Diagnosis final 1

DIAGNOSIS
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FUNCTIONALFUNCTIONAL
ANALYSISANALYSIS

• Modern orthodontics is not only restricted to static evaluation ofModern orthodontics is not only restricted to static evaluation of
the teeth and their supporting structures, but also includes allthe teeth and their supporting structures, but also includes all
functional units of the masticatory system (according tofunctional units of the masticatory system (according to
Eschler,1952), i.e. the somatognathic system. ThereforeEschler,1952), i.e. the somatognathic system. Therefore
functional analysis constitutes a considerable part of clinicalfunctional analysis constitutes a considerable part of clinical
examination, helps in etiologic evaluation of the malocclusionexamination, helps in etiologic evaluation of the malocclusion
and determining the type of orthodontic treatment indicated.and determining the type of orthodontic treatment indicated.

Three most important aspect of Functional analysis are:Three most important aspect of Functional analysis are:
• Examination of the postural rest position.Examination of the postural rest position.
• Examination of the temporomandibular joint.Examination of the temporomandibular joint.
• Examination of orofacial dysfunction.Examination of orofacial dysfunction.

Examination of the relationship: Postural Rest Position-Examination of the relationship: Postural Rest Position-
Habitual OcclusionHabitual Occlusion
• Determination of the postural rest position.Determination of the postural rest position.
• Registration of the postural rest position.Registration of the postural rest position.
• Evaluation of the relationship: postural rest position-habitual occlusion, inEvaluation of the relationship: postural rest position-habitual occlusion, in
three planes of space.three planes of space.

• In postural rest position, synergistic and antagonist muscularIn postural rest position, synergistic and antagonist muscular
components are in dynamic equilibrium; their balance iscomponents are in dynamic equilibrium; their balance is
maintained with basic muscle tonus. The rest position is themaintained with basic muscle tonus. The rest position is the
result of a myostatic antistretch reflex that responds only to theresult of a myostatic antistretch reflex that responds only to the
permanent exogenous force affecting the orofacial system i.e.permanent exogenous force affecting the orofacial system i.e.
gravitygravity..
The rest position should be determined with the patientThe rest position should be determined with the patient
relaxed and sitting upright. Patient should be looking straightrelaxed and sitting upright. Patient should be looking straight
ahead and the frankfurt horizontal plane parallel to the floor.ahead and the frankfurt horizontal plane parallel to the floor.

Determination of the postural rest positionDetermination of the postural rest position
• In order to determine the PRP, the patient’s orofacialIn order to determine the PRP, the patient’s orofacial
musculature must be relaxed. When the mandible is in PRP, it ismusculature must be relaxed. When the mandible is in PRP, it is
usually 2-3 mm below and behind the centric occlusion. Theusually 2-3 mm below and behind the centric occlusion. The
space between the teeth is referred to as the freeway space orspace between the teeth is referred to as the freeway space or
interocclusal clearence.interocclusal clearence.

Several methods are available to determine the postural restSeveral methods are available to determine the postural rest
position:position:
• Phonetic exercises.Phonetic exercises.
• Command methods.Command methods.
• Noncommand methods.Noncommand methods.
• Combined methods.Combined methods.

Phonetic exercisePhonetic exercise
• Patient is told to pronounce certain consonents or wordsPatient is told to pronounce certain consonents or words
repetitively e.g. Mississippi. The mandible returns to the posturalrepetitively e.g. Mississippi. The mandible returns to the postural
resting position 1-2 seconds after exercise, then dentist gentlyresting position 1-2 seconds after exercise, then dentist gently
parts the lips to observe the interocclusal clearence and tongueparts the lips to observe the interocclusal clearence and tongue
posture. In mixed dentition language habits vary and notposture. In mixed dentition language habits vary and not
stabilized so this method is less used as prime determinants.stabilized so this method is less used as prime determinants.

Command methodCommand method
• The patient is asked to perform selected functions; the mandibleThe patient is asked to perform selected functions; the mandible
returns to the PRP after each function. Usually, having thereturns to the PRP after each function. Usually, having the
patient lick the lips and then swallow produces the desiredpatient lick the lips and then swallow produces the desired
relationship as mandible returns to PRP with in 2 secs afterrelationship as mandible returns to PRP with in 2 secs after
exercise.exercise.

Noncommand methodNoncommand method
• In noncommand method the patient has no idea of theIn noncommand method the patient has no idea of the
parameter being examined. Careful observations are made as theparameter being examined. Careful observations are made as the
patient talks, swallow, and turns the head while being questionedpatient talks, swallow, and turns the head while being questioned
on a number of unrelated subjects.on a number of unrelated subjects.

Combined methodCombined method
• This method usually provides the best reproduction of PRP in the mixedThis method usually provides the best reproduction of PRP in the mixed
dentition.dentition.
• The patient performs a prescribed function e.g. swallowing and then relaxes.The patient performs a prescribed function e.g. swallowing and then relaxes.
After instructing the patient not to move, the clinician gently palpates theAfter instructing the patient not to move, the clinician gently palpates the
submental muscles to assess whether they are relaxed. An intraoralsubmental muscles to assess whether they are relaxed. An intraoral
examination by observing the relationship of the canine is performed.examination by observing the relationship of the canine is performed.
Normally the lower canine is 3mm below the upper canine. An interocclusalNormally the lower canine is 3mm below the upper canine. An interocclusal
space of 4mm may be considered normal.space of 4mm may be considered normal.

Registration of the postural rest position of theRegistration of the postural rest position of the
mandiblemandible
• Various methods are recommended for registration:Various methods are recommended for registration:
• Direct intraoral method.Direct intraoral method.
• Direct extraoral method.Direct extraoral method.
• Indirect extraoral method.Indirect extraoral method.

Direct intraoral methodDirect intraoral method
• This method is performed by using a plaster core registrationThis method is performed by using a plaster core registration
similar to that sometimes used in prosthodontics. Thissimilar to that sometimes used in prosthodontics. This
registration is not feasible in mixed dentition.registration is not feasible in mixed dentition.
• Millimetric calipers can be used to record the intraocclusal spaceMillimetric calipers can be used to record the intraocclusal space
in the canine or incisor area.in the canine or incisor area.

Direct extraoral methodDirect extraoral method
• Direct caliper measurements can be made on the patient’s profile byDirect caliper measurements can be made on the patient’s profile by
measuring the distance from soft tissue nasion to menton. This measurementmeasuring the distance from soft tissue nasion to menton. This measurement
is done in both postural rest and habitual occlusion. The difference betweenis done in both postural rest and habitual occlusion. The difference between
the two measurements constitutes the interocclusal clearance. Thethe two measurements constitutes the interocclusal clearance. The
disadvantage of this procedure are that the soft tissues reduces the reliability.disadvantage of this procedure are that the soft tissues reduces the reliability.

Indirect extraoral methodIndirect extraoral method
• This method is most reliable:This method is most reliable:
• Roentgenocephalometric registration.Roentgenocephalometric registration.
• Kinesiographic registration.Kinesiographic registration.

Roentgenocephalometric registrationRoentgenocephalometric registration
• Two cephalograms are required, either in lateral or frontal projectionTwo cephalograms are required, either in lateral or frontal projection
depending on how the question is formulated.depending on how the question is formulated.
One radiograph in centric occlusion.One radiograph in centric occlusion.
One with mandible in its rest position.One with mandible in its rest position.
The rest position and freeway space can be determined by comparing theThe rest position and freeway space can be determined by comparing the
radiographs.radiographs.

Kinesiographic RegistrationKinesiographic Registration
• The mandibularThe mandibular kinesiographickinesiographic, according to, according to jankelson(1984jankelson(1984),),
allows the mandibular rest position to be registered threeallows the mandibular rest position to be registered three
dimensionally. The position of the mandible is recordeddimensionally. The position of the mandible is recorded
electronically by:electronically by:
• A permanent magnet, which is fixed with rapid-setting acrylic toA permanent magnet, which is fixed with rapid-setting acrylic to
the lower anterior teeth.the lower anterior teeth.
• A sensor system of six magnetometers mounted on the spectacleA sensor system of six magnetometers mounted on the spectacle
frames.frames.

• Every movement of the mandible andEvery movement of the mandible and
the attached magnet out of centricthe attached magnet out of centric
occlusion, alters the strength of theocclusion, alters the strength of the
magnetic field. These changes aremagnetic field. These changes are
recorded by the sensors, processed inrecorded by the sensors, processed in
the kinesiograph and displayed on athe kinesiograph and displayed on a
storage oscilloscope.storage oscilloscope.
The mandibular movements and restThe mandibular movements and rest
position are recorded two-dimensionallyposition are recorded two-dimensionally
on two pre-selectable levels. Theon two pre-selectable levels. The
electronic circuitry also allows the restelectronic circuitry also allows the rest
position to be recorded as three-position to be recorded as three-
dimensional coordinates.dimensional coordinates.

Evaluation of the relationship between restEvaluation of the relationship between rest
position and habitual occlusionposition and habitual occlusion
• The movement of the mandible from the rest position to fullThe movement of the mandible from the rest position to full
articulation is analyzed three-dimensionally: In the sagittal,articulation is analyzed three-dimensionally: In the sagittal,
vertical, and frontal planes.vertical, and frontal planes.
• The closing movements of the mandible can divided into twoThe closing movements of the mandible can divided into two
phases:phases:
Free phase: Mandibular path from the postural rest to the initial orFree phase: Mandibular path from the postural rest to the initial or
premature contact position.premature contact position.
Articular phase: Mandibular path from the initial contact position toArticular phase: Mandibular path from the initial contact position to
centric or habitual occlusion. In case of functional equilibrium,centric or habitual occlusion. In case of functional equilibrium,
the articular phase does not occur.the articular phase does not occur.

