Introduction: Proper treatment plane depends on prompt diagnosis, good clinician should have a bird’s eyes to first identify the problem and find its etiology Definitions: = Grabber and Rackosi: defined diagnosis as: Recognition and systemic designation of anomalies, the practical synthesis of the finding, permitting therapy to be planned and identification to be determined =a continuous evaluation process in orthodontics starting right from the first interaction with the patient continuing through different stages till end of treatment and course follow up visits Goal of orthodontic diagnosis: Is to produce a comprehensive description of the patient’s problem and then to synthesis the various elements of description into a rational problem list Diagnostic aids: Data required for orthodontic diagnosis are derived from routine essential diagnostic aids and also from supplemental aids when needed, Graber categorized the diagnostic aids into essential and supplemental aids Essential: - Case history - Study models - Certain radiographs: periapical, bite wing, panoramic radiograph - Facial photographs - Intra-oral photographs Supplemental: - Specialized radiographs: occlusal of maxilla and mandible, lateral cephalogram - Hand &wrist radiograph - Electromyography - Endocrine test - Basal metabolic rate Case history: Complete case history includes all the relevant information derived from the patient and parents and essential for planning Personal details: Name: The patient’s name should be recorded for the purpose of identification and communications Calling the patient by his/her name not only establishes a good report but also imparts confidence in the patient mind about treatment providers In case of children, it might help to know their pet problems Age: = certain malocclusion occurring during growth period are transient and self-correcting = growth modification procedures such as functional appliances can be carried out during growth periods = surgical respective procedures such as orthognathic surgery are best carried out after cessation of growth = chronological age is important for the maintaining of shedding and eruption time tables as well Gender: = recording gender of the patient is important for treatment planning, females are observed to precede males in growth related events such as onset of growth spurt, eruption of the teeth and onset of puberty = gender may also have a bearing on patient’s compliance toward certain types of orthodontic treatment Occupation and address: Occupation of patient / or parents gives an idea about socioeconomic condition which might affect the selection of orthodontic appliances and can give an idea about awareness Address of patient determine the sociality of the patient and this effect on the treatment because some countries have normally bi-maxillary protrusion and also determine the awareness of patient about treatment and oral hygiene Patient behavior: Behavior of patient depend on: patient

1. 1
Dr. Mohammed Alruby
Diagnostic Aids
in orthodontics
{diagnosis, Examination}
part (1)
Prepared by:
Dr. Mohammed Alruby
Diagnostic Aids

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Dr. Mohammed Alruby
Introduction:
Proper treatment plane depends on prompt diagnosis, good clinician should have a bird’s eyes to
first identify the problem and find its etiology
Definitions:
= Grabber and Rackosi: defined diagnosis as:
Recognition and systemic designation of anomalies, the practical synthesis of the finding,
permitting therapy to be planned and identification to be determined
=a continuous evaluation process in orthodontics starting right from the first interaction with the
patient continuing through different stages till end of treatment and course follow up visits
Goal of orthodontic diagnosis:
Is to produce a comprehensive description of the patient’s problem and then to synthesis the
various elements of description into a rational problem list
Diagnostic aids:
Data required for orthodontic diagnosis are derived from routine essential diagnostic aids and
also from supplemental aids when needed, Graber categorized the diagnostic aids into essential
and supplemental aids
Essential:
- Case history
- Study models
- Certain radiographs: periapical, bite wing, panoramic radiograph
- Facial photographs
- Intra-oral photographs
Supplemental:
- Specialized radiographs: occlusal of maxilla and mandible, lateral cephalogram
- Hand &wrist radiograph
- Electromyography
- Endocrine test
- Basal metabolic rate
Case history:
Complete case history includes all the relevant information derived from the patient and parents
and essential for planning
Personal details:
Name:
The patient’s name should be recorded for the purpose of identification and communications
Calling the patient by his/her name not only establishes a good report but also imparts
confidence in the patient mind about treatment providers
In case of children, it might help to know their pet problems
Age:
= certain malocclusion occurring during growth period are transient and self-correcting
= growth modification procedures such as functional appliances can be carried out during
growth periods
= surgical respective procedures such as orthognathic surgery are best carried out after
cessation of growth

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Dr. Mohammed Alruby
= chronological age is important for the maintaining of shedding and eruption time tables as
well
Gender:
= recording gender of the patient is important for treatment planning, females are observed to
precede males in growth related events such as onset of growth spurt, eruption of the teeth and
onset of puberty
= gender may also have a bearing on patient’s compliance toward certain types of orthodontic
treatment
Occupation and address:
Occupation of patient / or parents gives an idea about socioeconomic condition which might
affect the selection of orthodontic appliances and can give an idea about awareness
Address of patient determine the sociality of the patient and this effect on the treatment because
some countries have normally bi-maxillary protrusion and also determine the awareness of
patient about treatment and oral hygiene
Patient behavior:
Behavior of patient depend on: patient motivation for treatment, what she / or he expects the
results of treatment, how patient cooperative on no cooperative is likely to be
== patient motivation:
External: that supplied by stress from other individual as parents or friends that they need the
teeth to looks better
Internal: comes from the individual and based on her or his assessment of situation and need for
treatment
It is difficult to find purely internal motivation especially in children but can de developed in
adolescence. Motivation affect the cooperation is better when the patient feel that the treatment is
benefit for him, SO, it is necessary to ask the patient, do you need the braces and why? To
establish what motivation is really
== patient expectation:
Is much related to the type of motivation
== patient cooperation:
This more likely to occurs in children than adults and determined by:
The extent to which the child sees the treatment is benefit
The degree of parental control
Chief complaint:
The patient chief complaint should be recorded by his / her own words. It should not include any
scientific medical or technical terms. It should mention the conditions the patient feels he /she
suffering from.
This helps the clinician to identifying the priorities and expectations of the patients. There are
two logical reasons for patient concern about the alignment and occlusion of the teeth:
Impaired dentofacial esthetics that can lead to psychological problems
Impaired function.
The objective is to find out what is important to the patient
Medical history:
= Ask about hospitalization or not, present of fracture or not, adenoidectomy, tonsillectomy
= to observe any problems of systemic disease that can affect the orthodontic as, patient with
diabetes needs special care during and before treatment. Patient with heart disease need special

