perform

certain functions like swallowing, after which the
mandible spontaneously returns to rest position.

 Non command method— patient is distracted,while

being distracted, the patient relaxes causing the
musculature to relax as well, and the mandible
reverts to postural rest position.
Few methods to measure Inter Occlusal
Clearance
 Direct Intraoral procedure: with vernier caliper

 Direct extra oral procedure: two marks placed on nose

and chin. The distance between these two points
measured after instructing the patient to remain at rest
position. Later the patient is asked to occlude the teeth
& distance between the two points is again measured.
The difference between two readings is free way space.

 Indirect extra oral procedures: Inter Occlusal space is

determined in radiograph
 DEGLUTITION
It is transit of food bolus or saliva from oral cavity
to the stomach.
EVALUATION OF SWALLOWING: - patient seated in
a relaxed position, ask the patient to
swallow. Note the mandibular movement.
In normal mature swallow, mandible rises
as teeth are brought together during
swallow & lip touches lightly. Place the
hand over temporal muscle to feel the
contraction.
 SPEECH
 Patientswith malocclusion have faulty
speech because of remarkably adaptive
characteristic of lip & tongue.
Evaluation of proper speech is needed
to rule out functional & organic disorder.
Examination of TMJ

Functional examination of TMJ is done to check incipient

symptoms of TMJ dysfunction.

Early symptoms of TMJ dysfunction are:

▪ Clicking or crepitus
▪ Sensitivity of Condylar region or
masticatory muscles
▪ Hypermobility, limitation of movement or
deviation
▪ Radiographic evidence of morphological or
positional abnormality
 Screening history and examination
Is done to identify patients with
 Subclinical signs
 Symptoms
patient may not relate but are commonly
associated with functional disturbances of the
masticatory system (i.e., headaches, ear symptoms).
The following can be used to identify functional
disturbances’:
1. Any difficulty in opening the mouth
2. Noises from the jaw joints
3. Frequent headaches
4. Jaw getting “stuck” or “locked”
5. Pain in or about the ears or cheeks

6. Pain on chewing or yawning

7. Any previous treatment of TMJ disorders

 PAIN

1. Location
2. Behavior
3. Quality
4. Duration
5. Degree
Location

•Pain related to a specific area (Myofascial

trigger point pain)
•A large ill-defined region ( myositis)
Behavior

 The pain occur in a single episode

( pain related to myositis or disc dislocation)

 Recurring with periods of remission inbetween

( myospasms associated with emotional stress)
Quality
1. Sharp pain : spontaneous disc dislocation
2. Dull aching pain : Myospasms
3. Throbbing pain : Myositis
Duration
Short duration : myositis
Long duration : degenrative joint disorders.

Degree (from none to extreme)

 Gives an idea of the patient’s discomfort.
DYSFUNCTION
 Limited jaw movement
 Joint sounds
 Any changes in the biting position (acute
malocclusion seen in Discitis, capsulitis etc.)
 The masticatory examination

• Muscles examined by palpation and

functional manipulation
• Joints
• Teeth
Muscle palpation
A routine neuromuscular examination includes
palpation of the following muscles or muscle groups:

 Temporalis
 Masseter
 Lateral pterygoid
 Medial ptrygoid
POSITIONING THE PATIENT

 The examination procedures for manual

functional analysis are performed from the
12 o'clock position, or more precisely,
between the 11 and 1 o'clock positions.
 Palpation…
Temporalis

Anterior part of temporalis is Middle part of temporalis is

palpated above zygomatic arch and palpated directly above the TMJ
anterior to TMJ
 Palpation…
Temporalis

Posterior part is palpated above and

behind the ear
 Palpation
Masseter
Deep portion Superficial portion

Deep masseter palpated at Superficial fibres palpated

its attachment to zygomatic near lower border of
arches mandible
MEDIAL PTERYGOID
LATERAL PTERYGOID
 The muscle is
palpated in close
proximity to the
neck of condyle
cranially behind the
maxillary tuberosity.
 Mouth open and

mandible displaced
laterally.
Functional manipulation

During functional manipulation each muscle is

contracted and then stretched. If the muscle is a
true source of pain, both activities will increase
the pain.
 Maximum interincisal distance
 The normal range of mandibular opening when
measured interincisally is 53-58 mm.
A restricted mandibular opening is considered as any
distance less than 40 mm.
•Seen in myospasms
•Myositis
•Disc dislocations
•Adhesions in superior joint cavity
•Ankylosis
 Maximum jaw opening- is usually measured
between the incisal edges of the incisors and
to this is added the over-bite
If mandibular opening is restricted test the ‘‘end
feel.’’

If the end feels “soft.” increased opening can be

achieved

A soft end feel suggests muscle-induced restriction.

If no increase in opening can be achieved, the end

feel is said to be hard.’

Hard end feel are associated with intracapsular

sources (e.g., a disc dislocation).
 Lateral excursion movement-

 Lateral movements of less than 8 mm are

generally classified as restricted .
 To measure lateral mandibular movements, the

upper midline is first projected onto the lower

midline. Then the patient executes a maximal
lateral movement and the distance between the
upper and lower midline is measured.
 TEMPOROMANDIBULAR JOINT EXAMINATION

Lateral
palpation
of joint

•Exert slight pressure on the condylar process with

index finger palpating both sides simultaneously.
•The coordination of action between left an right
condylar heads should also be recorded.
 Ifuncertainty exists regarding the
proper position of the fingers, the
patient is asked to open and close a
few times.
 The fingertips should feel the lateral
poles of the condyles passing
downward and forward across the
articular eminences.
 Any symptoms associated with

mandibular movement are recorded.

 Position the fingers in external auditory
meatus and palpate the posterior surface of
condyle during opening and closing
movement.

Posterior
palpation
of joint
 Auscultation

• Carried out with the help of stethoscope

• Joint sounds are either clicks or crepitation.
• A click is a single sound of short duration. If it is
relative loud, it is also referred to as a pop.
 Crepitation

Is a multiple gravel like sound or grating type of sound.

Joint sounds can be perceived by placing the fingertips
over the lateral surfaces of the joint and having the
patient open and close.
 Not only will the character of any joint
sounds be recorded (clicking or crepitation), but
also the degree of mandibular opening associated
with the sound.

• Initial clicking - retruded condyle in relation to

disc.
• Intermediate clicking – unevenness of the
condylar surface/.
• Terminal clicking – condyle being moved too far
anteriorly.
• Reciprocal clicking – in-cordination between
condyle and disc.
 An increase of crepitus in the absence of pain
indicates osteoarthrosis, non-inflammatory
stage of joint surface damage.

 If crepitus with pain is present –

osteoarthritis a inflammatory stage of joint
surface damage.

 If no crepitus but pain and limitation of jaw

opening – capsultis with disk displacement
can be suspected.
THANKYOU