Extra oral examination /certified fixed orthodontic courses by Indian dental academy

EXTRA ORAL
EXAMINATION

www.indiandentalacademy.com

INDIAN DENTAL ACADEMY
Leader in continuing dental education


Extra oral examination
INTRODUCTION
The purpose of examination is to record the information about the
frontal view, profile view and functional analysis of the facial structure,
which helps as a guideline during orthodontic therapy also to improve the
esthetic appearance of the face.
I. FRONTAL ANALYSIS
1.
Shape of the head (Cephalic index)
2.
Facial form (Facial index)
3.
Facial proportions
4.
Facial symmetry
5.
Forehead examination
6.
Nose examination
7.
Lip examination
a. Interlabial gap
b. Lip posture & tonicity
c. Lip step
d. Lip thickness & height proportions

SHAPE OF THE HEAD

Classification & index values according to martin & Saller (1957)
The index is basedon the anthropometrix determination of the
maximum width of the head & the maximum length.
Dolichocephalic patient have long and narrow dental arch
Mesocephalic patient have paraboloid or average dental arch
Brachycephalic and Hyperbrachycephalic patient have broad dental arch

FACIAL FORM

The morphologic facial height is defined as the distance
between nasion & gnathion, the bizygomatic width as the distance
between the zygomatic points.
Morphologic facial height – Nasion – Gnathion (gn)
Bizygonmatic width – Zygoma – Zygoma
This type of facial morphology has a certain relationship to the
shape of the dental arch. Euryprosopic face type have broad, square
arches. leptorposopic face types have narrow apical base / arches.

Euryprosopic Face

Leptoprosopic face

Mesoprosopic face


FACIAL PROPORTIONS
TRANSVERSE FACIAL
PROPORTIONS
The central fifth of the face
The middle two fifth of the face
The Outer two fifth of the face

VERTICAL FACIAL
PROPORTIONS
Upper third of the face
Middle third of the face
Lower third of the face
upper 1/3rd
lower 2/3rd www.indiandentalacademy.com

NORMATIVE VALUES
FOR FACIAL DIMENSIONS

Dimension

Distance

Inter pupaillary

65 mm
35 mm (adult)
30.3 mm (age9)
31.6 mm (age 16)
9.8 cm.

Inter canthal
Outer canthal.


FACIAL SYMMETRY

Facial Symmetry

Facial Asymmetry


STRUCTURAL CLASSIFICATION OF
DENTOFACIAL ASYMMETRIES

 Dental asymmetries
 Skeletal Asymmetries
 Muscular and soft tissue asymmetries
 Functional Asymmetries


SUB MENTAL VIEW


FORE HEAD EXAMINATION

FLAT
FOREHEAD

PROTRUDING
FOREHEAD

STEEP
FOREHEAD

NOSE EXAMINATION
Size of the nose

NOSTRILS

Leptorrhine nose

On profile leptorrhine nose have more nasal projection
On frontal view it is narrow and has more nasal height

Mesorrhine
nose

Platyrrhine
nose

Mesorrhine nose is most common to Asians and it frontally
characterized by lack of dorsal height and dorsal and alar wideness
Platyrrhine nose is most common in black populations.
Frontally it is characterized by broad alar base and nostrils.

LIP EXAMINATION

In Competent
lips

Competent lips

Potentially in
competent lips

Everted lips


LIP STEP

Positive lip Slightly negative Marked negative
lip step (normal
lip step
Step
cases)

PROFILE ANALYSIS


Facial profile



Facial divergence



Nasolabial angle



Nose examination in profile



Lip examination in profile



Mentolabial sulcus



Chin examination



Maxilla / Mandibular vertical proportions



Mandibular plane angle



Visualized treatment objective (VTO)

FACIAL PROFILE

The evaluation is
based upon 3 reference
Planes
1. Eye –ear plane
(Frankfurt horizontal plane)
2. Skin nasio perpendicular,
according to dreyfuss
3. Orbital perpendicular,
according to simon