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Dr. Mohammed Alruby
care about band formation to avoid bacterial endocarditis, the same for patient with hepatitis or
liver disease ------ vit K deficiency ----- bleeding disorders
= also observe other procedure surgically as adenoid s or tonsils, if it removed early or not that
can affect arising of other orthodontic problems related to it
= problems with metabolic disease that can effect on Ca and others absorption and excretion
that has major effect on the quality of bone and teeth formation
= some patients that take treatment for arthritis or osteoporosis, high dose of prostaglandin
inhibitor or inhibiting agents may impede orthodontic tooth movements
Chronic medical problems in adults or children do not contraindicate orthodontic treatment if
the medical problems are under control, but special precautions may be necessary if orthodontic
treatment is to be carries out.
= determine the presence of allergy or not especially from nickel or latex, the allergic history is
obtained by asking the patient about previous history of asthmatic attacks
= in female’s patients ask about pregnancy or not
= patients with thyroid hormone defect has generalized root resorption
= use of chronic steroids reduce the resistance of infection that lead some problems with
orthodontic appliances
Dental history:
= determine the attitude of patients and parents to dental health and also determine the
awareness about orthodontic treatment
= history of previous trauma that may can affect TMJ or bone itself that may lead to facial
asymmetry
= determine the caries index of the patient because orthodontic treatment increase the ability of
caries formation due to high chances for food accumulations
= determine that last visit for dentist and for what
Dental age determination:
Can be determined by two different ways:
Stage of eruption of the teeth
Stage of tooth mineralization on radiograph
Determination of dental age from observation has been the only method available for long time
Skeletal age evaluation:
Assessment of skeletal age is often made with help of radiograph which can be considered a
biological clock, for analysis of skeletal maturity the stage of mineralization of the carpal bones
must be determined thereafter the development of metacarpal bones and phalanges should be
evaluated
Family history:
= observe the abnormalities that present in the family of patient as certain types of malocclusion
has family background like: class II, III, bi-maxillary protrusion
= cleft palate and lip has familial background
Prenatal history:
Information regarding the condition of the mother during pregnancy. Infections like German
measles and intake of certain drugs that may cause congenital deformities of children
Type of delivery must be noted as injury to TMJ by forceps delivery may adversely affect the
mandibular growth of patient

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Dr. Mohammed Alruby
Postnatal history:
Include time of birth, position at birth, if has normal length and weight or not
Exam manner of feeding and nutritional defects at this time
Clinical examination
General examination:
= The general examination should begin as soon as the patient walks toward dental chair for
examination, a general appraisal of patient is done
= First step in any orthodontic diagnosis is to evaluate the patient general health, physical
appearance and his attitude toward orthodontic treatment
= general questions concerning the child health and part illness should be asked, of course
complete physical examination is the responsibility of the physician, but a matter of particular
interest to the dentist to ask about allergies and naso-respiratory obstruction and other conditions
that may have a direct bearing on orthodontic diagnosis
Height and weight:
The height and weight of the patient are measured and recorded. The physical growth and
maturation of the patient can be indirectly assessed which have a direct influence on orofacial
structure
Gait:
It is a manner or style of walking of a person, gait of person reflects the neuromuscular
coordination. Abnormal gaits are associated with neuromuscular and some forms of dental
malocclusion
Posture:
Posture refers to the way a person stands or position of limbs (the arm and legs) abnormal posture
like that of gait can predispose to malocclusion due to alteration in the balance between maxillary
and mandibular structures
Body build (physique):
Physique of an individual fall into one of the three categories as:
Generally:
Athletic: average with normal size of dental arches
Plethoric: short physique with broad dental arches
Esthetic: thin physique with narrow dental arches
According to Sheldon:
Mesomorphic: average physique
Endomorphic: short and obese physique
Ectomorphic: tall and thin physique
Extra-oral examination:
The patient should be seated in the dental chair in an upright position and his head is placed well
over the vertebral column, and the FH plane should be roughly parallel to the floor and this
position in the chair not usual for intra-oral examinations
Morphologic analysis of the face:
Facial types:
Mesocephalic face:
Avoid face with normal facial proportions and normal musculatures, the face is neither too long
nor too wide and is associated with normal jaw relationship

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Dr. Mohammed Alruby
Dolichocephalic face:
Long and narrow face with narrow dental arches and high palatal vault. It is common in class II
div 1 or class III malocclusion, also open bite is common features of this type, relatively there is a
weak musculature
Brachycephalic face:
Shor broad and square face, with broad dental arches and strong musculatures, it is commonly
associated with deep bite and class II division 2 malocclusion
Facial types of Sassoni:
Skeletal class II: convex profile, retruded chin and incompetent lips
Skeletal class III: concave profile, protruded chin, and incompetent lips
deep bite: short broad face, prominent forehead, large nose, and accentuated labiomental sulcus
Skeletal open bite: long narrow face, steep mandibular plane and incompetent lips
Cephalic and facial index:
Martin and Saller 1957 make a classification for facial and cephalic index as follow:
Cephalic index:
C I:= maximum skull width / maximum skull length
Dolichocephalic: long skull: x ------- 75.9
Mesocephalic: 76 -------- 80.9
Brachycephalic: 81 --------- 85.4
Hyper brachycephalic: 85.5 -------- x
Facial index:
Anthropometric measurements, the facial height is measured as a distance between the nasion and
Gnathion. The width of the face is measured as the distance between the tangent of the two
zygomatic points
F I: = morphologic facial height / bi-zygomatic width
Hypereuroprosopic: short with low facial skeleton: X ------ 78.9
Europrosopic: broad and short face, broad square arch: 79 ----- 83.9
Mesoprosopic: average normal face, normal dental arches: 84 ----- 87.9
Leptoprosopic: long and narrow face, narrow apical base arches: 88 ------ 92
Hyperleptoprosopic: extremely long face: 93 ------ X
The form of the facial morphology has a certain relationship to the shape of the dental arches, and
as a general rule in border line crowding with broad facial types, an expansion treatment should
be carried out but extraction should be considered with long face types
Soft tissue profile:
Usually follows the underlying skeletal profile, which may be:
Convex: class II: retrognathic face
Concave: class III: Prognathic face
Straight: class I: orthognathic face
Clinical assessment of facial profile:
= visual examination of patient during rest
= palpation of maxillary and mandibular basal bone by index and middle finger when the teeth in
occlusion, but the thickness of the lips may interfere with this assessment so the lips may retract to
allow good diagnosis

