DIAGNOSTIC AIDS FOR FUNCTIONAL

APPLIANCES AND CONSTRUCTION BITE

DR ASHISH SURANA

POST GRADUATE STUDENT

DEPT OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS
Diagnostic aids for functional
appliances

 Cephalometric analysis.

 functional analysis.
 Cephalometric analysis

Four major areas of emphasis which

exist in Cephalometric diagnosis for
patients treated during growth period.
1. Accomplishment of growth increments and
the direction or vector of growth.

– These factors vary not only among

individuals but also within an individual.

– Longitudinal studies by Graber at al(1967)

reveal that changes often occur in the
direction of growth, particularly during the
prepubertal period.
2. Assessment of the magnitude of growth change

– This helps in determining the direction of

growth.
– Growth magnitudes can be small, average, or
large
– As functional appliance are use in Class II,
division 1 malocclusions for patients with
underdeveloped mandibles, the greater the
amount of growth, the more favorable the
therapeutic prognosis
3. Inclination and position of the upper and
lower incisors

– to evaluate the probable reciprocal

growth increments of the jaw bases.
4. Radiographic Cephalometrics ---

– To allow the identification and localization of

anomalies and abnormalities of size ,shape, and
spatial relations.
– It can differentiate between skeletal and
dentoalveolar malocclusions and provides information
on the combination of factors involved in both areas.
– This differentiation is important - Consideration of the
etiology of malocclusions is important in treatment
decisions.
 Reference points used in
functional cephalometric analysis
• 1 . N-Nasion 2. S- Sell
• 3. Se- Midpoint of entrance to the sell
• 4. Sn- Subnasale 5 .Point A,subspinale
• 6. APMax-Anteriorly derived landmark for determining
length of maxilla
• 7. Pr-Prosthion 8. Is -Incisor superius
• 9 . A p I –Apicale UI 10. Ii (or T)-Incisor inferius
• 11. Ap T-Apicale T 12. Id-Infradentale
• 13. B-Point B, 14. Pog-Pogonion
• 15. Gn-Gnathion 16. Go-Gonion 17. Me-Menton
• 18. APMan- perpendicular line from Pog to the
mandibular plane
• 19. Ar-Articular 20. cd-Condylion 21. Or-Orbitale
• 22. Pn/2-point at bisect of the Pn vertical (dropped from
Se-N at N')
• 23. FH-R asc-intersectionof Frankfort horizontal and
posterior margin of the ascending ramus
• 24. ANS-Anterior nasal spine
• 25. PNS-Posterior nasal spine
• 26. S‘-in posterior sectiona perPendicular line from Se to
the palatal Plane
• 27. APOcc-Anteriody derived point for determining
occlusal plane-middle of the incisor overbite in occlusion
• 28. PPOcc-Posterior point for determining occlusal
plane-the most distal contact between the most
posterior molars in occlusion
• 29, Ba-Basio 30. Ptm-Pterygomaxillary fissure
 CEPHALOMETRIC ANALYSIS

The various cephalometric evaluations can be

divided into three groups:

• Analysis of the facial skeleton.

• Analysis of the jaw bases.

• Analysis of the Dentoalveolar relationships.

 Analysis of the facial skeleton

Analysis of the facial skeleton involves three

angular measurements and four linear
measurements.

The three angular measurements include:

• Saddle Angle
• Articular Angle
• Gonial Angle
 The four linear measurements include:
• Anterior facial height.
• Posterior facial height.
• Anterior Cranial Base Length.
• Posterior (Lateral) Cranial Base Length.
Linear measurements are particularly important
during treatment.
Angular measurements
SADDLE ANGLE (N-S-Ar)

Parameter for assessment

of the relationship
between anterior and
posterolateral cranial
bases.

Normal value: 123± 5o

• A large saddle angle usually signifies a posterior
condylar position and a mandible that is
posteriorly positioned with respect to the cranial
base and the maxilla- unless the deviation in
position of the fossa is compensated by angular
and/or linear relationships.

• A non-compensated posterior positioning of the

mandible caused by a large saddle angle is difficult
to treat.
SADDLE ANGLE
(N-S-Ar)
ARTICULAR ANGLE(S-Ar-Go)

• It is constructed between
the upper and the lower
parts of the posterior
contours of the facial
skeleton.

