Functional Examination: Textbook of Orthodontics

74
Textbook of Orthodontics
FUNCTIONAL EXAMINATION
Orthodontic diagnosis should not be restricted to
static evaluation of teeth and their supporting
structures but should also include examination of the
functional units of the stomatognathic system. A
functional analysis is important not only to
determine the etiology of the malocclusion but
also to plan the orthodontic treatment required.
A functional analysis includes:
1.
Assessment of postural rest position and
maximum intercuspation.
2. Examination of the temporomandibular joint.
3. Examination of orofacial dysfunctions.
ASSESSMENT OF POSTURAL REST POSITION
as he speaks and swallows while he remains

distracted. Patient is not aware that any examination is being carried out. While talking, the
patients musculature is relaxed and the mandible
reverts to the postural rest position.
d. Combined methods A combination of the above
methods is most suitable for functional analysis in
children. The patient is observed during swallowing and speaking. The Tapping test can also
be carried out to relax the musculature. Here, the
clinician holds the chin with his index finger and
thumb and then opens and closes the mandible
passively with constantly increasing frequency
until the musculature is relaxed. This can be
confir- med by palpating the submental muscles.
The rest position can then be determined.
Regardless of the method, mandible position is
checked extraorally and the patient is told not to
change the jaw, lip or tongue position. The lips are
then parted and the maxillomandibular relation as
well as the freeway space is determined.
Determination of postural rest position: The postural

rest position is the position of the mandible at which
the synergists and antagonists of the orofacial system
are in their basic tonus and balanced dynamically.
The space which exists between the upper and lower
jaws at the postural rest position is the interocclusal Registration of the Rest Position
clearance or freeway space which is normally 3 mm in 1. Intraoral methods
the canine region.
a. Direct method Vernier calipers can be used
The rest position should be determined with the
directly to measure the interocclusal clearance
patient relaxed and seated upright with the back
in the canine region.
unsupported. The head is oriented by making the
b. Indirect method Impression material is used to
patient look straight ahead. The head can also be
register the freeway space.
positioned with the Frankfurt horizontal parallel to 2. Extraoral methods
the floor.
a. Direct method Reference points are made on
Various methods to record the postural rest
the
position:
skin with plaster, one on the nose and the other
a. Phonetic method The patient is told to pronounce
on the chin in the midsagittal plane. The
some consonants like M or words like
distance between these two points is measured
Mississippi repeatedly. The mandible returns to
at rest position and centric occlusion. The
the postural rest position 1-2 seconds after the
difference between the two is the freeway
exercise.
space. b. Indirect method Includes
b. Command method The patient is asked to perform
Cephalometric registration: 2 cephalogram
selected functions like swallowing, at the end of
one at postural rest position and other in
which the mandible returns spontaneously to the
centric occlusion are taken to determine the
rest position. Phonetic exercise is also a type of
freeway space.
command method.
Kinesiographic registration: a magnet is
c. Non command method The clinician talks to the
fixed on the lower anterior teeth and the
patient on unrelated topics and observes the
mandibular movements are recorded by
patient
sensors which is then processed in the
Kinesiograph.
Diagnostic AidsCase History and Clinical Examination

75
EXAMINATION OF THE
Evaluation of the Path of Closure
TEMPOROMANDIBULAR JOINT (TMJ)
The path of closure is the movement of the mandible The clinical examination of the TMJ should include
from rest position to full articulation which should auscultation
and
palpation
of
the
be analyzed in all 3 planes of space, i.e. sagittal, temporomandibular joint and the musculature
vertical and frontal planes. The amount of rotation associated with mandibular movements as well as
and sliding during mandibular closure is analyzed.
the functional analysis of the mandibular
Sagittal Plane
movements. The main objective of this examination

is to look for symptoms of TMJ dysfunction such as
crepitus, clicking, pain, hypermobility, deviation,
dislocation, limitation of jaw movements and other
morphological abnormalities.
Specific TMJ radiographs may be indicated as part
of orthodontic diagnosis in exceptional cases,
Tomograms of the TMJ in habitual occlusion and
maximum mouth opening may be analyzed from
condyle position in relation to the fossa, width of the
joint space, etc.
Adolescents with Class II div 1 malocclusions and
lip dysfunction are most frequently affected by TMJ
disorders. Therefore, orofacial dysfunctions must
also
be assessed as they may lead to unbalanced joint
loading which can then trigger off TMJ disturbances.
In Class II malocclusions, 3 types of movements can