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Dr. Mohammed Alruby
= study of incisor inclination and degree of overjet:
This method is based on that the incisors when have correct inclination and relationship in class
I, the over jet will be in normal range
SO: normal overjet: straight profile: class I
Increased over jet: convex profile: class II
Reversed over jet: concave profile: class III
N: B:
Objective study of human facial esthetics was introduced by Woolnoth and Britisher 1865 of facial
classification: the general form and outline of all faces especially as they are seen in profile are of
three orders:
1- Straight face:
Considered the handsomest and may be detected by drawing straight line from the top of the f of
the forehead to the bottom of the chin without intersection more than apportion of the nose and a
very smart part of the upper lip
2- Convex face:
Drown from top of the forehead to the lower part of the chin, intersect all the features leaving the
forehead and chin behind and the nose forward
3- Concave face:
Drown from top of the forehead to the bottom of chin would seem to shut in the features and nearly
scape them all
Frontal examination of the face:
Firstly, divided the face into thirds: upper, middle and lower third
Upper: extended from hair line to glabella and composed of cranium and forehead and should be
one third of the entire face height
Middle: extended from glabella (supraorbital ridge) to the sub-nasal (junction of the nose and
upper lip)
Lower: extended from sub-nasal to menton (the lowest point of the chin), and the lower third is
divided into upper lip portion and lower lip portion
Generally, the three thirds should be equal to each other in its proportion, and this is for
examination of the face in vertical direction
For horizontal direction:
Determine the facial midline of the face that pass through soft tissue nasion, tip of the nose and
philtrum of the upper lip and this an imaginary line on the face and examine the structure of the
face on both sides in relation to this line, the both sides should equal to each other in horizontal
direction.
Alar width: equal from inner canthus of eye to inner canthus of eye on the other side
Mouth width: equal the inter-pupillary line of the eye
= ala of right side to the facial plane equal to the ala of the left side to the facial plane
= patient that has normal horizontal and vertical proportions is considered as normal facial
patient and generally the disproportion is occur mostly in lower facial height when related to the
middle facial height either increase or decrease.
= the following guide lines are helpful in determining the vertical disproportion:
1- Upper incisors to upper lip relationship: distance from incisal edge of upper incisors to the
inferior portion of upper lip usually 2 -3mm is normal value, if there is increase or decrease
give an indication for the maxillary excess or defect

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Dr. Mohammed Alruby
2- Inter-labial distance: lip competence: is the vertical distance between the most inferior
portion of the upper lip and most superior portion of lower lip when the lips are relaxed
position. Normally it is approximately 2mm, increase inter-labial distance denotes excessive
vertical facial height
3- Lower incisors to lower lip: the lower lip cover all the lower incisors
4- Upper incisors to lower lip: the lower lip cover about 2 -3mm of the upper incisor during
rest
= the width of the base of nose should be approximately the same as inter-canthus distance, while
the width of the mouth should approximately the distance between iris
Facial proportion and symmetry in frontal plane:
An ideally proportional face can be divided into central, lateral, and medial equal fifths. The which
should be equal, determine the central and medial fifths, the nose and chin should be centered
within the central fifth with the width of the nose the same as or slightly wider the central fifth. The
inter-pupillary distance should equal the width of the mouth
Profile examination:
= The vertical relationship of the face can be examined from the profile view as from the frontal
view, so divide the profile into 3 thirds and examine its relationship to each other
= profile of the face can classify into 3 classes or types: concave, convex, straight profile this can
obtained by joining the following two reference lines
Line joining the forehead and soft tissue A point (deepest point on the upper lip curvature)
Line joining the point A and soft tissue pogonion (most anterior point on the chin)
Based on this relationship between these two lines three types of profile exist:
Straight orthognathic profile: the two lines form straight line
Convex: the two lines form an acute angle which seen in class II div 1
Concave: the two lines form an obtuse angle which seen in class III
In assessing profile esthetics, the following features aid in the description of the deformity in the
vertical and anterior posterior planes:
Naso-labial angle:
evaluated from profile view, this angle normally from right to obtuse angle, this angle is influenced
by:
Nasal tip
Paranasal skeletal support
Position of maxillary incisors
As: maxillary dento-alveolus is positioned anteriorly and paranasal support is collapsed so the
angle is acute
As: the maxillary dento-alveolus is retracted, the angle become more obtuse
Chin position:
Is evaluated with the patient’s head oriented along the perpendicular to FH plane. If the chin falls
significantly behind the line, it indicates anterior posterior mandibular deficiency, if the chin is
significantly in front of this line, it indicates anterior posterior mandibular excess
Relation of maxilla to upper face:
An imaginary line pass from nasion and perpendicular to FH plane, Sn should be positioned
slightly anterior to this line to give good profile esthetic. The deformities present in two categories:
Excessive maxilla
Deficient maxilla

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Dr. Mohammed Alruby
Evaluation of mandibular plane angle to FH:
The mandibular plane can be evaluated clinically by placing a mirror handle or other instrument
along the lower border of the mandible. This is important because, a steeper mandibular plane
angle correlates with: long anterior facial vertical dimension and anterior open bite
While flat mandibular plane correlate with: short anterior facial height and deep bite
Facial convexity denotes the anterior posterior proportionality of the mandible and the maxilla to
the upper third of the face. If we use an imaginary line drawn from soft tissue nasion perpendicular
to FH, sub-nasal should position slightly anterior to this line for good profile esthetics
N: B:
Da Vinci 1590, study the face and the proportionality of its parts, he was the first to do such studies
Facial symmetry:
From the clinical point of view, there is no face that is symmetrical at all in all facial
dimension either for vertical or horizontal because there is a small degree of bilateral facial a
symmetry exists in all normal individuals, this can be revealed most readily by comparing full face
photographs with composites consisting of two right or two left sides and this called normal a
symmetry, which is usually result from small size differences between the two sides and this should
be distinguished from the high disproportion in horizontal and vertical direction
Evaluate the facial proportion as follow:
- The alar width with eyes
- Stomion width with eyes
- Stomion to outer canthus on one side should be equal that present on other side
Bird’s view:
Another method of assessing symmetry is by asking the patient to extend his neck back, visualize
the patient face from chin region, the midpoint of the chin, tip of the nose and nasion, glabella fall
in one line.
Examination of forehead:
For the harmony of facial morphology, the height of the forehead should be one third of the entire
face (Glabella to hair line) as long as the mid third and lower third
From the frontal view, the forehead width more or less equal to the bi-zygomatic width and this
relation determine if it wide or narrow
From profile view: the forehead flat, protruded or steep. In case of steep forehead, the dental
arches more Prognathic than other cases
In case of rickets there is a boxy head in which there is a prominence in parietal area and frontal
area
Examination of the nose:
Many congenital diseases are associated with abnormal nasal morphology as:
Congenital syphilis: depressed nasal bridge
Skeletal deep bite: large nose, wide apertures
Skeletal open bite: long slender nose, narrow apertures
The size, shape and position of the nose determine the esthetic appearance of the face, so the
assessment of the nose is important before the treatment, because the rhinoplasty may be necessary
later
= vertical nasal length measured one third of the total face