• Normal value:143± 6o
• Its size depends on the position of the mandible
• large- when the mandible is retrognathic
• Small- when the mandible is prognathic.
• The growth increments between 9 and 15 years –
– -2.89 degrees with horizontal growth( 139.5
degrees at 9 years) patterns
– -2.49 with vertical growth(142.4 degrees at 9
years) vectors.
• It can be influenced during orthopedic or
orthodontic therapy
Factors altering the Articular Angle
The angle decreases with:
• Anterior positioning of the mandible.
• Closing of the bite.
• Mesial migration of posterior teeth.

The angle increases with:

• Posterior relocation of mandible.
• Opening of the bite
• Distal driving of posterior teeth.
 It expresses the form of the
Gonial Angle mandible, also gives information
on mandibular growth direction.
• Normal value:128± 7o
• A small or acute Gonial angle is
suggestive of a horizontal
growth pattern.

• In patients with a large angle

functional appliance therapy is
contraindicated or the
appliance must be constructed
taking into account the growth
• In 9-year-old mixed-dentition children
– In horizontal growth patterns the Average
angle is 125.5 degrees with a lower angle of
69.5 degrees
– In vertical growth patterns the angle
increases to 133.4 degrees with a larger
lower angle of 78.3 degrees
• Between ninth to eleventh year of growth the
growth increment –
– -2.89 degrees with horizontal patterns
– -2.42 degrees with vertical pattern
linear measurements
Anterior and posterior facial height

• This is a linear millimetric

measurement.

• The Posterior Facial

Height i.e. S-Go and the
anterior facial height i.e.
N-Me are measured on a
Lateral Cephalogram.
 Posterior face heights
• in the longitudinal study of 9-year old
children-
– horizontal growth patterns - 69.5 mm
– vertical growth patterns- 64.1 mm.
• The growth increment between 9 and 15
years of age
– the horizontal growth pattern- 11.05 mm;
– the vertically growing group- 10.8 mm
 Anterior facial height
• The reverse ratio held true for anterior face
height.
– In horizontal patterns the average value-
103 mm with a growth increment of
12.18mm

– in vertical patterns the average value- 106.6

mm with a total growth increment of 12.71
mm
 Jarabak’s Ratio( I972)
Posterior face height x 100
------------------------------------------
Anterior face height

• Ratio under 62% expresses a vertical growth

pattern .
• Ratio above 65% expresses a horizontal
growth pattern.
• At 9 years
– In the horizontal growing group- ratio was
61.5%, inceasing to 69.9% by 15 years.

– In the vertically growing group- ratio was

60.1% , increasing to 62.7%by 15 years
Anterior Cranial Base Length
• Measurement from Se to
the Nasion.
• The correlation of this
criterion with the length of
the jaw bases enables the
assessment of the
proportional averages of
these bases.
• In the longitudinal study group the
average length of the anterior cranial
base in 9-year-old children
– horizontal growth patterns - 68.8 mm
– vertical growth patterns - 63.8 mm
• The incremental change between 9 and
15 years
– horizontal patterns - 4.46mm
– vertical patterns - 3.52 mm
Posterior (Lateral) Cranial Base Length

• Linear measurement
from S to Ar.

• This dimension is
dependent on the
posterior face height
and position of the
fossa.
• In 9-year-old children with
– horizontal growth Patterns- 32.2 mm with
an increment Of 9.36 mm in the following 6
years
– vertical patterns - 30 mm with an
increment of 4.41 mm in the following 6
years
• A short posterior cranial base occurs in vertical
growth patterns or skeletal open bites, which
gives a poor prognosis for functional appliance
therapy.
Analysis of the jaw bases
Analysis of the jaw bases involves.
1. The four angular measurements include:
– Angle SNA
– Angle SNB
– Base Plane Angle.
– Inclination Angle.
2. The rotation of the jaw bases
3. Linear measurement of the jaw bases and
ascending ramus.
SNA angle • Intersection of S-N plane
& line joining N-point A.
• Degree of protrusion or
retrusion of maxilla to
the cranial base.
• Mean value 820.
• > angle prognathic
maxilla class II.
• < angle retrognathic
maxilla class III.
THE AVERAGE VALUE
 The growth increments are small for this
criterion, and the difference between growth
direction types is insignificant

McNamara (1981) points out in his study that

the S-N-A angle did not vary much among the
different types of malocclusions, also it did not
change much with functional appliance
treatment .
• A moderate decrease of the S-N-A angle is
possible through the use of conventional
activator therapy.