• When closing from the rest position, the mandible may undergoWhen closing from the rest position, the mandible may undergo
both rotational and sliding movement. The objective of thisboth rotational and sliding movement. The objective of this
analysis is to determine the amount and direction of movementanalysis is to determine the amount and direction of movement
as well as the proportions of the rotational and slidingas well as the proportions of the rotational and sliding
components. The following movements of the mandible fromcomponents. The following movements of the mandible from
the rest position to habitual occlusion must be differentiated forthe rest position to habitual occlusion must be differentiated for
orthodontic diagnosis:orthodontic diagnosis:
• Pure rotational movementsPure rotational movements
• Rotational movement with an anterior sliding component.Rotational movement with an anterior sliding component.
• Rotational movement with a posterior sliding component.Rotational movement with a posterior sliding component.

Evaluation in the sagital planeEvaluation in the sagital plane
• Class II malocclusionsClass II malocclusions.. TreatmentTreatment prognosis for functional appliance therapyprognosis for functional appliance therapy
depends on the analysis of relationships and the determination of the path ofdepends on the analysis of relationships and the determination of the path of
closure category:closure category:
• 1. In classII malocclusion without functional disturbances the path of closure1. In classII malocclusion without functional disturbances the path of closure
from rest to occlusion is straight up and forward, with a hinge movement offrom rest to occlusion is straight up and forward, with a hinge movement of
the condyle in the fossa. These are true class II malocclusionsthe condyle in the fossa. These are true class II malocclusions

• 2. In class II malocclusion with2. In class II malocclusion with
functional disturbances a rotatoryfunctional disturbances a rotatory
action of the condyle in the fossa fromaction of the condyle in the fossa from
postural rest to initial contact ispostural rest to initial contact is
evident. From initial contact to fullevident. From initial contact to full
occlusion, condylar action is bothocclusion, condylar action is both
rotatory and translatory up androtatory and translatory up and
backward.backward. As Boman and BlumeAs Boman and Blume
(1952) showed in their reserch, this(1952) showed in their reserch, this
type of activity is most common,type of activity is most common,
particularly in excessive overbite cases.particularly in excessive overbite cases.
This type of class II cases appearsThis type of class II cases appears
more severe than it actually is sagitally.more severe than it actually is sagitally.
And have a good prognosis.And have a good prognosis.

• 3. In class II malocclusion with3. In class II malocclusion with
functional disturbances in which thefunctional disturbances in which the
path of closure ispath of closure is up and forwards,up and forwards,
mandible is anteriorly displaced frommandible is anteriorly displaced from
the initial contact as the cusp guide thethe initial contact as the cusp guide the
mandible into a forward position, withmandible into a forward position, with
translatory movement of the condylestranslatory movement of the condyles
down and forward. Rare conditiondown and forward. Rare condition
illustrated by Woodside. And thisillustrated by Woodside. And this
condition is more severe than as itcondition is more severe than as it
appears with the teeth in occlusion,appears with the teeth in occlusion,
having a poor prognosis.having a poor prognosis.

• CLASS III MALOCCLOSIONCLASS III MALOCCLOSION.. Hinge-type of condylar movementHinge-type of condylar movement
is often associated with straight path of closure. The possibility of successfulis often associated with straight path of closure. The possibility of successful
functional appilance therapy of this problem exist only if the magnitude offunctional appilance therapy of this problem exist only if the magnitude of
sagital dysplasia is not too great and the therapy is began in the early mixedsagital dysplasia is not too great and the therapy is began in the early mixed
dentition.dentition.
• If the path of closure is up and back the prognosis is poor.If the path of closure is up and back the prognosis is poor.
• In class III malocclusion with the anterior displacement that creates an upIn class III malocclusion with the anterior displacement that creates an up
and forward path of closure, the prognosis is much better and the treatmentand forward path of closure, the prognosis is much better and the treatment
success is possible, even in permanent dentitionsuccess is possible, even in permanent dentition

• Some times a skeletal class III malocclusion is partially compensated by labialSome times a skeletal class III malocclusion is partially compensated by labial
tipping of the maxillary incisors and lingual tipping of mandibular incisors.tipping of the maxillary incisors and lingual tipping of mandibular incisors.
Because of the extreme tipping possible an anterior sliding movement intoBecause of the extreme tipping possible an anterior sliding movement into
occlusion can occur. Uprighting the incisors into their proper axialocclusion can occur. Uprighting the incisors into their proper axial
inclinations results in severe class III sagital tooth relationship. Treatmentinclinations results in severe class III sagital tooth relationship. Treatment
with orthodontic means is difficult because dentoalveolar compensation iswith orthodontic means is difficult because dentoalveolar compensation is
not possible; as incisors are already overcompensated before treatment andnot possible; as incisors are already overcompensated before treatment and
orthognathic surgery should be considered. This type of malocclusion isorthognathic surgery should be considered. This type of malocclusion is
reffered to asreffered to as pseudo-forced bite.pseudo-forced bite.

Evaluation of path of closure from posturalEvaluation of path of closure from postural
rest to habitual occlusion in vertical planerest to habitual occlusion in vertical plane
• This evaluation is of special interest in the assessment of therapeutic potentialThis evaluation is of special interest in the assessment of therapeutic potential
in deep overbite cases. Two types of deep overbite can be differentiated.in deep overbite cases. Two types of deep overbite can be differentiated.
• 1. True Deep Overbite.1. True Deep Overbite.
The true deep bite with a large interocclusal clearence is caused byThe true deep bite with a large interocclusal clearence is caused by
infraocclusion of the posterior segments. It often results from a lateral tongueinfraocclusion of the posterior segments. It often results from a lateral tongue
posture or tongue thrust habit. Treatment in the mixed dentition periodsposture or tongue thrust habit. Treatment in the mixed dentition periods
requires the elimination of the enviromental factors inhibiting eruption ofrequires the elimination of the enviromental factors inhibiting eruption of
posterior teeth.posterior teeth.

Prognosis is good in a true deepbite problem with a vertical growth pattern. AndPrognosis is good in a true deepbite problem with a vertical growth pattern. And
the prognosis is fair with horizontal growth pattern.the prognosis is fair with horizontal growth pattern.

• 2. Pseudo-deep overbite with a small2. Pseudo-deep overbite with a small
interocclusal space already has normalinterocclusal space already has normal
eruption of the poserior segment teeth. Someeruption of the poserior segment teeth. Some
class II div. 2 malocclusion that produceclass II div. 2 malocclusion that produce
gummy smile and poor lip line relation fallgummy smile and poor lip line relation fall
into this category. The amount ofinto this category. The amount of
interocclusal clearence is a distinguishinginterocclusal clearence is a distinguishing
criterion. Clinician must intrude the incisorscriterion. Clinician must intrude the incisors
with slight extrusion of molars; it results in anwith slight extrusion of molars; it results in an
increases facial height and further TMJincreases facial height and further TMJ
problems. The clinician must derive theproblems. The clinician must derive the
maxillary molars distally to control the verticalmaxillary molars distally to control the vertical
dimension. Cases with pseudo-deep bite withdimension. Cases with pseudo-deep bite with
horizontal growth pattern have poorhorizontal growth pattern have poor
prognosis.prognosis.

Evaluation of the relationship between rest positionEvaluation of the relationship between rest position
and habitual occlusion in the Transverse Planeand habitual occlusion in the Transverse Plane
• The position of the midline of the mandible is observed while the jaw isThe position of the midline of the mandible is observed while the jaw is
moved from the postural rest to habitual occlusion. Depending on themoved from the postural rest to habitual occlusion. Depending on the
functional analysis two types skeletal mandibular deviation can befunctional analysis two types skeletal mandibular deviation can be
differentiateddifferentiated
• 1. LATEROGNATHY1. LATEROGNATHY
• 2. LATEROCCLUSION2. LATEROCCLUSION

• LATEROGNATHY: The centerLATEROGNATHY: The center
of the mandible is not aligned withof the mandible is not aligned with
the facial midline in rest and inthe facial midline in rest and in
occlusion. These dysplasiasocclusion. These dysplasias
constitutes true neuromuscular orconstitutes true neuromuscular or
anatomical asymmetry. A lateralanatomical asymmetry. A lateral
cross bite with laterognathy iscross bite with laterognathy is
termed true cross-bite. Thetermed true cross-bite. The
prognosis is unfavorable for causalprognosis is unfavorable for causal
therapy.therapy.

• LATEROCLUSION: The skeletalLATEROCLUSION: The skeletal
midline shift of the mandible canmidline shift of the mandible can
be observed only in occlusalbe observed only in occlusal
position; in postural rest positionposition; in postural rest position
both midlines are well aligned. Theboth midlines are well aligned. The
deviation is due to tooth guidancedeviation is due to tooth guidance
(functional non-true malocclusion).(functional non-true malocclusion).