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Dr. Mohammed Alruby
= the relationship between the vertical and horizontal length of the nose is 2:1 as from side view
= straight nasal contour reflects straight profile
= Convex nasal contour reflects convex profile
= Concave nasal contour reflects concave profile
= the width of nostril is approximately 70% of the length of the nose
Evaluate the naso-labial angle, the range from right to obtuse angle (90 -110 degree)
Increased naso-labial angle: as in class II div 2
Decreased naso-labial angle: as in class II div1
Persistence redness of nose may occur in case of chronic alcoholism or liver cirrhosis
Enlarged nose may occur in case of acromegaly or rhino-scleroma
Depressed nasal bridge may occur in case of syphilis, infantile myxedema, sickle cell anemia
Examination of chin:
The configuration of the chin not only determined by the bony structure but also the thickness and
tone of muscles as well as chin width and height (distance from menton to mento-labial sulcus)
= protruded chin ------ class III and sometimes deep bite
= retruded chin -------- class II and sometimes Openbite
= normal mento-labial sulcus: class I malocclusion
= shallow mento-labial sulcus: bi-maxillary protrusion
= deep mento-labial sulcus: class II div1 malocclusion
Mentalis activity:
Mentalis muscle does not show any abnormal contraction during lip closure in patients with
normal malocclusion, however hyper active mentalis muscle is seen in class II div1 or any
malocclusion with increased proclination of upper anterior teeth. in these cases, the hyper active
mentalis muscle causes over-protrusion of lower lip and puckering of the chin when lips are closed
Examination of lips:
In normal relaxed unstrained position of the lips, the lips are sealed together, upper lip
measured one third and lower lip measured two thirds of lower face height
Distance from inferior part of upper lip to incisal edge of upper central incisors measured 2-4mm
(tooth display)
Lower lip covered about 2mm of upper central incisors
Lower lip covered all the lower incisors
Inter-labial gap about 2mm
Color of lips:
The two lips should be had a similar color and texture but in some cases that the lower lip rests
beneath the upper incisors during swallowing, it usually red, heavier, moist and smooth.
Lip posture:
Lip posture and incisor prominent should be evaluated by viewing the profile with the patient
relaxed position. This is done by relating the upper lip to true vertical line passing through the
concavity that represent soft tissue A point of the lip, and relating the lower lip to similar line
passing through the soft tissue B point. If the lip is significantly in forward position from this line
it can be judged to be prominent
If the lips fall behind the line, it is retrusive, if the lips are both prominent and competent the
anterior teeth are excessively protruded
Lip steps:
The lip profile has a different variation according to Korkhaus
Positive lip step: class III

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Dr. Mohammed Alruby
Slightly negative lip step: as in normal case
Marked negative lip step: as in class II cases
Lip configuration:
- Competent lips: lip seal with slight contact when muscle is relaxed
- Incompetent lips: lips sealed by active contraction of muscles due to its shortness
- Potentially incompetent: due to interferences, the lips are not seal
Lip dysfunction:
Lip habits:
The various habits of the lips can have divided into: lip sucking, lip thrust, lip insufficiency. Lip
dysfunction can be observed while the patient is speaking and swallowing
The lower lip shows variation of dysfunction with regard to the tip of the tongue. The lower lip and
the tip of the tongue are often in contact
Hyper activity of mentalis muscle:
The deep mento-labial sulcus is characteristic of hyper active mentalis muscle, this habitual
pattern of muscle behavior imped the forward development of anterior alveolar process in the
mandible. The abnormal mentalis function often occurs together with lip sucking or lip thrust.
Cases with hyper aCases with hyper active mentalis muscle which occur in the family are usually
hereditary
Vertical lip relationship:
In a balanced situation, the upper lip length (distance from subnasal to stomion) is one third of the
lower third of the face.
Lip morphology:
a- Harmonious lip profile: with narrow mucosal element
b- Short upper lip with narrow mucosal element and disturbed lip seal
c- Short cutaneous upper and lower lip with undisturbed lip closure, the lip insufficiency is
compensated by eversion of the mucosal part
D, D of the lips:
a- Morphologically inadequate lips: the lips are morphologically short
b- Functionally inadequate lips: the lips are adequate size but fail to seal together due to dental
interferences as in cases of class II div 1
c- Functional abnormal lip: is associated with tongue thrust swallowing, the mentalis muscle
and inferior orbicularis oris muscle are enlarged, causing hypertrophied gingiva. gingivitis
in lower anterior region with absence of upper
Physiologic analysis of lips and face:
1- During rest:
During rest the upper and lower lips meet each other lightly without active contraction to provide
anterior oral seal, sometimes the lips may be habitual a part in few nasal breathers without and
dental interference
2- During function:
a- Mastication:
During normal mastication the lips are healed lightly together, strong contraction will be seen in
sever class II malocclusion with large overjet
b- Swallowing:
During normal mature swallowing, the lips touch lightly without active contraction, the
facial muscles do not contract, the temporal muscle contract to elevate the mandible, but in
infantile swallowing (teeth a part swallowing) the mentalis muscle and circum-oral contract

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Dr. Mohammed Alruby
strongly but no contraction noted in temporal if you retract the lips during swallowing, normal
swallowing is completed while teeth a part swallow is inhibited
c- Breathing:
In normal breathing the lips touch lightly and breathing is achieved through the nose. But
in mouth breathing the lips are a parted, the mandible and tongue assume in low position to provide
an adequate oral air way
Examination of breathing:
- In nasal breathing the lips are closed while in mouth breathing the lips is a parted
- Ask the patient to take deep breath, in nasal breather, the lips is closed but in mouth breather
the lips are a parted
- Ask the patient to close his lips and take deep breath through the nose, in nasal breather
there is contraction of external nares of the nose but in mouth breather there is no
contraction
- Mirror fogging test: place the mirror on the upper lip against the nasal orifices, it will cloud
in nasal breathers
- Cotton butterfly test: place a thin cotton fiber against the nasal orifices it will move in nasal
breathers, and exam each side of the nose
d- During speech:
= Speech, is a complex process involving innate neuro-muscular behavior pattern
= Speech production involves neuromuscular activity of the tongue, lips, muscles of the wall of
pharynx, soft palate, respiratory tract and nasal passage
= Speech is largely learned activity depends on the maturation of organism
= breathing produce a column of air which produce vibration necessary for sound, then lips,
tongue and velopharyngeal structures modify this air stream to produce variation of the sound
Most abnormal lip function during speech in children with malocclusion is an adaptation or
accommodation to abnormal tooth position
- Labio-dental sounds: upper teeth and lower lip produce the letter F, V
- Bi-labial sound: upper and lower lip produce the letter P. B, M, W.
- Linguo-dental: tongue tip and upper teeth produce letter TH
- Linguo-alveolar: tongue tip and alveolar ridge, produce letters, T, D, S, Z, N
- Liguo-palatal: tongue blade and hard palate: produce letters: CH, J, SH, R
- Liguo-velopharyngeal: tongue back, velum and pharyngeal wall: produce letters K, G
- Liguo-velor: tongue back and velum: produce letter: NG
- Glottal: produce letter H
Graber stated:
== There is no evidence that either speech can effect tooth position or abnormal tooth positon can
effect speech. – normal speech can occur in the presence of sever malocclusion, on the other hand
sever speech defect can take place in the presence of ideal occlusion
== there is certain circumstances in which abnormal muscle activity can effect tooth position and
speech, for example, endogenous tongue thrust ----- anterior open bite and lisping of speech. In
other circumstances the tooth position can affect speech, for example, cleft palate with severely
distorted dental arch but this is not certain because there is also articulatory speech defect