• A larger decrease is possible with special

activator construction as shown by the Clark
twin block appliance
SNB angle
• Angle b/w S-N plane &
line joining N-point B.
• Angle antero-
posterior positioning of
mand. to cranial base.
• Avg value 800
• > angle prognathic
mand. class III
• < angle retrognathic
mand. class II
• This angle provides information only on the
anterioposterior position of the mandible, not
on its morphology or growth direction.

• A posteriorly located mandible can be large or

small, if it is small, the prognosis for anterior
posturing in the mixed dentition is good
because a larger growth increment can usually
be expected.
• The average angles and growth increments

– in horizontal face types the average value

are much larger- 77.2 degrees at 9 years
and 80.5 degrees at 15 years
– in vertical growth patterns- 74.3 degrees at
9 years and 75.9 degrees at 15 years.
 Base Plane Angle (Pal-MP)

The base plane angle

between the maxillary
and mandibular jaw bases

also is used to determine

the inclination of the
mandibular plane
• In the horizontal growth pattern, this plane
angle is smaller (23.4º at 9 yrs. and 20.5º at 15
yrs.)
• in the vertical growth pattern (32.9º at 9 yrs.
and 30.9º at 15 yrs.)
• Normal value: 25degree
 Inclination Angle
• Assessment of the inclination
of the maxillary base.

• Normal value: 85o

• This angle is not correlated

with the growth pattern or
facial type.

It is the angle formed by the Pn Line (a perpendicular

dropped from N-Se at N’ ) and the palatal plane.
• A large angle expresses upward and forward
inclination

• A small angle indicates downward and

backward tipping of the maxillary base.

• Functional and therapeutic influences can

alter the inclination of the maxillary base,
hence the need for periodic assessment
during active treatment.
 Rotation of the iaw bases
• The two previous measurements (base plane
angle and inclination angle) are used to
evaluate the rotation of the upper and lower
jaw bases .
• These rotations are of special interest in
treatment with functional appliances because
they show whether such appliances are
indicated and provide the criteria for appliance
construction
• The rotation of the mandible is growth
conditioned and depends on the direction and
mutual relations of growth increments in the
posterior (condylar) and anterior (sutural and
alveolar) facial skeleton.

– If condylar growth proceeds at a greater

rate, horizontal rotation results.
– If growth increments are balanced, parallel
growth occurs
• Biork (1962) differentiates the two processes
involved in rotational growth of the mandible:
• 1. Remodeling of the mandible in the symphyseal
and gonial areas-
– This remodeling is called intermatrix rotation.
– It is a function of the periosteal matrix.
– More apposition in the gonial area and
resorption in the symphyseal area lead to
horizontal rotation.
– Greater apposition in the symphyseal area
and resorption in the gonial area causes
vertical rotation.
• 2. Vertical or horizontal rotation of the
mandible in its neuromusqular envelope-
– This rotation is called matrix rotation, or
relocation of the functional marix,
according to Moss and' Enlow (1962).

• Rotation observed cephalometrically is called

total rotation; it consists of both intermatrix
and matrix rotation.
• Mandibular rotation is caused by both growth-
dependent and functional influences.

• For this reason the rotation of the mandible

may be moderately influenced therapeutically.

• A down and back tipping of the anterior part

of the maxillary base is observed as a natural
compensation in patients with vertically
growing faces.
The inclination can be influenced by both fixed
orthopedic and functional therapeutic
techniques. All techniques should be
monitored during active treatment to prevent
excessive gingival display.
Mutual relationship of the rotating jaw bases

• Rotation of the mandible can decisively

establish the vertical proportions of the facial
skeleton.

• In horizontal rotation the anterior face profile

is short, whereas in a vertically rotating
mandibular pattern, it is long.
• The inclination of the maxillary base also is
important to the occlusal relationship.