Straight jawed profile

Backward slanting
profile

Forward slanting
profile

FACIAL DIVERGENCE
1. Straight
2. Convex
3. Concave
1
1

2

3


2

3

NASOLABIAL ANGLE

Acute

Obtuse

NOSE EXAMINATION IN PROFILE

Straight nose

Convex nose


LIP EXAMINATION IN PROFILE

Protrusive
upper & lower
lip

Retrusive lip
profile

Method of
evaluation


THE MENTO LABIAL SULCUS is defined simply as the fold
of soft tissue between the lower lip and the chin; it may vary greatly in
form and depth. It is affected by lower incisor position and by the
vertical height of the lower face.
Upright lower incisors tend to result in a shallow mentolabial
sulcus because of lack of lower lip projection.
A deep mentolabial sulcus is common in patient with short faces
& class II relationship because the lower lip is averted against the upper
incisors & lip redundancy in caused by the short lower face.
The patient with a long face has a tendency to have a flat
mentolabial sulcus because of the flattening of the mantalis muscle to
attain lip closure.
The deep mentolabial sulcus in characteristic of a hyperactive
mentalis muscle.

MENTOLABIAL SULCUS
Mentolabial sulcus

Deep mentolabial sulcus

Shallow mentolabial sulcus

Hyper activity of mentalis
muscle


CHIN EXAMINATION

Protruing chin with
mentolabial sulcus

Normal chin

Negative chin

Configuration of chin projection is determined by two
factors
The amount of bony projection.
The amount of softwww.indiandentalacademy.com bony projection.
tissue overlap the

Maxilla & Mandibular vertical
proportion


MANDIBULAR PLANE ANGLE

FRANK FURT MANDIBULAR PLANE
ANGLE
It depending upon the point where two
planes meet.
Frank furt horizontal plane
Mandibular plane
Clinical FMA


VISUALIZED TREATMENT OBJECTIVE


FUNCTIONAL EXAMINATION
1.

Respiration

2.

Mastication

3.

Deglutition

4.

Speech

5.

Centric relation / Centric occlusion discrepancy, protrusive
& lateral excursions, freeways space.

6.

Maximum mouth opening

7.

Smile analysis

8.

Peri oral muscle activity (Muscles of mastication)

9.

Tempro mandibular joint (TMJ)
a. Pain
b. Sound

c. Path of closure / opening

EXAMINATION OF BREATHING
MODE

Mirror Test

Nasal respiration –
observation of nostrils


Oro Nasal respiration
– alar muscles or
inactive nares do not
change their size

DEGLUTITION
Collecting stage

Transporting
stage 1st part

Transporting
stage 2nd part

Transporting
stage 3rd part

Third swallowing
stage

Fourth swallowing
stage

Final swallowing
stage


SPEECH
Speech sound

Problem

Related
malocclusion

/S/, /Z/ (sibilants)

Lips

Anterior open bite,
large gap between
incisors.

/T/, /D/ (lingualveolar
stops)

Difficulty in
production

/F/, /V/ (labio dental
fricatives)

Distortion

Irregular
incisors,
especially
gingival
position of maxillary
incisor.
Skeletal class II

Th,sh,ch (lingodental
fricatives) (voice or
voiceless)

Distortion

Anterior open bite


CENTRIC OCCLUSION : Condyles in the centre of the
articular discs and against the examinatia, as high up as anatomically
possible and contred transversely.
CENTRIC RELATION : A maxillo mandibular relationship in
which the condyles articulate with the thinnest a vascular position of
their respective disc with the condyle in antero superior position against
the slopes of articular eminences. This position is independent of tooth
contact.
This position is clinically as discernible when the mandible is
directed superiorly and anteriorly and restricted to a purely rotary
movement about the transverse horizontal axis.
IMPORTANCE
OF
CENTRIC
RELATION
IN
ORTHODONTICS
Diagnosis and treatment planning should be performed by an
evaluation of the occlusion with mandible in centric relation in order to
obtain the maxillary and mandibular skeletal and dental relation ship.
If this is overlooked, an in correct diagnosis and treatment plan
of the actual mal occlusion, along with its unfavourable consequences
may result.