EXAMINATION OF THEEXAMINATION OF THE
TEMPOROMANDIBULAR JOINTTEMPOROMANDIBULAR JOINT
• The objective of this aspect of functional examination is to assess whetherThe objective of this aspect of functional examination is to assess whether
incipient symptoms of TMJ dysfunction are present.incipient symptoms of TMJ dysfunction are present.
• These symptoms are important for two reasons:These symptoms are important for two reasons:
1. Through the early elimination of functional disturbances, some incipient1. Through the early elimination of functional disturbances, some incipient
TMJ problems can be prevented or eliminated. This is an indication for earlyTMJ problems can be prevented or eliminated. This is an indication for early
orthodontic treatment.orthodontic treatment.
2. During functional therapy the condyle is displaced or dislocated to achieve2. During functional therapy the condyle is displaced or dislocated to achieve
a remodeling of the TMJ structures and a change in muscle function. If thea remodeling of the TMJ structures and a change in muscle function. If the
temporomandibular structures are abnormal at the start and hypersensitivitytemporomandibular structures are abnormal at the start and hypersensitivity
is a problem, the possibility of exacerbating the symptoms exist.is a problem, the possibility of exacerbating the symptoms exist.

EXAMINATION OF TMJ:
Auscultation Palpation Functional Analysis Radiographic
Examination
•TMJ •TMJ
•Musculature
•TMJ
•Mandibular
excursion
•Occlusion
•Rest position
•Premature contacts
•Dysfunctions
•TMJ
SYMPTOMS
•Crepitus
•Clicking
•Palpatory
pain
•Dislocation
•Hypermobility
•Limitation
•Deviation
•Orofacial dysfunction
•Dislocation
•Changes in shape
and structure.

• AUSCULTATION:AUSCULTATION: is carried out with a stethoscope, clicking and crepitus inis carried out with a stethoscope, clicking and crepitus in
the joint may be diagnosed during anteroposterior and eccentric movementsthe joint may be diagnosed during anteroposterior and eccentric movements
of the mandible.of the mandible.
• JOINT CLICKING IS DIFFERENTIATED AS FOLLOWS:JOINT CLICKING IS DIFFERENTIATED AS FOLLOWS:
1.Initial Clicking: is a sign of retruded condyle in relation to the disc.1.Initial Clicking: is a sign of retruded condyle in relation to the disc.
2.Intermediate Clicking: is a sign of unevenness of the condylar surfaces and2.Intermediate Clicking: is a sign of unevenness of the condylar surfaces and
of the articular disc, which slide over one another during movements.of the articular disc, which slide over one another during movements.
3. Terminal Clicking: occurs most commonly and is an effect of condyle being3. Terminal Clicking: occurs most commonly and is an effect of condyle being
moved too far anteriorly, in relation to the disc, on maximum jaw opening.moved too far anteriorly, in relation to the disc, on maximum jaw opening.
4. Reciprocal Clicking: occurs during opening and closing, and expresses an in4. Reciprocal Clicking: occurs during opening and closing, and expresses an in
coordination between displacement of the condyle and disc. Clicking of thecoordination between displacement of the condyle and disc. Clicking of the
joint is rare in children.joint is rare in children.

• PALPATION OF THE TEMPOROMANDIBULAR JOINT: DuringPALPATION OF THE TEMPOROMANDIBULAR JOINT: During
opening maneuvers will reveal possible pain on pressure of theopening maneuvers will reveal possible pain on pressure of the
condylar areas. Besides the right and left condyles can thus be checkedcondylar areas. Besides the right and left condyles can thus be checked
for synchrony of action.for synchrony of action.
Palpation – pain on pressure of the
condylar areas. Right & left condyles
checked for synchrony of action.
* Lateral palpation of TMJ
– Slight pressure on the condyloid
process with the index finger.
* Posterior palpation of
TMJ – Position the little finger in the
external auditory meatus and palpate
the posterior surface of the condyle
during opening and closing.

• Palpation of lateral pterygoid
muscle
- is palpated close proximity to
the neck of the condyle and the
joint capsule, cranially behind the
maxillary tuberosity. It is carried
out with mouth open and
mandible displaced laterally.
• Palpation of Temoporalis
Muscle:
Bilaterally & Extraorally

Palpation of masseter muscle
– Superficial massater muscle is palated beneath the eye, inferior
to zygomatic arch.
- Deep portion is palpated on the same level, 2 finger width infront
of tragus.

Recording of the maximum inter incisal distance:
Maximum jaw opening – distance between incisal edges of the upper and
lower central incisors are measured with Boley gauge. It is usually 40-45mm.
In over bite cases this amount is added to the obtained value whereas in open
bite it is subtracted. In cases with TMJ dysfunction, hypermobility is often
registered in the initial stages and limitation in the later stages.

Opening and closing movements of the mandible:Opening and closing movements of the mandible:
• The opening and closing movements of the mandible as well as its protrusive,The opening and closing movements of the mandible as well as its protrusive,
retrusive and lateral excursion are examined as part of the functional analysis.retrusive and lateral excursion are examined as part of the functional analysis.
The size and direction of these actions are recorded during clinicalThe size and direction of these actions are recorded during clinical
examination. Deviations in speed can only be registered with electronicexamination. Deviations in speed can only be registered with electronic
devices (Kinesiograph).devices (Kinesiograph).
• The first signs of initial temporomandibular joint problems include deviationsThe first signs of initial temporomandibular joint problems include deviations
of the mandibular opening and closing paths in the sagittal and frontal planes.of the mandibular opening and closing paths in the sagittal and frontal planes.
In patients with malocclusion and malaligned teeth, disturbances inIn patients with malocclusion and malaligned teeth, disturbances in
mandibular movement are the result of an asynchronic pattern of musclemandibular movement are the result of an asynchronic pattern of muscle
contractions. The characteristic movement deviations include incongruencycontractions. The characteristic movement deviations include incongruency
of the opening and closing curves and uncoordinated zigzag movements. Theof the opening and closing curves and uncoordinated zigzag movements. The
“C” and “S” types of deviations are typical signs of functional disturbances.“C” and “S” types of deviations are typical signs of functional disturbances.

Occlusal analylsis on an articulator is mostly not necessary in adolscents. It is only
indicated in patients with manifest symptoms of temporomandibular joint
disease.

Pattern of mandibular movements
during opening and closing maneuvers:
Opening and closing paths in sagittal
plane.1. opening and closing arcs cross
over inconsistency.
2. The opening movements show
greater deviations.
3. The closure pattern is straighter and
more constant.
OPENING AND CLOSING ARCS
IN HORIZONTAL PLANE: 1. the
opening path is pathologically C-shaped
At the end of the closing movement,
the mandible shifts slightly toward the
left.
OPENING AND CLOSING PATHS
IN THE FRONTAL PLANE. The
extent of jaw opening is normal and
mandible towards left due to occlusal
interferences.

Temporomandibular joint- RadiographicTemporomandibular joint- Radiographic
ExaminationExamination
• Only in limited cases radiographic examinations indicated forOnly in limited cases radiographic examinations indicated for
patients with functional disturbances of the temporomandibularpatients with functional disturbances of the temporomandibular
joint.joint.
• When analyzing the radiographs following findings areWhen analyzing the radiographs following findings are
registered:registered:
1. Position of the condyle in relation to the fossa.1. Position of the condyle in relation to the fossa.
2. Width of the joint space2. Width of the joint space
3. Changes in shape and structure of the condyle head or the3. Changes in shape and structure of the condyle head or the
mandibular fossa.mandibular fossa.
Adolescents with class II, Div. 1 malocclusion and lipAdolescents with class II, Div. 1 malocclusion and lip
dysfunction (lip sucking or sucking) are most frequently affecteddysfunction (lip sucking or sucking) are most frequently affected
by TMJ disorders.by TMJ disorders.

Diagnostic imaging of the TMJDiagnostic imaging of the TMJ
• PANORAMIC VIEWPANORAMIC VIEW
• TRANSORBITAL VIEWTRANSORBITAL VIEW
• TRANSPHYRENGEAL VIEWTRANSPHYRENGEAL VIEW
• TRANSCRANIAL VIEWTRANSCRANIAL VIEW
• ARTHROGRAPHYARTHROGRAPHY
• CONVENTIONAL TOMOGRAPHYCONVENTIONAL TOMOGRAPHY
• COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY
• MAGNETIC RESONANCE IMAGINGMAGNETIC RESONANCE IMAGING
• CONE BEAM COMPUTERISED TOMOGRAPHYCONE BEAM COMPUTERISED TOMOGRAPHY

EXAMINATION OF OROFACIAL DYSFUNCTIONEXAMINATION OF OROFACIAL DYSFUNCTION
CONTANTSCONTANTS
• 1. Swallowing1. Swallowing
• 2. Tongue2. Tongue
• 3. Speech3. Speech
• 4. Lips4. Lips
• 5. Respiration5. Respiration

SWALLOWINGSWALLOWING
• Normal mature swallowing takes place without contracting the muscles of facialNormal mature swallowing takes place without contracting the muscles of facial
expression. The teeth are momentarily in contact and the tongue remains inside theexpression. The teeth are momentarily in contact and the tongue remains inside the
mouth.mouth.
• Abnormal swallowing is caused by tongue thrust, either as a simple thrusting action orAbnormal swallowing is caused by tongue thrust, either as a simple thrusting action or
as tongue-thrust syndrome. The following symptoms distinguish this syndrome:as tongue-thrust syndrome. The following symptoms distinguish this syndrome:
• 1. Protrusion of the tip of the tongue1. Protrusion of the tip of the tongue
• 2. No contact of the molars2. No contact of the molars
• 3. contraction of perioral muscles during deglutitional cycle3. contraction of perioral muscles during deglutitional cycle
During their first few years, infants swallow viscerally. i.e. with the tongue between theDuring their first few years, infants swallow viscerally. i.e. with the tongue between the
teeth. As the deciduous dentition is completed, the visceral swallowing is graduallyteeth. As the deciduous dentition is completed, the visceral swallowing is gradually
replaced by somatic swallowing. If visceral swallow persists after fourth years of age, itreplaced by somatic swallowing. If visceral swallow persists after fourth years of age, it
is consideredis considered OROFACIAL DYSFUNCTION.OROFACIAL DYSFUNCTION.