be seen.
a. Pure rotational movement without a sliding
componentseen in functional true Class II
malocclusion.
b.
Forward path of closurei.e. rotational
movement with anterior sliding movement. The
mandible slides into a more forward position,
therefore, Class II malocclusion is more
pronounced than can be seen in habitual
occlusion.
c.
Backward path of closure, i.e. rotational
movement with posterior sliding movement. In
Class II div 2 cases, the mandible slides backward
into a posterior occlusal position because of
premature contact with retroclined maxillary
EXAMINATION OF OROFACIAL DYSFUNCTIONS
incisors.
Includes evaluation of:
Vertical Plane
Swallowing
It is important to differentiate between two types of Tongue
Speech
overbites.
Lips
The true deep overbite is caused by infraocclusion
of the molars and can be diagnosed by the presence Respiration
of a large freeway space. The prognosis with Swallowing
functional therapy is favorable. Pseudo-deep bite is
caused due to over-eruption of the incisors and is At birth the tongue protrudes anteriorly between the
characterized by a small freeway space. Prognosis gum pads to establish lip seal. Therefore the infant
swallows viscerally for the first 1 to 2 years of age.
with functional therapy is unfavorable.
This infantile swallow is gradually replaced by the
mature swallow as the deciduous dentition is
Transverse Plane
comple- ted. If infantile swallow persists beyond the
During mandibular closure, the midline of the fourth year, it is considered as an orofacial
mandible is observed. In case of unilateral crossbite, dysfunction. The difference between infantile and
this analysis is relevant to differentiate between mature swallow has been discussed in the chapter on
laterognathy and laterocclusion. Laterognathy or oral habits.
true crossbite-the centre of the mandible and the
facial midline do not coincide in rest and in
occlusion. Laterocclusionthe centre of the Tongue
mandible and facial midline coincide in rest position
but in occlusion the mandible deviates due to tooth Tongue thrust is one of the most common
dysfunction of the tongue. Tongue dysfunction can
interference leading to non-coinciding midlines.
be assessed
76
Textbook of Orthodontics
clinically
by
electromyographic
examination,
cephalometric analysis, cine radiographic,
palatographic and neurophysiologic examinations.
Cephalograms can help to evaluate the position
and size of the tongue in relation to the available
space. However, in orthodontics diagnostic
registration of tongue position is usually more
important than its size. Palatography involved
applying a thin layer of contrasting impression
material to the patients tongue.
Diagnosis of habits has been also covered in the
chapter on habits. The students are request to refer to
the same.
The findings should be recorded in a systematic
manner. Conclusions drawn should be compared to
the results obtained from cephalometric analysis. No
decision should be taken arbitrarily, and all possible
safeguards should be taken to prevent diagnosing a
case wrongly.
FURTHER READING
1. Anderson GM. Practical Orthodontics, 9th ed., CV Mosby
Co., 1960.
2. Case CS. A Practical Treatise on the Techniques and
Principles of Dental Orthopedia, Reprinted Leo Bruder.
New York, 1963.
3. Graber TM. Diagnosis and panoramic radiography, Am J
Orthod, 1967;53:799-821.
4. Graber TM. Orthodontics: Principles and Practice, ed. 3,
WB Saunders 1988.
5. Moorrees CFA, Grn AM. Principles of orthodontic
diagnosis, Angle Orthod, 1966;36:258-62.
6. Moyers RE. Handbook of Orthodontics, ed. 3, Chicago,
1973, Year Book.
7. Proft WR, Fields HW (Eds). Contemporary Orthodontics,
3rd ed, Mosby, 2000.
8. Salzmann JA. Practice of Orthodontics. J.B.lipincott Co.,
1966.
9. Simon P. Fundamental Principles of a Systematic
Diagnosis of Dental Anomalies. Translated by B.E.Lisher,
Boston, Stratford Co. 1926.

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74

as he speaks and swallows while he remains

Determination of postural rest position: The postural

Diagnostic AidsCase History and Clinical Examination

movements. The main objective of this examination

In Class II malocclusions, 3 types of movements can

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