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Dr. Mohammed Alruby
Stages of development of speech:
Stage Age Articulation
I 0 -8 weeks Reflexive crying and negative
sounds
II 8 -20 weeks Cooing and laugher
III 16 – 30 weeks Vocal play
IV 25 – 50 weeks Reduplicated babbling:
consonant vowel syllables
V 50+ weeks Non- reduplicating babbling
VI Around 1 year First words
Examination of eye:
Eye is important because it is commonly affected by disease than any other organ
- Ptosis: dropping of the eyelids, in ability to open the eye completely due to dysfunction of
third cranial nerve
- Bell’s palsy: in ability to close the lids with excessive lacrimation
Associated with atrophy of facial musculatures by prolonged paralysis
- Exophthalmos: protrusion of the eye ball from its socket and is characteristic finding of
gravis disease (hyperthyroidism)
- Blue sclera: common in osteogensis imperfecta
- Interstitial keratitis: associated with congenital syphilis and vit D deficiency
Esthetic –pleasing of the patient:
= Need consultation to detect it. It is difficult to detect whether it is pleasing or not because esthetic
is variable in its means and differ from one person to another
= pleasing of esthetic depend on the opinion of patient and doctor and depend on the coincident
of facial proportions to each other either in vertical or horizontal direction, presence of symmetry
or not and presence of defective area of growth or not, etc
Intra-oral examination:
Gingiva:
Should be checked for the following:
- Color
- Contour
- Texture type: thick, fibrous, thin, fragile
- Height of the gingiva: gingival shape refers the curvature of the gingiva
a- Lateral incisor: ----- half oval or circle
b- Central and canine: ----- more elliptical
c- Gingival zenith: the most apical of the gingival tissue should be located distal to the long
axis of the central incisors and canine while it should coincident to the long axis of
central
- Muco-gingival lesions
In children the most common form of gingivitis is caused by plaque accumulation and can be
resolved by improving the oral hygiene
In other cases of gingivitis particularly in adult patients, periodontal treatment must be carried
out (scaling, muco-gingival surgery, curettage) prior orthodontic treatment
Gingivitis and poor oral hygiene are contraindicated for orthodontic treatment
In case of mouth breathing: ------- generalized hypertrophied gingivitis

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Dr. Mohammed Alruby
In case of hyper active mentalis muscle: ------- gingivitis for lower anterior segment
Palate:
The palate should be examined for the following finding:
- Variation in palatal depth occurs in association with facial form as in dolichol-facial
patients have deep palate, brachyfacial patient have broad and shallow palate
- A traumatic deep bite can lead to mucosal ulceration and indentation in anterior palatal
region
- Pathologic palatal swelling
- Scar tissue following palatal surgery
Lip and check frenum:
= Heavy labial frenum may be the cause of central diastema, frenectomy is indicated when the
attachment is inserted deeply with fiber extension into the inter dental papilla. The x-ray film shows
a bony fissure between the roots of upper central incisors as the sign of an intraosseous fiber
course
= Frenectomy should be done after eruption of upper central incisors. The condition of true
diastema is existing by interdental running fibers and the excision has to be dissect out not only
the soft tissue but also the interosseous fibers
= The mandibular labial frenum is less often associated with median diastema. It frequently has
abroad insertion which exerted a strong pull on the free and attached gingiva, this can lead to
gingival recession in the lower anterior region already in the mixed dentition
= The presence of buccal attachments must be examined carefully especially in adolescence and
adults
Cheek dysfunction:
In case of cheek sucking or cheek biting the soft tissue are interposed between the occlusal surfaces
of the teeth, which promotes the formation of lateral open bites
Increased lateral pressure by cheek musculatures imped the transverse development of the jaws,
this type is common in buccal non occlusion (cross bites)
Tonsillar pillar and throat:
Tonsils should be examined for size and the degree of inflammation present, inflamed tonsils due
to various causes may lead to alter the positon of the tongue in forward direction and lower jaw
posture in downward direction. This altered position lead to certain special characteristics of
malocclusion
Dental arches and dentitions:
Open mouth examination:
= evaluate the number, size, shape, and position of individual teeth (Microdontia, Macrodontia,
absence of teeth), also evaluate spacing, crowding, and any other anomalies
= malposed teeth should be evaluated according to the developmental status not by their ultimate
position in the line of the arch as: maxillary canines usually erupt high in the alveolar process
mesially and labially such a position is normally only if there is adequate space in the arch for the
tooth
= evaluate the sequence of eruption of upper and lower teeth is normal or not. Sequence of eruption
should follow: U 6-1-2-4-5-3-7 and L 6-1-2-3-4-5-7
= Symmetry of the shape of the arch should be examined individually, there are three types of arch
form that coincident to the shape of the face:

15. 15
Dr. Mohammed Alruby
- Normal or oval shape
- Narrow or V shape
- Square or U shape
= evaluate the amount of curve of spee in anterior posterior direction, ideally the curve of spee
should be flat or zero millimeter, clinically 1-1.5mm of curvature is considered normal, but the
vertical distance is more than 2mm it is exaggerated curve of spee, increased curve of spee is seen
in true deep bite cases ( measured by put a flat instrument on or tongue blade touch the mandibular
last molar cusp tip and incisal edge of anterior teeth and measure the vertical distances at most
deepest region at premolar area)
Closed mouth examination:
= evaluate the midline of the upper arch coincide to the facial midline or nor and evaluate the
amount of deviation if present
= evaluate the lower arch midline is coinciding to the upper midline or not and evaluate the amount
of deviation
= evaluate the apical base:
The teeth should be brought in centric occlusion and exam the upper and lower relations in all
dimensions as:
a- Sagittal plane:
Examine the inter-maxillary relationship either class I or II or III and also examine the overjet
which is the horizontal space between upper and lower incisors that is usually 2-3mm. any reversed
overjet should be noted
b- Vertical plane:
Examine the vertical maxilla-mandibular relationship by measuring the amount of vertical overlap
between the upper and lower incisors which that 2 -3mm is considered normally. It is always better
to measure the overbite as percentage of overlap which is 40% and over than 40% is considered
as deep bite
If there is no vertical overlap between upper and lower or absence of overbite is called Openbite
c- Transverse plane:
Should be examined for lateral shift and posterior crossbites, examine buccal or lingual crossbites
either upper or lower
Tongue examination:
= Examine the tongue shape, color, and configuration are assessed at first clinical examination,
the tongue may be long, small, or broad, these finding not allow conclusion to be drawn about
relative tongue size. Long, broad tongue does not mean that this case is Macroglossia
= Change in tongue position and mobility are often associated with an abnormal lingual frenum.
= Rough assessment of tongue size in relation to the size of oral cavity can be made by studying a
lateral cephalometric radiograph
== the clinical pictures of long tongue that can reach the tip of nose, this single finding does not
permit the diagnosis of Macroglossia
Analysis of tongue musculatures:
= it is very difficult to analysis the tongue function because of the tongue and lips functions are
very correlated and coordinated, so that when someone retract the lips to observe tongue the
normal tongue activity is inhibited and the only observed activity at that moment is the reflex
accommodation of the tongue to the lip stretching. SO the normal tongue function is only expected
from abnormal function of the lips and facial muscles
1- Tongue position during rest:

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Dr. Mohammed Alruby
Observe the tongue when mandible in physiologic rest, this is achieved clinically by careful
examination of the tongue – lip relationship while the patient is seated in upright position
The tip of the tongue normally rest in the lingual fossa or at cervices of mandibular incisors
Dorsum of tongue is lightly touch the palate
Lateral border of the tongue touches the lingual cusps of molars and premolars
2- Abnormal position during rest:
Tip of tongue lies above mandibular incisors ------- Openbite
Tip retracted behind the lower incisors (cocked tongue) ---- does not cause malocclusion
Tongue in low position and the dorsum do not touch the palate ------ collapsed arches
3- Tongue position during function:
a- Mastication:
Recognition of tongue activity during mastication is very difficult procedures except for most
obvious abnormalities
Activity during mastication is combined with its activity during swallowing
b- Swallowing:
The patient should be in an upright position
Try to observe the unconscious swallowing then place a small amount of water beneath the tongue
and ask the patient to swallow and notice the mandibular movements
In normal swallowing:
- the mandible raises as the teeth brought together during swallowing
- Lips touch lightly without active contraction
- Facial muscles do not contract in normal mature swallowing
- Temporal muscle contract to close the mandible
In abnormal swallowing:
- Teeth apart swallowing
- Strong contraction of mentalis and facial muscles
- No contraction of temporal muscles
The unconscious swallowing can be examined as follow:
Place more amount of water below the tongue tip and ask the patient to swallow more than one
time with your hand placed over temporal muscle usually the last swallow is unconscious type
Other methods of tongue examination:
- Electo-myographic examination
- Cephalometric analysis of tongue
- Recording the tongue pressure exerted intraorally (palatography) a thin uniform layer of
contrasting impression material is applied to the patient tongue with spatula, once the
consonant has been pronounced or the tongue movement carried out as in swallowing the
palatogram can be documented
N: B:
Surgical correction of sever skeletal dysplasia is often successful and relapse may be occurring
due to failure of the tongue to adapt to the altered skeletal morphology

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Dr. Mohammed Alruby
Functional analysis
Orthodontic diagnosis should not restrict to static evaluation of the teeth and their supporting
structure but also include examination of the functional units of the dynamic Stomatognathic
system
Functional analysis includes the followings:
Assessment of postural rest position:
Postural rest position is the position of mandible at which muscles that close and open the mandible
are in state of minimal contraction and balanced dynamically to maintain the posture of the
mandible
This space between upper and lower arch measured 3mm at canine region (freeway space)
The rest position is determined with the patient in upright relaxed seated position with the back
unsupported. The head is oriented by making the patient look straight ahead and positioned with
FH is parallel to the floor
Methods of determination of rest position:
1- Phonetic method:
The patient is asked to repeat some consonants like M or C or repeat a ward like Mississippi, the
mandible usually return to the postural rest position 1-2 seconds after repeating these words, the
patient is told not to change the lips, tongue, and jaw position after phonation exercise. Now the
patient lips are a parted to study the inter-occlusal distance
2- Command method:
The patient is commanded to perform selection function like swallowing after which the mandible
spontaneously returns to the rest position
3- Non- command method:
This is usually carried out by talking about topics not related to patient while carefully observing
the patient while he/she speaks or swallows
4- Combined method:
A combination of above methods is most suitable for functional analysis in children. The patient is
observed during swallowing and speaking, the tapping test can be carried out to relax the
musculature and the patient is then distracted similarly to when using the non-command method
Tapping test:
The clinician holds the chin by thumb and index finger and then opens and close the mandible
passively with constantly increasing frequency until the musculature is relaxed. This can be
confirmed by palpating the submental muscles. The rest position can then determine by the above
methods
Registration of rest position:
1- Direct intra-oral procedure: the freeway space can be measured directly in the patient
mouth in the canine or the incisor region with the help of Vernier caliper
2- Direct extra-oral procedure: two reference points are made on the skin with plaster, one on
the nose and the other on the chin in midsagittal plane. The patient is asked to occlude the
teeth and the distance between the two points is measured. The patient is instructed to take
a swallow and remain in rest position, now again the distance between these two points is
measured. The difference between the two reading is the freeway space
3- Indirect extra-oral method by using two cephalometric radiograph either lateral or frontal,
one in habitual occlusion and the other in rets position

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Dr. Mohammed Alruby
4- Indirect extra-oral method by using the mandibular kinesiograph (T E N S) according to
Jankelson 1984 to detect the true freeway space. This method allows the mandibular rest
position to be registered in three dimensional:
- A permanent magnet which is fixed with rapid seating acrylic to the lower anterior teeth
- A sensor system of six magnetometers.
Every movement of the mandible and attached magnets out of centric occlusion, which alter
the strength of the magnetic field, these changes are recorded by sensors processed in
Kinesiograph
TENS: transcutaneous electrical nerve stimulation: that made deconditioning of the muscles by
eliminating the proprioceptive sensory input from the existing malocclusion
TENS, is applied to the motor division of the 5th
cranial nerve
Mode of action of TENS:
a- Reduce the muscle spindle feed back
b- Block the 5th
cranial motor nerve fibers
c- Inhibition of upper motor neuron on the motor nucleus of trigeminal nerve deactivation
of the gamma motor neuron drive to the muscle spindle
==Results of TENS: reduce the elevator muscle stretch reflex and thus reducing the
resting EMG activity of masticatory muscles
==True FWS is larger than adaptive FWS 1.8: 2.9 respectively according to Konchack
There is a significant correlation between adaptive freeway space and Sn-Mp angle also
ALFH
==Normal FWS; 2 – 4mm
== <2mm: open bite
== >4mm: deep bite
Path of mandibular closure from resting position to centric occlusion:
= the patient usual occlusal position may be not the same as ideal occlusal position due to the
presence of occlusal interference or guiding teeth. note that, the path of mandibular closure from
rest to centric occlusion determine any shifting or avoidance reflexes
= shifting due to prematurity may be seen at any age but most commonly in primary and mixed
dentition, shifting in path of closure in permanent dentition is more likely due to over eruption or
un-contoured restoration
The following procedure clinically should be done:
a- With the patient sitting in an upright position, ask him to open and close the jaw slowly, pay
particular attention to the chin and mandibular incisors during the last stage of closure,
any shifting in the path of closure or any change in the overjet as the teeth come into
occlusion should be detected
= shifting indicate cuspal interferences while change in the overjet value indicate guiding
effect of maxillary incisors as in class II div 2 malocclusion
= the use of dots marked on the midline of the face is useful in diagnosing lateral shift (in
case of shift the chin dot will be lateral to the other points)
= the use of wax bite and articulating paper is helpful in determining cuspal interferences
b- Ensure that the upper and lower midline are coincident during closure
c- Guide the mandible into the most retruded position and note any cuspal interference
between the retruded position and occlusal position (usually lies in the area of primary
cuspids during mixed dentition)
d- From the most retruded position, ask the patient to move the mandible laterally and note
any occlusal interferences

