Dr. Ahmed AL-Mayali B.D.S M.Sc. Ortho.

Kufa university Dr. Ahmed AL-Mayali

Dentistry College
Orthodontic department B.D.S M.Sc. Ortho.
5th stage
Lec: 2

Clinical Examination
I-GENERAL EXAMINATION
General examination should begin as soon as the patient first comes to the
clinic. The orthodontist should observe the gait & posture of the patient.
Height and weight are recorded to assess for the physical growth and
development of the patient.

Body Build

The body build can be classified into:

A. Ectomorphic: Tall and thin physique
B. Mesomorphic: Average physique
C. Endomorphic: Short and obese physique.

II-Cephalic and Facial Examination

The shape of the head can be evaluated as follow:

A• Mesocephalic ………………….. (Average)
B• Brachycephalic ………………... (Short, broad skull)
C• Dolicocephalic…………………. (Long, narrow skull)

Assessment of Facial Symmetry

A certain degree of asymmetry between the right and left sides of the face
is seen in most individuals. The face should be examined in the transverse
and vertical planes to determine a greater degree of asymmetry. Gross
facial asymmetries may be seen in patients with:
A. Hemifacial atrophy or hypertrophy.
B. Congenital defects.
C. Unilateral condylar hyperplasia
D. Unilateral Ankylosis (Figure 1).

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 Dr. Ahmed AL-Mayali B.D.S M.Sc. Ortho.

Facial Profile
The profile is examined from the side by making the patient view at a
distant object, with the FH plane parallel to the floor. Clinically, the
profile can be obtained by joining two reference lines:
a. Line joining Glabella and soft tissue Subnasale
b. Line joining Subnasale and soft tissue pogonion.
Three types of profiles are seen (Figure 2 A, B&C):

Fig. 1 A-Facial asymmetry B-The cant of the occlusal plane

A. Straightl or Orthognathic profile: The two lines form an straight line.

B. Convex profile: The two lines form an acute angle with the concavity
facing the tissues. This type of profile is seen in Class II div 1 patients
due to either a protruded maxilla or a retruded mandible.

C. Concave profile: The two lines form an obtuse angle with the
convexity facing the tissues. This type of profile is seen in Class III
patients due to either a protruded mandible or a retruded maxilla.

Fig. 2 A Straight facial profile B convex facial profile C concave facial profile

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 Dr. Ahmed AL-Mayali B.D.S M.Sc. Ortho.

ASSESSMENT OF ANTEROPOSTERIOR JAW RELATIONSHIP

A fair picture of the sagittal skeletal relationship can be obtained
clinically by placing the index and middle fingers at the approximate A
and B points after lip retraction, ideally the maxilla is 2 to 3 mm anterior
to the mandible in centric occlusion. In skeletal Class II cases, the index
finger is much ahead of the middle finger where as in Class III the middle
finger is ahead of the index finger.

ASSESSMENT OF VERTICAL SKELETAL RELATIONSHIP

A normal vertical relationship is one where the distance between the
Glabella and Subnasale is equal to the distance from the Subnasale to
the Menton of the chin.

-Reduced lower facial height is associated with deep bite.

-Increased lower facial height is seen in anterior open bite.

III-Examination of the Soft Tissues

A-Extraoral
1-Forehead
The esthetic prognosis of an orthodontic case is determined by its profile,
which in turn is influenced by the shape of the forehead and the nose. For
a face to be harmonious, the height of the forehead (distance from
hairline to glabella) should be as long as the mid-third (glabella-to-
subnasale) and the lower third (subnasale-to-menton), i.e. each of these
is one-third the total face height (Figure 3).

Fig.3 facial height

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 Dr. Ahmed AL-Mayali B.D.S M.Sc. Ortho.

2-Nose Size
Shape and position of the nose determines the esthetic appearance of the
face and is therefore important in the prognosis of a case, the nose width
should be equal to the inter canthal with of the eyes (Figure 4).

Fig. 4 Nose width

3-Lips
Lip length, width and curvature should be assessed. In a balanced face,
the length of the upper lip measures one-third, the lower lip and chin two
thirds of the lower face height (Figure 3). The upper incisal edge
exposure with the upper lip at rest should be normally 2 mm.

Lips can be classified into:

I. Competent lips: Slight contact of lips when is relaxed.
II. Incompetent lips: Anatomically short lips, which do not contact when
musculature is relaxed. Lip seal is achieved only by active contraction of
the orbicularis oris and mentalis muscles.
III. Potentially competent lips: Lip seal is prevented due to the
protruding maxillary incisors despite normally developed lips (Figure 5).
IV. Everted lips: These are hypertrophied lips.

Fig.5 Potentially competent lips

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 Dr. Ahmed AL-Mayali B.D.S M.Sc. Ortho.

4-NASOLABIAL ANGLE
This is the angle formed between a tangent to the lower border of the
nose and a line joining the subnasale with the tip of the upper lip
(Figure 6). Normal value is 110 degrees. In patients with maxillary
prognathisim and proclined upper anterior teeth this angle reduces
whereas it becomes more obtuse in cases with a retrognathic maxilla or
retroclined maxillary anteriors.

Fig.6 Nasolabial angle

5-Chin
The configuration of the chin is determined not only by the bone
structure, but also by the thickness and tone of the mentalis muscle.
Mentalis activity:
A normal mentalis muscle becomes hyperactive in certain malocclusions
like Class II div 1 cases.
Mentolabial sulcus :
It is the concavity present below the lower lip. Deep sulcus is seen in
Class II cases whereas a shallow sulcus is seen usually in bimaxillary
protrusion.

Chin height:
The distance from the Mentolabial sulcus to menton, over development
of chin height will alters the lower lip position and interferes with lip
closure.

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 Dr. Ahmed AL-Mayali B.D.S M.Sc. Ortho.

Chin position and prominence:

Prominent chin is usually associated with Class III malocclusions
whereas recessive chin is seen in Class II malocclusion.

Fig. 7 Fig. 8 Fig. 9

Clinical case 1 (Figure 7):

The long face due to excessive downward growth of the maxilla, will
results in a disproportionately long lower third of the face.
FIGURE 6-12

Clinical case 2 (Figure 8):

A short upper lip, which can result in excessive gingival display in a
patient with normal facial thirds

Clinical case 3 (Figure 9)

For this girl with Class II malocclusion, retraction of the maxillary
incisors would damage facial appearance by making the relatively large
nose look even bigger. The size of the nose must be considered when the
position of the incisors and amount of lip support are evaluated.

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