• Following types of rotations can be

differentiated, as shown by Lavergne and
Gasson (1982) in human implant studies.
• 1. Convergent rotation of the jaw bases-This
rotation creates a severe, deep overbite that is
difficult to manage using functional methods .
• 2. Divergent rotation of the jaw bases-This
rotation can cause marked open-bite
problems. In severe cases, orthognathic
surgery is required for correction.
• 3. Cranial rotation of both jaws -a relatively
harmonious rotation of both jaws occurs in an
upward and forward direction. This rotation of
the maxilla compensates for upward and
forward mandibular rotation, offsetting a deep
bite. The result is a normal overbite .
• 4. Caudal, or down and back, rotation of both
bases- This rotation occurs in a relatively
harmonious manner. The down and back
maxillary rotation offsets the open bite
created by down and back mandibular
rotation .
Linear measurement of jaw bases
• In the determination of indications for
functional appliance therapy, not only the
position but also the length of the jaw bases
must be assessed.

• If the mandible is retrognathic the clinician

must decide whether its size is relatively small
or large.

• This decision is important in the consideration

of etiology and therapy for each patient.
• The length of the maxillary and mandibular
bases and ascending ramus is measured relative
to Se-N. [ Schwarz 1958 roentgenostatic
analysis].

• The ideal dimension relative to Se-N is

calculated using the following ratios
– N-Se:ManBase 20:21.
– Ascending ramus:ManBase 5:7
– MaxBase:ManBase 2:3
 Extent of the mandibular base
• Determined by measuring the distance gonion
to pogonion projected perpendicular to the
mandibular plane .
• Ideally the mandibular base should be 3 mm
longer than Se-N until the twelfth year and 3.5
mm longer after the twelfth year.

• A length of 5 mm less than this average is

considered within normal limits until 7 years ,
however, and a length of 5 mm more is normal
until 15 years
• In the longitudinal study of children discussed
earlier, basal length and growth increments
were both higher in horizontal patterns than
they were in vertical growth patterns.

• In horizontal patterns the average length at 9

years was 67.59 mm, increasing to 77.35 mm
at 15 years.
• In vertical patterns the length at 9 years was
65. 23 mm, increasing to 73. 5 mm by 15
years.
 Extent of the maxillary base
• The extent of the maxillary base is determined
by measuring the distance between the
posterior nasal spine and point A projected
perpendicularly onto the palatal plane.

• The evaluation of this dimension has two

"ideal" measurements:
– one related to N-Se
– the length of the mandibular base
• The difference in length of the maxillary base
between the two growth patterns studied was
slight and the growth increment was lower
than were those of the mandibular base.

• In horizontal patterns the average length at 9

years was 44.56 mm, increasing to 48.6 mm in
the 15-year-old sample .
• In vertical patterns the average length was
44.0 mm at 9 years and 47.16 mm at 15 years.
• As Johnston (1976) points out, the mandible
outgrows the maxilla.

• This observation correlate the impression of many

clinicians that the mandible is less retrognathic
after 12 years.

• The recognition that the mandible outgrows the

maxilla by as much as 5 mm is especially important
to functional appliance proponents and, of course
to the Class II patients being treated.
 Length of the ascending ramus
• The measurement of the Length of the
ascending ramus is made by calculating the
distance between gonion and condylion .

• The location of condylion may be simplified by

the construction of a Frankfort horizontal plane
intersected by a tangent to the ramus. The
point of intersection represents constructed
condylion .
• The Frankfort horizontal plane is constructed as
follows:
– The distance between soft tissue nasion (N')
and the palatal plane is bisected along the Pn
line
– from this point a straight line (H-line) is
drawn parallel to the Se-N plane; this
becomes the ideal Frankfort horizontal.

• This construction should not be used for

comparison with Frankfort plane measurements
derived in other studies.
• The length of the ramus is important in the
determination Of posterior face height and
subsequent relation to anterior face height.

• The ramus tends to be longer in horizontally

growing patterns, with an avenge length of 48.9
mm in 9-year-old children and 58.67 mm in l5
year-old adolescents;
• it is shorter in vertical patterns, with an average
length of 44.47 mm in 9-year-old children and
51.7 mm in 15-year-old adolescents .
Evaluation of the Length of the
jaw Base
 Mandibular base
• If the length of the mandibular base corresponds
to the distance N -Se (ManBase=N-Se +3 mm)- it
indicates an age-related normal mandibular
length and an average growth increment can be
expected.