Phases of swallowingPhases of swallowing
1]Preparatory phase1]Preparatory phase
• During the first stage food is collected inDuring the first stage food is collected in
the foremost part of the mouth, in front ofthe foremost part of the mouth, in front of
the retracted tongue. The posterior archedthe retracted tongue. The posterior arched
part of the dorsum is in contact with thepart of the dorsum is in contact with the
soft palate. The lips are not in contact andsoft palate. The lips are not in contact and
the teeth are not occluding.the teeth are not occluding.

• TRANSPORTING STAGE:TRANSPORTING STAGE:
11stst
part of movement.part of movement.
During the second phase of swallowing, i.e.During the second phase of swallowing, i.e.
the transporting stage, the tip of the tonguethe transporting stage, the tip of the tongue
first moves upward and the anterior sectionfirst moves upward and the anterior section
of the dorsum is depressed.of the dorsum is depressed.
22ndnd
part of movement.part of movement.
The entire anterior section of the tongueThe entire anterior section of the tongue
then moves upward and the central sectionthen moves upward and the central section
of the dorsum is depressed. This peristalsisof the dorsum is depressed. This peristalsis
transports the bolus rearward.transports the bolus rearward.

• TRANSPORTING STAGETRANSPORTING STAGE
33rdrd
part of movementpart of movement
At the end of the transporting stage, theAt the end of the transporting stage, the
soft palate is displaced upward andsoft palate is displaced upward and
rearward. The lip musculature contractsrearward. The lip musculature contracts
simultaneously, the lips are together, thesimultaneously, the lips are together, the
mandible is raised and the teeth comemandible is raised and the teeth come
into contact.into contact.

• THIRD SWALLOWING STAGETHIRD SWALLOWING STAGE
The dorsum of the tongue is depressed even further during the third stage soThe dorsum of the tongue is depressed even further during the third stage so
that the bolus can pass through the oropharyngeal isthmus; simultaneouslythat the bolus can pass through the oropharyngeal isthmus; simultaneously
the anterior part of the tongue is pressed against the hard palate, thus forcingthe anterior part of the tongue is pressed against the hard palate, thus forcing
more food rearward. Passavant’s pad and soft palate form themore food rearward. Passavant’s pad and soft palate form the
palatopharyngeal seal and close the nasopharynx. The teeth are in fullpalatopharyngeal seal and close the nasopharynx. The teeth are in full
occlusion and the lips are in contact.occlusion and the lips are in contact.

• FOURTH SWALLOWING STAGEFOURTH SWALLOWING STAGE
During the fourth stage of the swallowing act, the dorsum of the tongue isDuring the fourth stage of the swallowing act, the dorsum of the tongue is
moved further upward and rearward against the soft palate and squeezes themoved further upward and rearward against the soft palate and squeezes the
remaining food bolus out of the oropharyngeal area.remaining food bolus out of the oropharyngeal area.

FINAL STAGE OF SWALLOWINGFINAL STAGE OF SWALLOWING
• Once the swallowing act has been completed the mandible returns to its restOnce the swallowing act has been completed the mandible returns to its rest
position.position.

VISCERAL OR INFANTILEVISCERAL OR INFANTILE
SWALLOWSWALLOW
• Jaws apart with tongue between gumJaws apart with tongue between gum
pads.pads.
• It is triggered off by sensoryIt is triggered off by sensory
interchange between the lips and tongue.interchange between the lips and tongue.
• Peristalsis commences in the vestibulePeristalsis commences in the vestibule
• Associated with tongue and mandibularAssociated with tongue and mandibular
thrustthrust
• The transverse section shows that theThe transverse section shows that the
tongue is positioned low in mouth andtongue is positioned low in mouth and
that the central furrow is depressed.that the central furrow is depressed.

• SOMATIC SWALLOW:SOMATIC SWALLOW:
• As swallowing is triggered off byAs swallowing is triggered off by
contraction of mandibular elevators, thecontraction of mandibular elevators, the
teeth occlude momentarily during theteeth occlude momentarily during the
swallowing act and the tip of the tongue isswallowing act and the tip of the tongue is
enclosed in the oral cavity.enclosed in the oral cavity.
• Transverse section shows that the dorsumTransverse section shows that the dorsum
of the tongue is less concave andof the tongue is less concave and
approaches the palate during swallowingapproaches the palate during swallowing

TONGUE THRUST:
Tongue thrust has an important effect on the etiopathogenesis of malocclusion.
The thrust may take place in the anterior or lateral regions or can be complex
Tongue-thrust
PRIMARY
SECONDARY
ANTERIOR
LATERAL
COMPLEX
ENDOGENOUS
HABITUAL
ADAPTIVE

ANTERIOR OPEN BITE
Open bite in a deciduous dentition, caused by a
tongue dysfunction as a residuum of a sucking
habit.
HABITUAL POSITION:
The tongue is positioned forward during
functioning, thus impeding the Vertical development
of the dentoalveolar Structures.

LATERAL OPEN BITE
In this type of open bite the occlusion on
both sides is supported only anteriorly and by
the first molars.
HABITUAL POSITION
The tongue thrust between the teeth laterally.
The tongue dysfunction occurs in conjunction
with a disturbance in the physiologic growth
processes around the first and second deciduous
molars.

COMPLEX OPEN BITE
Severe vertical malocclusion. The teeth occlude
only on the second molars. Tongue thrusting
occurs during function.
TONGUE DYSFUNCTION AND
MALOCCLUSION
In mandibular prognathism, the downward
forward displacement of the mandible often
causes an anterior tongue-thrust habit.

So tongue thrust may be considered primary or secondary.So tongue thrust may be considered primary or secondary.
1. The primary dysfunctions cause malocclusions and the treatment must concentrate1. The primary dysfunctions cause malocclusions and the treatment must concentrate
on eliminating the orofacial dysfunction.on eliminating the orofacial dysfunction.
2. Secondary dysfunction can be considered an adaptive phenomenon to an existing2. Secondary dysfunction can be considered an adaptive phenomenon to an existing
skeletal or dento-alveolar deviation in the vertical development. These secondaryskeletal or dento-alveolar deviation in the vertical development. These secondary
abnomalities usually correct spontaneously while the morphological discrepanciesabnomalities usually correct spontaneously while the morphological discrepancies
are being treated.are being treated.
TONGUE FUNCTION:
The significance of tongue thrust and its role in the etiology of malocclusion have
been evaluated by no. of authors. One school of thought asserts that the tongue
thrust is the consequence of an abnormal morphologic relationship, an adaptive
phenomenon. Other investigators like Andrew, Hopkins consider tongue thrust a
primary etiologic factor for malocclusion. Abnormal tongue posture and function
can be primary factors as consequences of retained infantile deglutition patterns or
other abnormal oral habits, but they also may be strictly secondary or adaptive to
unfavorable morphologic pattern.

CAUSES OF TONGUE DYSFUNCTION
CAUSES OF DYSFUNCTION
PRIMARY SECONDARY
1. Endogenous
2. Heredity
3. Imitation
Adaptive

• PRIMARY TONGUE DYSFUNCTIONPRIMARY TONGUE DYSFUNCTION
IN CONJUCATION WITH HYPERPLASTICIN CONJUCATION WITH HYPERPLASTIC
TONSILS. A retracted tongue would touchTONSILS. A retracted tongue would touch
infected, swollen tonsils if these were toinfected, swollen tonsils if these were to
protrude far out of the surrounding structures.protrude far out of the surrounding structures.
in order to avoid painful sensation and toin order to avoid painful sensation and to
keep the oral airway open the mandible iskeep the oral airway open the mandible is
dropped and the tongue postured forward.dropped and the tongue postured forward.
HYPERPLASTIC TONSILS:HYPERPLASTIC TONSILS:
Moderately swollen palatine tonsils whichModerately swollen palatine tonsils which
protrude significantly from the tonsillar sinus.protrude significantly from the tonsillar sinus.

ADAPTIVE TONGUE DYSFUNCTION.
After loss of teeth, the tongue is used to fill the gaps, thus
Sealing the oral cavity i.e. compensatory dysfunction.
ADAPTIVE DYSFUNCTION WITH SKELETAL
MALOCCLUSION.
Cephalogram of an open bite due to rickets. The tongue
Dysfunction is an adaptation to the skeletal and
dentoalveolar Morphology.
OPEN BITE DUE TO RICKETS. The skeletal and
dentoalveolar open bite is aggravated by the adaptive tongue
dysfunction.