19. 19
Dr. Mohammed Alruby
e- Observe carefully the jaw movements during unconscious swallow and during various
functions as mastication, respiration, speech
Examination of Stomatognathic system:
Stomatognathic system is composed of passive components as: TMJ and teeth whereas muscles of
mastication are active components
1- Examination of teeth:
The dentition should be observed for any pathologic condition from trauma, any enamel fractures,
tooth migration, periodontal breakdown and mobility should be noted
If occlusal trauma is suspected so fremitus test is indicated as: place the tip of index fingernail on
maxillary central incisors and the patient is asked to tap the teeth in centric occlusion. In normal
individuals no vibration or fremitus is felt because the anterior teeth make no contact in centric
occlusion. In case of occlusal trauma, fremitus test is positive and vibration occurs when the patient
taps the teeth
2- Examination of TMJ:
The functional examination should routinely include inspection, auscultation and palpation of TMJ
and musculatures associated with the mandibular movements
- Auscultation:
sounds made by temporomandibular joints can be evaluated with a stethoscope, even slight
abnormal sounds must be recorded, also the time of clicking during opening or closing
should be noted
Clicking: characteristic sounds during movement of the condyle, may not painful process
Initial clicking: retruded mandible in relation to disc
Intermediate clicking: condylar surface and disc slide over one another
Terminal clicking: condyle far anteriorly
Reciprocal clicking: during opening and closing and express in-coordination between
displacement of condyle and disc
Crepitus: continuous noise on TMJ during opening of the mouth due to tear in the posterior
ligament of the disc, so the disc takes anterior posterior position to the condyle so the
condyle make pressure on the posterior part of the disc until complete attrition of it
This sound due to crepting of the condyle to the disc
The patient has history of limitation of the mouth opening from long time
The crepitus is painful process
- Lateral palpation of TMJ:
Exert slight pressure on the condyloid process with the index fingers, palpate both sides
simultaneously to:
= register any tenderness to palpation of the joints
= any irregularities in condylar movement during opening and closing maneuver
= assess the coordination of the action between the left and right condylar heads
- Posterior palpation of TMJ:
Position of the little finger in the external auditory meatus and palpate the posterior surface
of the condyle during opening and closing movement of the mandible
Palpation should be carried out in such a way that the condyle displaces the little finger
when closing in full occlusion
- Palpation of muscles of mastication
- Recording the maximum inter-incisal distance:

20. 20
Dr. Mohammed Alruby
On maximum jaw opening the distance between the incisal edges of upper and lower central
incisors is measured by Boley gauge. The extent of maximum jaw opening between the
incisal edges is usually 40-45mm, in case of TMJ dysfunction, hypermobility is often
registered in the initial stages and limitation in the latter stage
- Range of border movements:
From centric occlusion ask the patient to protrude, retrude and laterally move the mandible
and note any limitation in this movements which may indicate TMJ disorders
- Visual inspection:
The joint should be carried out for any asymmetry, signs of trauma, gross abnormalities, or
hypertrophic condition of the muscles of mastication particularly the masseter which is
clearly visible
- Forward path of closure:
Usually mandible slides forward 1 -2mm during normal closure but in case of pseudo class
III or patient with edge to edge bite, the mandible is guided to a more forward position then
in centric occlusion, and the reverse is happening in case of class II division 2.
- Ascertain any abnormal movement of jaws during speech
- Observe the jaw movements during swallowing:
Place the fingers lightly over both joints and feel the condylar –meniscus relationship
during opening and closing
Note the amount of maximal opening
Palpate individually the temporal, lateral pterygoid, masseters, and infra-mandibular
muscles
Palpate the joints intra-orally, noting inter-capsular pain and any loss of intimacy between
meniscus and condyle. Four pain scale are used:
0: pressure only, no pain
1: pain on pressure only
2: chronic pain, pain to palpation, the pain increased by pressure
3: chronic pain, the patient grasp dentist’s hand
Evaluation of the relationship between rest position and habitual occlusion:
The movement of the mandible from rest position to full articulation is analyzed three
dimensionally: sagittal, vertical, and horizontal planes
The closing movement of mandible can be divided into two phases:
Free phase: mandibular path from postural rest to the initial or premature contact position
Articular phase: mandibular path from initial contact to centric or habitual occlusion
The following movements of the mandible from the rest position to habitual occlusion must be
differentiated for orthodontic diagnosis:
- Pure rotational movement (hinge movement)
- Rotational movement with an anterior sliding component
- Rotational movement with a posterior sliding component.
a- Evaluation in sagittal plane:
When evaluating the relationship of the rest position to the habitual occlusion in sagittal plane the
features of class II or class III should be analyzed:
Class II malocclusion can divide into three types:
= rotational movement without a sliding component: there is no functional disturbances
(functional true class II malocclusion)

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Dr. Mohammed Alruby
= rotational movement with anterior sliding movement: starting from relatively posterior rest
position, the mandible slides forward into habitual occlusion
= rotational movement with posterior sliding movement: the mandible slides backward and is
guided into posterior occlusal position. This finding reveals a functional class II malocclusion and
not a true class II malrelatioship
Class III malocclusion:
The closing path of the mandible from rest position can be divided into three types:
= rotational movement without sliding action: the anatomic / morphologic relationship is
corresponding to the functional relationship, (nonfunctional, true class III, unfavorable prognosis)
= rotational movement with anterior sliding action: during the articular phase, the mandible shifts
forward into Prognathic bite, (functional no-skeletal, pseudo class III, favorable prognosis)
= rotational movement with posterior sliding action: in case with pronounced mandibular
prognathism, the mandible may slide posteriorly into the position of maximum intercuspation, this
masks the true sagittal dysplasia
b- Evaluation in vertical plane:
One should differentiate between two types:
= true deep overbite with large freeway space: is caused be infra-occlusion of posterior teeth, the
prognosis is favorable for successful therapy with functional method, as the inter-occlusal
clearance is large so sufficient freeway space will remain after extrusion of the molars
= pseudo deep bite has small freeway space: the deep overbite is caused by over-eruption of
incisors, the prognosis for elevating the bite using functional appliances is unfavorable.
If the freeway space is small the extrusion of molars may adversely affect the rest position and may
create TMJ problems or cause relapse of the deep overbite
c- Evaluation in transverse plane:
The position of the midline of the mandible is observed while the jaw is moved from the postural
rest to habitual occlusion
Depending on the functional analysis, two types of skeletal mandibular deviation can be
differentiated into:
= laterognathy: the center of the mandible not aligned with the facial midline in rest and occlusion
= laterocclusion: the skeletal midline shift of the mandible can be observed only in occlusal
position. In postural rest both midlines are well aligned
d- Examination of muscles:
= Palpate the masticatory and cervical muscles and search for the areas of tenderness or sustained
contraction. Begin with sternocleidomastoid, trapezius and posterior cervical muscles
= Palpate the masseter muscle at its attachment to the zygomatic arch and angle of the mandible
= The temporalis both in temporal fossa and intra-orally along the ascending ramus of the
mandible and the medial pterygoid bi-manually, placing one finger externally at the medial aspect
of the angle of the mandible and the other finger orally in the lingual vestibule in the retro-molar
region
= The lateral pterygoid muscle is accessible to the examining finger intra-orally posterior to
maxillary tuberosity

