CLINICAL EXAMINATION

LECTURER DR. MĂDĂLINA MOLDOVAN

 MAXILLO-FACIAL ANATOMY
The maxillofacial area presents a series of anatomical peculiarities
• The prominence of certain features such as earlobes, nose, zygomatic bone, upper incisors,
and chin being more frequently involved in traumatic pathology
• The cavities of the facial structure, including the orbits, nasal cavities, paranasal sinuses,
and oral cavity, should be assessed during the local clinical examination
• The mandible - being the only mobile bone in the facial structure, exhibits a wide variety of
traumatic lesions, including dislocations and fractures.
• Important éléments of the soft tissues in the cervicofacial region including eyeballs, eye
muscles, facial nerve, trigeminal nerve, salivary glands, and their excretory ducts (especially
the parotid gland), as well as significant blood vessels (EJV, IJV, ECA, ICA, facial artery
and vein, temporal artery, etc.).
• Dentition, periodontium, alveolar bone, and oral mucosa are also crucial aspects

• Maxillofacial surgery encompasses trauma, oncology, plastic and reconstructive

procedures, aesthetics, orthognathic surgery, and dentistry.
 MEDICAL HISTORY

• Precedes the clinical examination:

• identification data, gender, age, living and working conditions,
vices, relevant personal and family history, allergies, past or
current treatments
• Objectives
• General symptoms (e.g., fatigue, weight loss, fever, anorexia)
• Functional symptoms (e.g., pain on a scale of 1 to 10).
• Circumstances/time of the incident (in traumatic pathology).
• Evolutionary characteristics of chronic pathology (morning,
evening, postprandial symptoms, etc.).
• The primary reason for the presentation
CLINICAL EXAMINATION:

• Thorough and systematic:

• An essential step in establishing the diagnosis.
• Can be challenging in certain circumstances.
• Nature of the trauma.
• Significant swelling.
• Associated functional disturbances, of local or
general etiology (e.g., limited mouth opening due to
trismus, ankylosis, scleroderma; central or
peripheral neuromuscular involvement)
 CLINICAL EXAMINATION

• Objective - screening for pathological elements

• Changes in volume and contour of a region.
• Normal color changes: hyperpigmentation / depigmentation.
• Changes in consistency.
• Pathological mobility of teeth, mandible, tongue, etc.
• Functional changes such as hyposalivation, diplopia,
hypoesthesia, etc.
• Changes in temperature: inflammation / ischemia.
• Pain - spontaneous or induced.
 CLINICAL EXAMINATION

• Bilateral and comparative.

• Initially external, then intraoral.
• Guides the indications for additional examinations.
• In medico-legal situations, especially in trauma cases,
all detected pathological elements must be
meticulously documented.
• Photographic documentation of the case, with the
patient's consent (frontal, left profile, right profile, 3/4
views from left and right, intraoral photos).
CLINICAL EXAMINATION

• Inspection

• Palpation

• Percussion

• Auscultation
CLINICAL EXAMINATION-
INSPECTION
 CLINICAL EXAMINATION-
INSPECTION
• Face - the area
between the
hairline and the
horizontal plane
passing through
the base of the
mandible
 CLINICAL EXAMINATION-
INSPECTION

• Cervical region - from the base of the mandible to

the biclavicular plane and the jugular notch.
 CLINICAL EXAMINATION-
INSPECTION
• The general shape and symmetry of the face.
• Symmetry of facial landmarks (nose, ears, lips,
cheekbones, chin).
 CLINICAL EXAMINATION-
INSPECTION
• Balance between the relative projection of different facial
levels (upper 1/3, middle 1/3, lower 1/3) in both the frontal and
sagittal planes (e.g., reduced/enlarged lower level;
retro/prognathism of the maxilla or mandible).
CLINICAL EXAMINATION-
INSPECTION
• Parallelism of the lines between the pupils and the
corners of the mouth in both the frontal and
sagittal planes.
CLINICAL EXAMINATION -
INSPECTION
• Anomalies in the projection of the eyeball
(exophthalmos / enophthalmos - quantified in
millimeters using an exophthalmometer).
• Interpupillary distance (increase = hypertelorism)
and intercanthal distance (increase = telecanthus).
CLINICAL EXAMINATION -
INSPECTION
• Skin lesions: fistulas, ulcers...
CLINICAL EXAMINATION -
INSPECTION
• Postural anomaly in the cervicofacial region
(for example, torticollis due to SCM
contracture).
 CLINICAL EXAMINATION – STATIC
INSPECTION
• Appearance of eyelashes,
eyebrows, mustache, and their
implantation line.
• Skin texture and color
(erythema, cyanosis, angioma...).
• Presence of edema and swelling -
location, significance.
 CLINICAL EXAMINATION – STATIC
INSPECTION