CONFIGURATION OF THE CRANIOFACIAL ANDCONFIGURATION OF THE CRANIOFACIAL AND
DYSFUNCTIONSDYSFUNCTIONS
• The morphology of the facial skeleton and the effects of tongue thrusting areThe morphology of the facial skeleton and the effects of tongue thrusting are
correlated to a certain degree.correlated to a certain degree.
• Horizontal growth pattern in conjuncationHorizontal growth pattern in conjuncation
with tongue thrusting usually results inwith tongue thrusting usually results in
bimaxillary dental protrusion.bimaxillary dental protrusion.

• In vertical growth pattern with tongueIn vertical growth pattern with tongue
thrust the lower incisors are often are inthrust the lower incisors are often are in
lingual inclination. From the differentiallingual inclination. From the differential
point of view it is important to clarifypoint of view it is important to clarify
both the skeletal relationship and theboth the skeletal relationship and the
tongue dysfunction in order to localizetongue dysfunction in order to localize
the results of the abnormal tonguethe results of the abnormal tongue
functioning.functioning.

METHODS OF EXAMINATIONMETHODS OF EXAMINATION
• Various methods can be used to examine tongue dysfunctions. The differentVarious methods can be used to examine tongue dysfunctions. The different
types of clinical examinations are : electronic recordings, electromyographictypes of clinical examinations are : electronic recordings, electromyographic
examinations, recording of the pressure exerted by the tongue intraorally,examinations, recording of the pressure exerted by the tongue intraorally,
roentgenocephalometric anaylsis, cineradiography, palatographic,roentgenocephalometric anaylsis, cineradiography, palatographic,
neurophysiologic examination.neurophysiologic examination.
• The position and size of the tongue in relation to the available space isThe position and size of the tongue in relation to the available space is
assessed by using roentgenographic cephalometrics. However, in mostassessed by using roentgenographic cephalometrics. However, in most
orthodontic cases, registrating the position of the tongue is more importantorthodontic cases, registrating the position of the tongue is more important
then determining its size.then determining its size.

PALATOGRAPHY
It involves recording the contact surfaces of the tongue with the palate and teeth while
the patient produces speech sounds or performs certain tongue functions.
A thin layer of contrasting precise impression mat. On
Patients tongue. Once the consonants are pronounced
Patalogram is documented photographically.
Accurate prononciation of “S”. During articulation the
mandible is lowered and pushed forward. The tongue
rests on the teeth and alveolar processes, and a groove
is formed in the center throgh which the air stream is
directed.
INTERDENTAL SIGMATISM (lisping).
During this defective pronounciation of the “S”
sound, the tongue is usually protruded.

PALATAL SIGMATISM. This abnormal
pronounciation is caused by an unphysiologic
friction noise between tongue and hard palate.
LATERAL SIGMATISM ON THE LEFT SIDE.
The tongue rest on the anterior teeth. The column
of air escapes on the left side.
BILATERAL SIGMATISM. Palatogram of this type
of defective articulation in a patient with microglossia.
SIGMATISM DUE TO LATEROFLEXION TO
THE LEFT SIDE. The tip of the tongue is raised
too high and rest on upper incisors. The tip of the
tongue deviates to the left.

TONGUE SIZE:
The size and shape of tongue have many variations- bulky and short, narrow and
long and wide and long.
Numerous clinical methods may be used to assess tongue size. The most
common is to check whether the patient can touch the chin with the tongue tip.
A positive result is considered an indication of macroglossia.. Other symptoms
associated are:
1.The oral cavity is filled by the tongue mass
2.Narrow epipharynx.
3.Indentations on the tongue periphery.
4.Spaces exist between incisors, which are procumbent.
5.Tongue is protruded with open bite present.

But in the case with microglossia or hypoglossia, the protruded tongue tip reaches
lower incisor at best and the floor of the mouth is elevated and visible on each
side. Other features:
1. The dental arch is collapsed and reduced in size
2. Extreme crowding is seen in the premolar region.
3. A severe class II relationship is usually evident.
4. Third molars are usually impacted at the angle of the jaw.
5. In severe cases of microglossia and aglossia posterior segments are tipped so
markedly to the lingual that they touch each other in the midline.

TONGUE POSTURE:
Some investigators hold that the tongue posture is more important than tongue
function. The posture of the tongue can be flat or arched, protracted or
retracted, narrowed and long, or spread laterally and shortened. Tongue
posture is examined clinically with the mandible in the postural rest position.
Sagittal cephalometric registration of this relationship also is possible.
From the basal tongue posture at rest position an assessment of three regions-root,
dorsum, and tip was made and disclosed the following:
1. The root is usually flat in cases of mouth breathing, deep overbite caused by a
small tongue; in all other cases, slight contact of the tongue usually occurs with
the soft palate.
2. In class II div. I malocclusion with deep overbite the dorsum of the tongue is
arched and high; in all other malocclusion the tendency exist for the tongue to
flatten.
3. The tip of the tongue is usually retracted in class II div. I, but in all other
categories of malocclusions a slight anterior gliding of the tongue tip occurs as
mandible moves into postural rest position.

METRIC EVALUATON OF TONGUE POSTURE
Assessment of tongue
size from metric analysis
requires measurement of
the distance between the
superior tongue surface
and the roof of the
mouth. This is done
along the seven
constructed lines. These
measurements indicate
the relative size of the
tongue. Only if the entire
oral cavity is filled can a
diagnosis of macroglossia
be made.

TRACING OF THE
ANALYSIS ON THE
LATERAL
CEPHLOGRAM.
Marking of the contours
of the bony palate and
dorsum of the tongue.
Left. The morphologic
relationships in case of
retracted, elevated
tongue.
Right. Relationship in
case of a downward
forward tongue posture.

TEMPLATE FOR METRIC ANALYSIS OF TONGUE POSITION.
Transparent plastic template with an inscribed millimeter scale for analyzing the
position of the tongue on the lateral cephalogram. The template is oriented on
the point O.

LIP DYSFUNCTIONS:
The etiology of lip dysfunction is similar to that of tongue habits and is
assessed in relation to the configuration and functioning of the lips.
Configuration of lips:
The configuration of lips differs a great deal and can be classified as follows:
1. Competent lips. The lips are in contact when
the musculature is relaxed.
2. Incompetent lips. Anatomically short lips with a
wide gap between the upper and lower lip in relaxed
position.
Consciously closed lips. Incompetent lips can only
be closed by increasing contraction of the
orbicularis oris and mentalis muscle.

3. POTENTIALLY INCOMPETENT LIPS.
Upper incisors are labially tipped and their incisal margins
interpossed between the lips preventing the normal lip seal.
CONCIOUSLY CLOSED LIPS. Lip contact is achieved
without increased contraction of the perioral
musculature.
4. EVERTED LIPS. Frontal and profile views with lip closed.
Due to weak tonicity of the lip musculature, these patient
often exhibit bimaxillary dental protrusion.

LIP HABITS:
Various habits of lips can be divided into:
1. Lip sucking
2. Lip thrust
3. Lip insufficiency
Lip dysfunctions can be observed while the patient is speaking and swallowing.
The lower lip often shows variations of dysfunction with regard to the tip of the
tongue. The lower lip and tip of the tongue are often in contact. In such cases, the
lower lip is sucked in and is pressed against the tip of the tongue. It is a symptom
of orofacial dysfunction. Visual evidence of mentalis muscle activity is also
abnormal.

LIP SUCKING. Extra oral findings
Lower lip is positioned behind the
upper incisors, this malpositioning
occurs in conjunction with hyper
active mentalis.
Lat. Cephalogram indicates that
lower lip dysfunction causes further
protrusion of the upper incisors. And
impedes the forward development of
the anterior alveolar process.

LIP THRUST.
Characteristic profile of the lower
third of the face in a case of
hyperactivity of the mentalis muscle.
Lat. Cephalogram. This type of lip
habit is combined with lingual
inclination of the incisors.

CHEEK DYSFUNCTION:
In cases of cheek sucking and cheek biting, the soft tissues are interposed between
the teeth, which promotes the formation of the lateral open bite or deep over bite.
Increased lateral pressure by the cheek musculature impedes the transverse
development of the jaws.

HYPERACTIVITY OF MENTALIS MUSCLE:HYPERACTIVITY OF MENTALIS MUSCLE:
• The deep mentolabial sulcus is characteristic of the hyperactive mentalisThe deep mentolabial sulcus is characteristic of the hyperactive mentalis
muscle. This muscle behavior impedes the forward development of themuscle. This muscle behavior impedes the forward development of the
anterior alveolar process in the mandible.anterior alveolar process in the mandible.

MOUTH BREATHING
The mode of respiration is examined to establish whether the
nasal breathing is impeded or not. Chronically disturbed nasal
respiration represents a dysfunction of the orofacial musculature;
it can restrict development of the dentition and hinders the
orthodontic treatment.

Causes leading to mouth breathing:Causes leading to mouth breathing:
• Chronic respiratory obstruction.Chronic respiratory obstruction.
• Mechanical obstruction.Mechanical obstruction.
• Size of the nostril.Size of the nostril.
• Pharyngeal tonsils or adenoids (adenoid facies).Pharyngeal tonsils or adenoids (adenoid facies).
• Greater effort required to breath through the nose – tortuous nasal passages.Greater effort required to breath through the nose – tortuous nasal passages.
• Partial blockage of the nose leads to resistance of airflow – person shifts toPartial blockage of the nose leads to resistance of airflow – person shifts to
mouth breathingmouth breathing

Clinical findings of patients
with oral respiration :
1. High palate
2. Narrowness of upper arch
3. Crossbite
4. Hyperplasia of the gingiva
5. Adenoid facies
6. Rotation of mandible laterally
and backwards.
7. Increased overjet.