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Dr. Mohammed Alruby
Examination of neuromuscular orofacial dysfunctions:
Include evaluation of: posture, swallowing and respiration
Posture:
Generally bodily posture and head posture are often diagnostic significance
Note a symmetry in shoulder position, spinal curvature and the natural placement of the head a
top the vertebral column
Solow and Tallgren have shown a relationship between facial proportion and head posture on
population basis in adults and similar finding have been demonstrated in children: a head up and
chin up posture is more associated with disproportionate anterior facial height
With posturing the head down and chin down is more associated with shorter anterior facial height
Respiration:
The nasal and pharyngeal air way may be assessed by the otolaryngologist using
nosopharyngoscopy and is a consideration prior to the administration of endotracheal anesthesia
The presence of mouth breathing should be diagnosed. A number of simple tests exist that can be
employed to diagnose the mode of breathing:
- Mirror or fog test: used double sided mirror that held between the nose and mouth and
investigate the fogging is at nose side or mouth side
- Cotton or butter-flay method:
- Water holding test: hold the water inside moth for a period of time, this test is used to
assess whether that patient is obligatory mouth breather or not
- Observation: study the patient’s breathing unobserved as the nasal breather usually their
lip is lightly touching during rest and relaxed breathing
Swallowing:
The patient should be in an upright position
Try to observe the unconscious swallowing then place a small amount of water beneath the tongue
and ask the patient to swallow and notice the mandibular movements
In normal swallowing:
- the mandible raises as the teeth brought together during swallowing
- Lips touch lightly without active contraction
- Facial muscles do not contract in normal mature swallowing
- Temporal muscle contract to close the mandible
In abnormal swallowing:
- Teeth apart swallowing
- Strong contraction of mentalis and facial muscles
- No contraction of temporal muscles
Differential diagnosis:
Careful differentiation should be made to among different type of swallowing
Normal infant swallowing:
= the tongue lies between the gum pads.
= the mandible stabilized by the contraction of facial muscles.
= the buccinators muscles are strongly acting.
= this type is present in the neonate and gradually disappears with the eruption of the buccal
teeth in primary dentition.
= the cessation of the infant swallow and appearance of mature swallow is not on and off
phenomena but there is a transitional period or transitional swallowing.

23. 23
Dr. Mohammed Alruby
Normal mature swallowing:
= teeth present in centric occlusion.
= muscles of facial expression are in rest.
= contraction of the elevator muscles to bring the teeth into occlusion.
1- Simple tongue thrust swallowing:
Contraction of the lips, mentalis, mandibular elevators muscles.
The teeth are in occlusion (teeth together swallowing) but the tongue is thrust to give an
anterior seal for the open bite.
The open bite is well circumscribed and has definite beginning and ending, this open bite
is due to thumb sucking.
The incidence of simple tongue thrust swallow is diminishing with increasing the age.
Treatment: steps in treatment are as follow:
= Acquaint the patient with abnormal swallow by placing the index finger on the tip of
the tongue and then at the junction of the hard and soft palate and saying to the patient
(most people swallow with this part of tongue on this part of palate. Now put your tip up
here, close your lips, close your teeth and swallow while holding the tongue in this
position), the patient should be instructed to practice correct swallowing at least 40 times
/ day.
= when the new swallowing pattern has been learned on the conscious level, it is
necessary to reinforce it subconsciously. At the second appointment the patient should be
able swallow correctly at will. However, abnormal unconscious swallow will be seen flat
sugarless fruit drops on the tip of tongue and to hold the fruit drops against the palate in
the correct position until the candy has dissolved completely. At first the child will be able
to hold the fruit drop in place for only a few seconds, but gradually the periods will
lengthen.
= a well-adapted soldered lingual arch wire having short, sharp, strategically placed
spurs can be inserted. Protectively, the tongue is withdrawn from the abnormal position
and placed properly during swallowing. Do not place such an appliance as the first step
in therapy, because it is much traumatic to the patient.
2- Complex tongue thrust swallowing:
= there is a contraction of the lips, mentalis, facial muscles and lack of contraction of the
mandibular elevators.
= the patient is suffering from naso-respiratory distress, the open bite of this type is more
diffused than simple and difficult to define.
= when examined the dental casts there is poor occlusal fit and instability of inter-
cuspation because the inter-cuspal position is not repeatedly reinforce during swallowing.
This type does not diminish by age.
= it is possible to have a complex tongue thrust but no open bite if the tongue is positioned
even a top of all teeth during swallow.
= the patient attention must have brought to the problem and the difficult prognosis
explained carefully at the start of treatment, the patient should know at the start of
treatment that much responsibility for successful therapy lies with himself or herself.
Treatment:
= it is advisable to treat the occlusion first, when the orthodontic treatment is in its
retentive stage, careful occlusal adjustment is completed. The muscle training program
the begun that similar to that for a simple tongue thrust with minor modification:

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Dr. Mohammed Alruby
 When teaching patient to swallow properly, great emphasis must be placed on keeping the
teeth together and the first step of treatment is prolonged.
 It is always necessary to use the third step of treatment, for considerable time to reinforce
the newly learned reflexes. A maxillary lingual arch with sharp short spurs may be used as a
retainer, even after the patient has mastered the newly swallow and the abnormal action of
the lip and mentalis are seen no longer.
3- Retained infantile swallowing:
= persistence of infant type of swallow after present of permanent teeth, this patient demonstrates
very strong contraction of lips and facial muscles.
= tongue thrust strongly between the teeth anterior and posterior.
= patient has inexpressive face, and facial muscles used for stabilizing the mandible during
swallow.
= patient has high difficulties in mastication, the patient occludes only on one molar in each
quadrant.
= patient restrict to the soft diet.
= this type occurs due to defect on the transitional phase of swallowing from infant to adult
swallow.
= the prognosis for correction of this type of swallow is poor. Fortunately, the true retained
infantile swallow is rare.
N: B: the following clinical observation regarding improper swallowing habits is made by
Atkinson:
== Hold your hand on the chin of the patient while the patient in the act swallowing, if the jaw is
opened during the act of swallowing, the supra-hyoid muscle will pull the body of the mandible
downward, bending it just anterior to the angle of the jaw.
== The abnormal swallowing habit should be detected and corrected early to facilitate normal
development of the palate and dentition. In its early detection, it should correct immediately with
mechanical appliance to limit the tongue into its proper position.