– If the base is shorter, the growth increment is

probably larger
– If it is longer, the growth increment may be
smaller
• The correlation between the length and
position of the mandibular base also should
be examined.

• A retrognathic mandible may have either a

short or long base, If the base is short, the
cause of the retrognathism is probably a
growth deficiency.
 A mandibular base that is both long and
retrognathic can result from two possibilities

• 1. The mandible is in a functionally retruded

(forced) position because of overclosure and
occlusal guidance. In postural rest, it is
anterior to habitual occlusion.
• 2. The mandible is morphogenetically "built"
into the facial skeleton in a posterior position.
The temporal fossa is posterior and superior.
This discrepancy is not compensated despite
the long mandibular base. The prognosis for
functional appliance therapy in these cases is
poor.
 Maxillary base

• Assessment of the length of the maxillary

base has two ideal values :

– one related to the distance N –Se ,

– the other to the length of the mandibular
base.
• If the maxillary base corresponds to the
mandibular base-related norm, the facial
skeleton is proportionally developed,
particularly if the ramal length also
corresponds to these values .

• If the N-Se length does not relate to these

three proportionate measurements the facial
skeleton is proportionate but either too large
or small
 Ascending ramus
• Evaluation of ramal length is performed
similarly.

• In horizontal patterns -If the ramus is too

short in relation to the other proportions, a
large amount of growth can be expected
• In vertical growth patterns the ramus remains
short.
 Morphology of the mandible

• Various facial types (orthognathic ,

retrognathic , prognathic ) reflect to some
degree the morphology of the mandible.
• In the orthognathic type of face-
– the ramus and body of the
mandible are fully developed , and
the width of the ascending ramus is
equal to the height of the body of
the mandible, including the height
of the alveolar process and incisors.
– The condylar and coronoid
processes are almost on the same
plane,
– the symphysis is well developed
• In the prognathic type-
– the corpus is well developed
and wide in the molar region.
– The symphysis is wider in
the sagittal plane.
– The ramus is wide and long,
– the gonial angle is acute or
small.
• In the retrognathic facial type-
– the corpus is narrow,
particularly in the molar region.
– The symphysis is narrow and
long,
– the ramus is narrow and short.
– The coronoid process is shorter
than the condylar process,
– the gonial angle is obtuse or
large.
• The prognathic type of mandible grows
horizontally. Even if an average or a slightly
vertical growth direction is evident in the
mixed dentition shifting of the mandible to a
horizontal growth direction can be expected in
the following years.

• In a retrognathic mandible, shifting of the

growth pattern in the opposite direction is less
likely .
 Analysis of the dentoalveolar
relationships:

This includes:
• Axial inclination of
the incisors.
• Position of the
incisors.

with respect to the anterior cranial base, their

apical bases and each other
Axial inclination of the incisors
 Upper incisors

• SN-UI ANGIE-The long axis of the

maxillary incisors is extended to
intersect the S-N line, and the
posterior angle is measured .

• Until the seventh year this angle

averages from 94 to 100 degrees.
A year or two after eruption of
the permanent teeth the
inclination increases to an
average of 102 degrees.
Lower incisors
• LIMP ANGLE- Measurement of
the posterior angle between
the long axis of the lower
incisors and the mandibular
plane.

• The ideal angle often stated is

90 degrees ,but in most studies
of heterogeneous samples , it
is 4 to 5 degrees more .
• Between the sixth and twelfth years, it
increases from 88 degrees for relatively upright
deciduous incisors to 94 degrees on average for
normal samples.

• A smaller angle may indicate lingual tipping of

the incisors, which is advantageous for
functional appliance treatment.

• If the lower incisors are already labially tipped,

functional appliance treatment is more difficult.
Position of the incisors
• Linear measurements
are the best assessors of
the position of the
incisors with respect to
the profile.

• The most common

assessment method is to
measure the distance of
the incisal edges to the
line N-Pog, (facial plane).
• The average position of the
maxillary incisors is 2 to 4 mm
anterior to the N-Pog line.

• The lower incisors vary from 2

mm posterior to 2 mm anterior
to this line.