PATTERN OF FACIAL MORPHOLOGY:
The configuration of the facial skeleton and oral respiration are correlated to
certain degree. Impeded nasal breathing shows a higher frequency in facial types
with vertical growth tendency. Proliferation of the adenoids is more common
and more pronounced in patients with oronasal respiration. The incidence of
hypertrophied tonsils is also increased in this group.
Slight proliferation of
lymphoid tissue. On upper
and rear wall.
Marked proliferation
occupying half of the
pneumatic cavity.
Lymphatic tissue
occupying most of
pneumatic cavity.www.indiandentalacademy.com

TONGUE POSTURE:
Two different tongue posture are possible in case of oronasal respiration:
Type I
The tongue is flat and its tip is behind
the lower incisors. This type is often
encountered on conjunction with
a anterior cross bite.
TYPE II
The tongue is flat and retracted.
This type of abnormal tongue posture
is common in cases with oral
respiration and disto occlusion.

EXAMINATIONOF BREATHING MODE:
Following are the various clinical methods of examination:
1. Cotton pledget test
2. Mirror test
3. Observation of nostrils

DIFFERENTIAL DIAGNOSIS:
Differential diagnosis must be used to determine whether the problems in nasal
respiration are due to an obstruction of the upper nasal passages or habitual oral
respiration. The orthodontic treatment planning for patients with restricted nasal
respiration must be related to diagnosis of the ENT specialist.

SUPPLEMENTAL FINDINGS
The health of oral hard and soft tissues must be assessed for potential orthodontic
patients as for any other. It is important that any dental caries or pulpal pathology
be treated before orthodontic therapy. A thorough peridontal evaluation is an
important part of orthodontic examination. Potential or actual mucogingival
problems are of special interest. Any orthodontic examination should include
gentle probing through the gingival sulci, not to establish pocket depths but to
detect any areas of bleeding. Bleeding on probing indicates active disease, which
must be brought under control before other treatment is undertaken. Inadequate
attached gingiva around crowded incisors indicates the possibility of tissue
dehiscence developing when the teeth are aligned, especially with nonextraction
treatment.

RADIOLOGIC EXAMINATIONRADIOLOGIC EXAMINATION

RADIOLOGIC EXAMINATIONRADIOLOGIC EXAMINATION
• Radiological examination is absolutely essential in orthodontic diagnosis.Radiological examination is absolutely essential in orthodontic diagnosis.
In clinical practice, the type and number of radiographs should, subjectIn clinical practice, the type and number of radiographs should, subject
patient to as little radiation exposure as possible while providing maximalpatient to as little radiation exposure as possible while providing maximal
information at the same time. Radiographs of the hands andinformation at the same time. Radiographs of the hands and
temporomandibular joints are not among the routine requirements oftemporomandibular joints are not among the routine requirements of
orthodontic diagnosis.orthodontic diagnosis.
 POSTEROANTERIOR VIEWPOSTEROANTERIOR VIEW
 CEPHALOGRAMSCEPHALOGRAMS
 PANORAMIC VIEWPANORAMIC VIEW
 ENLARGED PANORAMIC VIEWENLARGED PANORAMIC VIEW
 PERIAPICAL VIEWPERIAPICAL VIEW
 OCCLUSAL VIEWOCCLUSAL VIEW
 MENTAL SPINE VIEWMENTAL SPINE VIEW
 TMJ VIEWSTMJ VIEWS

POSTEROANTERIOR VIEW:
The straight posteroanterior view is so
named because the x-ray beam passes in a
posterior to anterior direction through the
skull. This projection is used to examine
the skull for disease, trauma, or
developmental abnormalities. It also
provides good record for detecting
progressive mediolateral dimension
changes of the skull, including asymmetric
growth. It also offers good visualization
of facial structures, including the frontal
and ethmoidal sinuses, nasal fossae and
orbits.

CEPHALOMETRICS
Cephalometrics is a tool for dealing with variations in craniofacial morphology. Its
purpose is always comparison. In practice these comparisons are made for one
of five reasons.
1. To describe morphology or growth.
2. To diagnose anamolies.
3. To predict future relationship.
4. To plan treatment.
5. To evaluate the results of the treatment.
1.DESCRIPTION: Cephalometric description aids in the specification, localization,
and understanding of abnormalities. It comprises of three kinds of comparisons.
a. comparison with standard.
b. comparison with ideal.
c. comparison with self.

a. Comparison with standard: Research population provide extensive statistics for
details of cranifacial morphology and growth. Measures of central tendency-
mean, median, and mode- are often used as norms with which an individual
patient is compared; in this sense, they present “normal” form.
b. Comparison with ideals: certain clinicians have also contrived subjective ideals
of facial form for use of clinical comparison. The difference between standard
and ideal is important. Standards are objective measures stastically derived from
populations. Ideals are arbitrary, subjective concepts of facial esthetics
represented with numbers.
c. Comparison with self: The patient may also be described by cephalometric
comparisons with his or her earlier cephalogram.

2. DIAGNOSIS: In orthodontics, diagnosis is determination of significant deviations
from the normal. The diagnostic purpose of cephalometrics is to analyze the nature of
the problem and to classify it precisely. For instance, cephalometric diagnosis leads to
assignment to facial types and classes. Since some aspects of facial morphology are
relatively stable under treatment, cephalometric diagnosis contains a strong
component of prediction.
3. PREDICTION: Description, diagnosis, and prediction are conceptually and
practically quite different. To make a cephalometric prediction is to observe certain
quantities, assumes they will behave in determinate ways, and extrapolate the
consequences. The clinician would like to be able to predict well several important
aspects of craniofacial growth, for example, changes in principal directions of growth,
or the cessation of such periods. Therefore, the most practical prediction currently
involves the exploitation of “craniofacial constants” to supply predictions of shape
approximately independent of net amount of growth remaining.

4. PLANNING TREATMENT:
If the clinician can describe, diagnosis, and predict craniofacial morphology, a clear
plan of orthodontic treatment can be derived. All treatment occurs after the initial
cephalogram in a face which is constantly changing. Clinicians use the cephalogram
to define expected changes resulting from growth and treatment is applied
prediction.
5. EVALUATION OF TREATMENT RESULTS:
Successive cephalogram are used to discern the progress of treatment and to plan
any changes in treatment which may seem necessary. Evaluation of treatment
results is recurrent description and diagnosis.

OBTAINING THE CEPHALOGRAM:
A cephalometric apparatus consists of a cephalostat or head holder, an x-ray
source, and a cassette holder. Cephalostats are of two types. The Broadbent-
Bolton method utilizes two x-ray sources and two film holders so that the subject
need not be moved between the lateral and posteroanterior exposures. Although
this method makes more precise three dimensional studies possible, it requires
two x-ray heads and more space and it precludes oblique projections.
The Higley method used in most modern cephalostats, uses one x-ray source and
film holder with a cephalostat capable of being rotated. The patient is
repositioned in the course of the various projections. This method is more
versitile, but care must be taken so that the horizontal relationship of the head
does not alter during reposition.

The x-ray sorce must produce sufficiently high voltage
(usually above 90 kVp) to penetrate the hard tissue well
and to provide good delineation of both hard and soft
structures. A small focal spot results in sharper
radigraphic images.

PANORAMIC VIEWPANORAMIC VIEW
• For orthodontic diagnosis this is superior to all other radiographic methods.For orthodontic diagnosis this is superior to all other radiographic methods.
One single film provides a total survey of the dental status and adjacent bonyOne single film provides a total survey of the dental status and adjacent bony
structures of both jaws. It involves least exposure to radiation. A disadvantagestructures of both jaws. It involves least exposure to radiation. A disadvantage
of this rotary laminographic technique is a possible distortion in the anteriorof this rotary laminographic technique is a possible distortion in the anterior
region. Some cases will, therefore, require supplementary radiographs, such asregion. Some cases will, therefore, require supplementary radiographs, such as
an enlarged panoramic view or periapical view.an enlarged panoramic view or periapical view.