Moreover during every appointment the patient has to be
monitored in centric relation if monitoring is not done in this manner
the treatment may finish with the mandible in centric occlusion, with
several prematuraties. This may later cause trauma from occlusion and
TMJ disorder.
FREE WAY SPACE
The space between the teeth when mandible is at rest position
it is usually 2-3mm referred as freeway space or inter occlusal
clearance.
METHODS TO DETERMINE
Phonetic method
Command method
Non- command method
Combined method


MAXIMUM MOUTH
OPENING

Deflection

Deviation


SMILE ANALYSIS

Smile mesh by Ackerman

EXCESSIVE MAXILLARY INCISOR SHOWS
Gender
Male

Maxillary
incisor
1.91 mm

Female

central

3.40 mm

Mandibular central
incisor
1.23 mm
0.49 mm

Excessive maxillary incisors shows due to
 Short upper lip philtrum height
 Excessive vertical growth of the maxilla can cause
excessive incisor display
 Excessive crown height
Detorqued maxillary incisors

INADEQUATE INCISOR DISPLAY

 Excessive upper lip philtrum height

Inadequate growth of the maxilla may result in
inadequate
incisor show
 Inadequate crown height
 Flared maxillary incisors.
 High frenum attachment

GINGIVAL DISPLAY ON
SMILE

Gummy Smile
 Short philtrum
 Vertical maxillary excess
 Excessive “Curtain” on smile
 Short incisal crown height
 Upright maxillary incisors
 High frenal attachment.

TEMPRO MANDIBULAR JOINT
EXAMINATION
Ausculation

Lateral Palpation of TMJ

Posterior palpation of TMJ

Lateral pterygoid M. Palpation

Temporalis M. Palpation

Messater M. Palpation


FUNCTIONAL MANIPULATION
Muscle

Contracting

Inferior
lateral
pterygoid muscle

Protruding
resistance,
pain

Superior
lateral
pterygoid muscle

Clenching on
increase pain

Medial
muscle

pterygoid

Stretching
against
increase

Clenching on teeth,
increase pain
Clenching
on
separator, no pain

teeth,

Clenching on teeth,
increase painClenching
on separator, increase
painOpening mouth, no
pain

Clenching on teeth,
increasing pain
Clenchingon separator,
increasing pain

Opening
mouth,
increasing pain.

THE EIGHT COMPONENTS OF BALANCED SMILE
Roy Sabri, DDS, MS
JCO , March 2005.


UPPER LIP LENGTH FROM VARIOUS STUDIES (MM)
Male

Female

Burstone

23.6±1.5

20.1 ±1.9

Farkas et al.

21.8 ±2.2

19.6 ±2.4

Powell, Humphreys

23.8 ±1.5

20.1 ±1

Wolford

22 ±2

20 ±2

Peck et al.

23.4 ±2.5

21.2 ±2.4

Arnet, Bergman
(Male and female combined) 19-22


Patient with low lip line
due to vertical maxillary deficiency

Patient with gingival smile,
over bite, and short clinical crowns


Lip line with reduced incisor display due
to proclined maxillary incisors

Patient with reverse smile arc


Patient with arch asymmetry due to peg-shaped lateral incisor.
Symmetrical arch after extraction of peg lateral and orthodontic space closure


CONCLUSION
The modern orthodontics includes a series of different types of
treatment requiring precise diagnosis techniques in order to produce a
positive out come. The careful and complete extra oral examination of
patient will guide in proper treatment plan.




REFERENCES

1. Colour Atlas of Dental Medicine
Orthodontic diagnosis
Thomas Rakosi
2. Orthodontics current principles and techniques, 3rd Ed.
Graber, Vanarsall
3. Dento facial orthopedics with functional appliance, 3rd Ed.
Graben Rakosi Petrovic
4. Contemporary orthodontics, 3rd Ed.
William R. Proffit
5. Esthetic Orthodontics & Orthognathic surgery
David M. Sarver
6. Management of TMJ Disorder & Occlusion
Jeffery P. Okeson
7. Contemporary treatment of dento facial deformity
Proffit, White, Sarver

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