• The presence of wounds -

appearance, location, size, depth,
involved anatomical elements.
• Presence of bruises (superficial) or
hematomas (deep) - location, size.
 CLINICAL EXAMINATION – STATIC
INSPECTION
• The presence of secretions externalized
from the natural orifices of the face.
• Note their character:

• Serous,
• Mucous,
• Purulent,
• Bloody (otorrhagia, epistaxis,
hematemesis),
• Cerebrospinal fluid (otorrhea,
rhinorrhea).
• Also, document the volume.
 CLINICAL EXAMINATION -
DYNAMIC/FUNCTIONAL INSPECTION.

• Global facial motility -

Cranial nerve VII.
• Extrinsic eye motility -
Cranial nerves III, IV, VI.
• Functionality of other cranial
nerves - Cranial nerves I, II, V,
VIII, IX, and XII - intraoral
examination.
• Masticatory function.
CLINICAL EXAMINATION -
DYNAMIC/FUNCTIONAL INSPECTION
• Global facial motility.
• Functional tests for cranial nerve VII.
• Paresis/paralysis.
• Central/peripheral.

© Malamed S.F. 2004

CLINICAL EXAMINATION - PALPATION.

• Palpation begins at a distance from the painful area

indicated by the patient.
• Palpation of bony landmarks follows the contours,
including the jawbones, nasal pyramid, orbit, and
mandible.
• Detectable changes:
• Painful area -
• Direct or indirect palpation (LeBourg maneuver).
• Abnormal mobility.
• Deformation/discontinuity.
MANŒUVRE LEBOURG
CLINICAL EXAMINATION - PALPATION

Tumorous/Deformity Lesion:
Precise description of location (topographical areas of
interest)
1. Size in centimeters.
2. Shape (regular, irregular, infiltrative).
3. Consistency (hard, soft, resistant, fluctuant).
4. Local temperature.
 CLINICAL EXAMINATION - PALPATION

5.Relationship with adjacent tissues.

6.Condition of adjacent tissues (hardened, edematous,
crepitant, accentuated vascular pattern).
7.Sensory disturbances (Vincent D'Alger).)
CLINICAL EXAMINATION - PALPATION

Temporomandibular Joint (TMJ):

• Mobility of the condyle.
• Symmetry of movements.
• Absence of cracking, joint popping, pain
(temporomandibular joint dysfunction syndrome -
TMJ syndrome)
 CLINICAL EXAMINATION - PALPATION

Sinus Points:
• Frontal Sinus
• Ethmoid Sinus
• Maxillary Sinus
 CLINICAL EXAMINATION -
PALPATION
Cervico-facial lymph node regions
 Submandibular
• Retroauricular
• Preauricular  Submental

• Parotid  Cervical Superficial Anterior to

• Buccal SCM (Sternocleidomastoid)

 Cervical Superficial Posterior to

SCM (Sternocleidomastoid)

 Deep Cervical, Jugular

 Supraclavicular
CERVICO-FACIAL LYMPH NODES
THE TECHNIQUE FOR PALPATING LYMPH NODES
THE TECHNIQUE FOR PALPATING LYMPH NODES
THE TECHNIQUE FOR PALPATING LYMPH NODES
CLINICAL EXAMINATION - PALPATION
Lymph Node Examination!!!
• Location
• Dimension
• Number
• Consistency
• Mobility
• Relationship with nearby anatomical structures
• Sensitivity
• Appearance of overlying skin
CLINICAL EXAMINATION -
PALPATION

The major salivary glands:

• Parotid, Submandibular, Sublingual
• Preauricular, Retro and Subangular mandibular
• Submandibular
• Paramedian, floor of the mouth
 CLINICAL EXAMINATION-
PALPATION
• Tumefaction, consistence, lesion, aspect of saliva
CLINICAL EXAMINATION-
AUSCULTATION
Rarely used.
• TMJ - joint noise.
• Gas crepitation in cervical-facial infections like gangrene
or cellulitis.
• Superficial vascular abnormality – murmur indicating an
arteriovenous malformation.
 ENDOORAL EXAMINATION
Minimum Requirements:

• Lighting1.
• Instruments: probe, forceps, mirror; tongue depressor, periodontal probe.
• Spray to test tooth vitality.
• Gauze for displacing soft deposits.
• Saliva and secretions may require aspiration.
• Magnifying loupe.

Technique:

• Patient in the dental chair with their head resting on the headrest.
• The physician to the right of the patient or behind the patient.
ENDOORAL EXAMINATION

Patient wearing a prosthesis:

• Examination with the prosthesis in place and
without the prosthesis.
• Examination of the prostheses (stability, integrity,
degree of wear, and microbial load).

Systematic examination of all mucosal areas and

dento-parodontal units to detect potential lesions.
 SYSTEMATIC APPROACH TO THE
INTRAORAL EXAMINATION.

• Mouth Opening

• The Buccal Vestibule

• Oral Cavity

• Dental Arches
 EXO-ORAL CLINICAL EXAMINATION

• Evaluation of mouth opening

• Mouth opening range of 40 + 5
mm
• Mouth opening on a straight path
• Propulsion movements, laterality
INTRAORAL CLINICAL
EXAMINATION
• Low mouth opening amplitude:
• Trismus
• Constriction
• TMJ Ankylosis
 INTRAORAL CLINICAL
EXAMINATION
• The oral vestibule
• Labial mucosa
• The condition of the mucosa
• Muscular tone of the lips
• Appearance of labial
frenulum
• Mucosa
• Papilla of Stensen's duct in
the upper vestibule (M2)
 CLINICAL INTRAORAL
EXAMINATION: PALATE

Oral cavity
• Mucosa of the hard palate and
soft palate
• Midline and symmetrical
position of the uvula
• Mobility of the soft palate
CLINICAL INTRAORAL EXAMINATION:
PALATE

G. Laskaris
CLINICAL INTRAORAL
EXAMINATION: PALATE
CLINICAL INTRAORAL EXAMINATION: PALATE

G. Laskaris
INTRAORAL CLINICAL
EXAMINATION

• Lingual mucosa, floor of the mouth, pelvian-lingual

sulcus, tonsillar crypts, oropharynx, glossoepiglottic
folds.
• Areas of increased oncological risk
• Direct examination / fibroendoscopy
• Bimanual palpation of the floor
INTRAORAL CLINICAL EXAMINATION: FLOOR OF
THE MOUTH
INTRAORAL CLINICAL EXAMINATION: FLOOR
OF THE MOUTH
INTRAORAL CLINICAL EXAMINATION: FLOOR
OF THE MOUTH
INTRAORAL CLINICAL EXAMINATION: THE TONGUE
INTRAORAL CLINICAL EXAMINATION: THE TONGUE

G. Laskaris
 INTRAORAL CLINICAL EXAMINATION: THE TONGUE

G. Laskaris
 INTRAORAL CLINICAL EXAMINATION: THE
TONGUE

G. Laskaris
INTRAORAL CLINICAL EXAMINATION: THE TONGUE
INTRAORAL CLINICAL EXAMINATION: THE TONGUE
 INTRAORAL CLINICAL EXAMINATION: DENTAL
ARCHES

• inspection

• palpation

• percussion
INTRAORAL CLINICAL EXAMINATION:
DENTAL ARCHES
INTRAORAL CLINICAL EXAMINATION:
DENTAL ARCHES
INTRAORAL CLINICAL EXAMINATION:
DENTAL ARCHES
INTRAORAL CLINICAL EXAMINATION:
DENTAL ARCHES

G. Laskaris
INTRAORAL CLINICAL EXAMINATION:
DENTAL ARCHES
INTRAORAL CLINICAL EXAMINATION:
DENTAL ARCHES