ADVANTAGES:ADVANTAGES:
1. It provides an over all view of the teeth and the jaws.1. It provides an over all view of the teeth and the jaws.
2. It serves as a screening projection to identify odontogenic diseases and other2. It serves as a screening projection to identify odontogenic diseases and other
disorders that may be the source of TMJ symptoms.disorders that may be the source of TMJ symptoms.
3. Gross osseous changes in the condyles may be identified, such as asymmetries,3. Gross osseous changes in the condyles may be identified, such as asymmetries,
extensive erosions, large osteophytes, or fractures.extensive erosions, large osteophytes, or fractures.
4.Useful aid in serial extraction procedures to study the status of erupting teeth.4.Useful aid in serial extraction procedures to study the status of erupting teeth.
LIMITATION: No information about condylar position, or function isLIMITATION: No information about condylar position, or function is
provided and mild osseous changes may be obscured.provided and mild osseous changes may be obscured.
DISADVANTAGES:DISADVANTAGES:
1. No display of fine anatomic details1. No display of fine anatomic details
2. Unequal magnification2. Unequal magnification
3. Geometric distortion in the anterior region3. Geometric distortion in the anterior region
4. Occasionally presence of overlapping structures of cervical spine4. Occasionally presence of overlapping structures of cervical spine

ENLARGED PANOROMIC VIEWENLARGED PANOROMIC VIEW
• Advantage :- accurate imaging of anterior regionAdvantage :- accurate imaging of anterior region
• Disadvantage :- distortion in the posterior regionDisadvantage :- distortion in the posterior region
PERIAPICAL VIEWPERIAPICAL VIEW
Intraoral radiographs are the backbone of imaging. A full series of intraoralIntraoral radiographs are the backbone of imaging. A full series of intraoral
radiographs (10 to 16 films) is required for assessment of the periodontalradiographs (10 to 16 films) is required for assessment of the periodontal
state in adults. Otherwise periapical films are only indicated where thestate in adults. Otherwise periapical films are only indicated where the
panoramic view suggests possible pathological conditions. (e.g. congenitallypanoramic view suggests possible pathological conditions. (e.g. congenitally
missing teeth or malposed tooth germs).missing teeth or malposed tooth germs).

USES:
1. To confirm the presence or absence of teeth or supernumerary teeth.
2. To assess the extent of calcification and root formation.
3. To study the alveolar bone and periodontal ligament.
4. To study height and contour of alveolar bone.
5. To assess the axial inclination of roots.
6. To detect retained root fragments and root stumps.
7. To determine the size and shape of unerupted teeth.
DISADVANTAGES:
1. Assessment of entire dentition requires much of radiation exposure.
2. Children may not allow placement of films.
3. They cannot be used in patients having high gag reflex and trismus.

GLOBULOMAXILLARYGLOBULOMAXILLARY
CYSTCYST

ENAMEL PEARLENAMEL PEARL
TAURODONTISM

FUSIONFUSION

BUCCOLINGUAL SPATIAL LOCATION OFBUCCOLINGUAL SPATIAL LOCATION OF
OBJECTSOBJECTS
• Mesiocentric periapical view :- X-rayMesiocentric periapical view :- X-ray
tube angulated at 30 degrees mesial totube angulated at 30 degrees mesial to
the perpendicular projection.the perpendicular projection.
• Distocentric periapical view :- X-rayDistocentric periapical view :- X-ray
tube angulated at 30 degree distal to thetube angulated at 30 degree distal to the
perpendicular projection.perpendicular projection.

OCCLUSAL VIEWOCCLUSAL VIEW
• Displays relatively large segment of a dental arch.Displays relatively large segment of a dental arch.
• Used in following situations :-Used in following situations :-
-To precisely locate roots of supernumerary, unerupted, impacted canines and-To precisely locate roots of supernumerary, unerupted, impacted canines and
third molars.third molars.
-Localize foreign bodies in salivary gland ducts.-Localize foreign bodies in salivary gland ducts.
-Location,nature,extent and displacement of fractures.-Location,nature,extent and displacement of fractures.

SAILOLITHSAILOLITH FRACTURE

MENTAL SPINE/GENIAL TUBERCLE VIEWMENTAL SPINE/GENIAL TUBERCLE VIEW
This is an occlusal view of the anterior section of the mandible to determine its
midline
1,2,3 are the individual exposure position.
gg- genioglosus.
gh- geniohyoid.
mh- mylohyoid
1. The double spine of the superior part of the
mental spine
2. The unpaired spine of the inferior part as
well as the bilateral st. of the superior genial
tubercle in the center.
3. 3 bony spines , the bony contours of the
inferior genial tubercles .

TRANSPHARYNGEAL PROJECTION:
• The tranpharyngeal projection provides a sagittal view of the medial pole of
the condyle. Because of the negative beam angulation, this view depicts the
medial aspect of the condyle. The transpharyngeal view provides limited
diagnostic information because the temporal component is not imaged well.
The transpharyngeal projection is effective for visualizing erosive changes of
the condyle rather than more subtle changes.

TRANSORBITAL PROJECTION:
This projection is similar to the transmaxillary
projection in that both provide an anterior view
of the TMJ, perpendicular to transcranial and
transpharyngeal projections. The entire
mediolateral dimension of the articular
eminence, condylar head, and condylar neck is
visible, which makes this view particularly useful
for visualizing condylar neck fractures. The
morphology of the convex surface of the
condylar head can be evaluated, making this
projection a useful adjunct to transcranial and
transpharyngeal projection in the diagnosis of
the gross degenerative changes or other
anomalies.

CLOSED MOUTH
OPEN MOUTH
TRANSCRANIAL PROJECTION:
It provides a sagittal view of the lateral aspect of the condyle and temporal
component.
Because of the positive beam angulation, the central and medial aspects of the
joint are projected inferiorly, and only lateral joint contours are visible in this
projection. The transcranial projection is useful for identifying gross osseous
changes on the lateral aspect of the joint only, displaced condylar fractures, and
range of motion.

SPECIALIZED TECHNIQUESSPECIALIZED TECHNIQUES
• CONVENTIONAL TOMOGRAPHY.CONVENTIONAL TOMOGRAPHY.
• COMPUTED TOMOGRAPHY.COMPUTED TOMOGRAPHY.
• MAGNETIC RESONANCE IMAGING.MAGNETIC RESONANCE IMAGING.
• ULTRASONOGRAPHY.ULTRASONOGRAPHY.
• ELECTRONIC THERMOGRAPHY.ELECTRONIC THERMOGRAPHY.
• ARTHROGRAPHYARTHROGRAPHY
• FINITE ELEMENT ANALYSIS..FINITE ELEMENT ANALYSIS..
• PALATOGRAPHY.PALATOGRAPHY.
• CINERADIOGRAPHY.CINERADIOGRAPHY.
• ELECTROMYOGRAPHY.ELECTROMYOGRAPHY.
• BONE SCANNING.BONE SCANNING.
• LASER SCANNING.LASER SCANNING.
• VIDEOCEPHALOMETRY.VIDEOCEPHALOMETRY.

TOMOGRAPHY:
Conventional film-based tomography , also called body section radiography, is a
radiographic technique designed to image more clearly objects lying with in the
plane of interest. This is accomplished by blurring the images of structures lying
superficial and deep to the plane of interest through the process of motion
unsharpness. Conventional tomography now is applied primarily to high contrast
anatomy, such as that encountered in temporomandibular joint and dental implant
diagnosis.
This technique produces thin image slices, permitting visualization of an anatomic
structures essentially free of superimpositions of overlapping structures. This
technique can provides a true condylar position and osseous erosive changes, and
is a valuable adjunct to plain film radiography.

TOMOGRAM OF TMJTOMOGRAM OF TMJ

COMPUTED TOMOGRAPHY:
Computed tomography is indicated when more information is needed about the
three dimensional shape and internal structure of the osseous components of the
joint. CT produces digital image slices in both the axial and coronal planes,
although coronal images are more useful. Three dimensional reformatted images
also can produced. These are useful for assessing osseous deformities of the jaws
or surrounding structures. CT cannot produce accurate images of the articular
disk.. CT may be considered for determining the presence and extent of ankylosis
and neoplasms and the extent of bone involvement in some arthritis, imaging
complex fractures, and evaluating complications from the use of silicon sheet
implants such as erosions into middle cranial fossa and ectopic bone growth.
ADVANTAGE:1. Accurate visualization of an area of interest is possible
2. The computer programming makes it possible to view the images in different
shade and densities.
3. CT is useful for diagnosis of diseases in maxillofacial complex, including
salivary gland and TMJ.

CT SCAN SHOWING
LESION IN MANDIBULAR
RAMUS AREA.

MAGNETIC RESONANCE IMAGING:
MRI uses a magnetic field and radiofrequency pulses rather than ionizing
radiation to produce multiple digital image slices. To produce an MR image,
the patient is placed inside a large magnet, which induces a relatively strong
external magnetic field. This causes the nuclei of many atoms in the body,
including hydrogen to align themselves with the magnetic field. After
application of an RF signal, energy is released from the body, detected and
used to construct the MR image by computer. MRI has several advantages
over other diagnostic imaging procedures.
1. It offers the best resolution of tissues of low contrast.
2. No ionizing radiation is involved.
3. The region of the body imaged in MRI is controlled electronically so a direct
multiplanar imaging is possible without reorienting the patient.
4. In diagnosing a suspected internal derangement of the TMJ and evaluating
the treatment of that derangement after surgery; identifying and localizing
orofacial soft tissue lesions; and providing images of salivary gland
parenchyma.

ADVANTAGES:
MRI does not have hazards as it uses non-ionising electromagnetic
radiation.
Anatomical details are as good as in C.T. scan.
Imaging of blood vessels, blood flow, visualization of thrombus is possible.
DISADVANTAGES:
Time taken is more.
It is not used in patients with cardiac pacemaker.
Non visualization of bone makes it useless in bony lesions.

MRI OF TMJ

ULTRASONOGRAPHY:
By definition, ultrasound has a periodicity greater than 20 KHz. Thus it is
distinguished from other mechanical waves forms simply by having a vibratory
frequency greater than the audible range. As the ultrasonic beam passes through
or intersects with tissues of different acoustic impedance, it is attenuated by a
combination of absorption, reflection, refraction, and diffusion. These sonic echo
waves are reflected back to transducer which are amplified, processed, and
ultimately displayed on the monitor. Consequently, not only changes in echo
pattern delineate different tissues, they also can be correlated with pathologic
changes in a tissue. Differentiation between a cyst and tumor can be done and in
visceral and somatic swallowing patterns.

Ultrasound image showing
parasagittal image of the TMJ area
showing the articular disk in its
normal location superior to the
condyle in the closed mouth
position.

ELECTRONIC THERMOGRAPHY:
Thermography is a term given to methods of temperature pattern resolution and
analysis. The utility of thermography in diagnosis is based on the fact that disease
process and abnormal conditions may result in different temperature patterns
because of altered blood supply or presence of inflammation.
1. Diagnosing disease of the maxillofacial complex.
2. Determining tooth vitality.
3. Evaluating a case of atypical odontalgia
4. Assessing an internal derangement of the TMJ.

ARTHROGRAPHY:
Arthorography is a technique in which an indirect image of the disk is
obtained by injecting a radiopaque contrast agent into one or both joint
spaces under fluoroscopic guidance. A perforation is detected by the flow of
contrast agent into the superior joint space from the lower space, and
adhesion are detected by the manner in which contrast agent fills the joint
space. After the joint space is filled, disk function is studied using the
fluoroscopy during the opening and closing movements. Arthorgraphy is
indicated when information about Disk position, function, morphology and
the integrity of the diskal attachment is required. The risk of this procedure
include allergic reaction to the nonionic iodine contrast agent and infection.

FINITE ELEMENT METHOD:
Albeit initially developed this methid for aeronautical engineers, the finite has
found its place in medical and dental research over the last few years. It was
originally developed for studying the stresses in the complex air frame. It can also
be used for vibration analysis, thermodynamic analysis, fluid flow and
distribution of electric and magnetic fields. The application of FEM most related
to orthodontics is the structural stress analysis. There is a plethora of studies in
orthodontic literature using the FEM. These include studies of wire
configuration, stresses in the periodontal ligament, determination of centers of
resistance and rotation of teeth with normal or reduced bone height, stresses on
TMJ, jaws and cranium, stresses in brackets and adhesives, design of ceramic
brackets and studies of craniofacial growth.

DIGITAL CINERADIOGRAPHY:
PRINCIPLE:
Using flash x-ray sources, gated cameras are triggered simultaneously with
each x-ray source in succession at the rate desired. The gated cameras can
be set for exposure times between 5 nanoseconds and 33 milliseconds. In
cineradiography, the idea is to freeze motion in a series of images to track
motion in discrete steps. It helps in recording motion of dynamic events
like swallowing pattern.
LIMITATIONS: The images captured by digital cameras that have poorer
spatial resolution than that of film.

Cineradiography
showing various
steps involved in
swallowing.

ELECTROMYOGRAPHY:
Electromyography is a medical technique for evaluating and recording
physiologic properties of muscle at rest and while contracting. EMG is
performed using a instrument called an electromyograph, to produce a record
called an electromyogram. An electromyograph detects the electrical potential
generated by muscle cells when these cells contract and also when cells are at
rest.
• Structural basis of Emgram is – motor unit.Structural basis of Emgram is – motor unit.
• Electrical potential developed by the activation of one motor unit is called – motor unitElectrical potential developed by the activation of one motor unit is called – motor unit
potential.potential.
• Lasts for 5 to 8 milli sec and has an amplitude of 0.5 mv.Lasts for 5 to 8 milli sec and has an amplitude of 0.5 mv.
• EP recorded from whole muscle shows smaller potentials if the force of contraction is less.EP recorded from whole muscle shows smaller potentials if the force of contraction is less.
• When force is increased,due to recruitment of more & more number of motor neurons,largerWhen force is increased,due to recruitment of more & more number of motor neurons,larger
potentials are obtained.potentials are obtained.

USES:
1. Helps to distinguish primary muscle conditions from muscle weakness
caused by neurologic disorders.
2. It is used to find causes of muscle weakness, hyperactivity, paralysis,
involuntary twitching, and abnormal levels of muscle enzymes.
3. In severe class II Div. I cases the upper lip is hypofunctional. Thus during
swallowing, the lower lip extends upwards and forwards to force the maxilla
labially and a strong mentalis activity is seen. EMG can be used to study such
condition.
4. Abnormal buccinator activity in class II malocclusion.
5. Overclosure of jaws is associated with accentuated temporalis muscle
activity.
6. Children with cerebral palsy.
7. EMG can be carried out after orthodontic therapy to see if muscle balance is
achieved. www.indiandentalacademy.com

XERORADIOGRAPHY:
Xeroradiography was invented by Chester F. Carlson in 1937. xeroradiography
employs reusable photoreceptor plate and ultimately produces an image on
paper. xeroradiographic head films is used for routine cephalometric analysis. A
xeroradiographic picture or print resembles a blue print, but it shows all tissue
densities with fine detail. Xeroradiography is primarily used for evaluation of
breast lesion, larynx and temporomandibular joint.
CLINICAL ADVANTAGES:
1. It can be viewed without transillumination.
2. It is not necessary to make the typical cephalometric planes and points be
traced and subsequent tracings paper applied directly over the original head
film thereby reducing tracing error.
3. All densities of soft and bony tissue are displayed in one picture
4. Intraosseous detail and soft-tissue boundary definitions are superior to the
conventional radiograph
5. Teeth are more readily visualized.

BONE SCANNING:
A bone scan looks for abnormalities in the bone and joints. The scan uses a large
camera called a ‘GAMMA CAMERA’. This camera picks up radioactivity. First the
radioactive substance is injected into the blood stream and radioactive substance
should be small amount, not enough to harm. The radionuclide travels through the
blood and collects in bones and more of it collects in areas where there is lot of
activity in bone. Activity means the bone breaking down or repairing it self. These
areas are picked out by camera and commonly called spots

LASER SCANNING:
Laser scanning provides a method of capturing the face for planning or
evaluating outcome of orthodontic or orthognathic treatment.
The scanning is performed using the Vivid 700 (Minolta, resolution : 400*400
pixels), a 3-dimensional scanner operating on a laser-light stripe triangulation
range-finder principle.
The patient is instructed to sit still
in a chair with facial muscles
relaxed and eyes and lips lightly
closed for 0.6 second during the
scanning( 1.0 m apart from
scanner,

Benefits:
1) An accurate evaluation of pre- and post-treatment soft tissue facial
profile is possible.
2) The pre- and post-treatment superimposition provided visualization
of the treatment results.
3) A quantitative assessment of the soft tissue changes were possible
with the use of the color coding system.
4) The soft tissue facial profile could be evaluated in any direction.
5) Much more diverse information and measurements could be
obtained curved surface, volume, etc
6) Excellent & very easy & fast data acquisition was possible.
7) The accurate data could be used for resolution of medical disputes.

LIMITATIONS:
1. Safety related issues.
2. Inability to capture the soft tissue texture, which results in difficulties in
identification of landmarks.

VIDEOCEPHALOMETRY:
Computerized videoimaging technology offers a mutual visual template by which
orthodontist can effectively communicate with patients, it also allows greater
potential for quantification of treatment plans which maximize chances of delivering
proposed treatment plan. In other words, coordination of calibrated profile images
permits precise measurements of bony and dental movements, and through the
application of algorithmic prediction ratios, images are produced that express the
expected surgical and orthodontic outcome.
Requirements are same of radiographic cephalometry plus control of magnification
or distortion introduced by hardware (i.e. camera, monitor, software and
cephalograms).
USES: 1. Counseling of patient.

2. Treatment planning:
The purpose of calibrating the cephalogram to the profile video is:
a. Relate the underlying hard tissue to the overlying soft tissue.
b. Allow quantification of movements. By knowing where the teeth are in relation
to the face, judgments can be made about the basic changes needed for the
occlusal correction. Consideration can then be given to what other procedures
may be needed for the esthetic ideal.
c. Permit the treatment plan to be designed to match the patient’s wishes as closely
as possible
d. Allows realistic movements to be planned.

BIBILOGRAPHY:
1. ORTHODONTIC DIAGNOSIS- RAKOSI
2. DENTOFACIAL ORTHOPEDICS – GRABER, RAKOSI AND
PETROVIC
3. RADIOGRAPHIC CEPHALOMETRY- ALEXANDER JACOBSON
4. FUNDAMENTALS OF OCCLUSION AND
TEMPOROMANDIBULAR DISORDERS- J.P. OKESON
5. CONTEMPORARY ORTHODONTICS- W.R. PROFFIT
6. ORAL RADIOLOGY- WHITE AND PHAROAH
7. HANDBOOK OF ORTHODONTICS- ROBERT E. MOYERS
8. CURRENT PRODUCTS AND PRACTICES IN ORTHODONTICS –
M.Y. HAJEER AND MILLET (journal of orthodontics vol.31 2004)
9. ELECTROMYOGRAPHY AND ITS APPLICATION IN
ORTHODOTICS- MEENAKSHI IYER. CURRENT SCIENCE VOL.
80, 2001.
10. CURRENT PRINCIPLES AND CONCEPTS-- GRABER AND
VANRASDALL

IF WE COULD KNOW
WHERE WE ARE AND
WHITHER WE ARE
TENDING, WE COULD
BETTER JUDGE WHAT TO
DO AND HOW TO DO IT
-ABRAHAM LINCOLN

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