• If the labially malpositioned

incisor already has a good axial
inclination, bodily movement is
required.
 • The amount and direction of the
growth spurt should be considered in
the mixed dentition while the ideal
position of the incisors at the end of
treatment is being planned.
CEPHALOMETRIC VALUATION OF
TREATMENT PROGRESS IN THE
MIXED DENTITION
• One of the most important tasks of roentgenographic
cephalometrics is the objective assessment of changes
induced by therapy, growth, and development as
treatment progresses.

• This assessment should be performed periodically .

• Growth increment and direction, patient cooperation,

and untoward treatment response are difficult factors to
control.

• Early changes in treatment plans may make the

difference between success and failure.
• In addition to the cephalometric criteria
described at the beginning of this
presentation, other complementary
measurements can be used both during and
after active treatment.
Angular Measurements
Linear
Measurements
• Comparing measured growth with average
values differentiated according to the
morphogenetic pattern also is possible.

• These comparison methods assist in

determining whether the growth increments
and directions are high or low or favorable or
unfavorable in the skeletal areas causing the
greatest concern.
• A special evaluation is available
in activator cases. The distance
Ar-Pog is measured and Ar-
Point A is substracted from it .

• alternatively, condylion can be

used as posterior terminus in
these measurements .

• If the mandible is postured

anteriorly, this coefficient
increases.
FUNCTIONAL ANALYSIS
• Appraisal of the functional status of each
patient is a priority before any form of
orthodontic therapy is instituted.

• Because many functions occur in the

stomatognathic system, a multiple
assessment is necessary to analyze-
mastication, deglutition, respiration, speech,
posture, and the status of each component
involved in accomplishing functional activity.
• Much can be done with proper clinical
examination ,which is important for not only
in determining the current relationships
among and past effects of each function on
structure .

• This is also helps in understanding the role of

function or group of functions in the future.
 FUNCTIONAL ANALYSIS

• DIAGNOSTIC EXCERCISES:
a) Determination of postural rest position of the
mandible and interocclusal clearance.
B) Examination of the TMJ and condylar
movements.
C) Assessment of the functional status of the lips,
cheeks, tongue with particular attention to the
roles they play in dentofacial abnormalities.
• The initial task of functional analysis is the
assessment of mandibular position as determined
by the musculature.

• This position in the adult dentition is generally a

centric relation that can be registered with a variety
of gnathologic techniques.

• Gnathologic principles cannot be applied in the

deciduous or mixed dentition, however, because
occlusion is in a transitional stage and growing
condylar structures have not yet reached their adult
forms.
• Because a major determinant of adult shape
is the functional pattern (originating from the
postural rest position of the mandible),
registration of this relatively unchanging
neuromuscularly derived relationship is a
priority.

• The functional pattern is more likely to be

normal and less likely to be affected by
skeletal abnormalities and neuromuscular
compensation .
• Postural rest position : The position of the
mandible at which the synergists and
antagonists of the orofacial system are in their
basic tonus and balanced dynamically .

• Determination of the postural rest position:

Patient seated upright and relaxed with head
positioned with the Frankfort horizontal
parallel to the floor .
 Various methods to record

 Phonetic : Pronounce consonants { M}.

 Command : perform functions

{swallowing}

 Non- command : Pt unaware and examine

 Combined methods .
 Registration of rest position
INTRA-ORAL METHODS
a) DIRECT METHODS : Vernier calipers
b) INDIRECT METHODS : Impression materials .

EXTRAL ORAL METHODS

c) DIRECT METHODS : Reference points on Nose
& Chin.
b) INDIRECT METHODS :
 CEPHALOMETRIC REGISTRATION : 2 CEPHS
one at rest other at occlusion .
 KINESIOGRAPHY : MAGNET on lower teeth ,
sensor records mandibular movements.
EVALUATION OF PATH OF CLOSURE
• The movement of the mandible from postural rest
to habitual occlusion is of special interest for all
functional analysis.
• It consists of two components:
– hinge (rotary) action - the free phase from postural rest
to the point of initial or premature contact
– translatory (sliding) movement- the articular phase
from initial contact to the centric or habitual occlusal
position
• The objective of examination is to assess not only
the magnitude and direction of these movements
but also the extent of action of each hinge or sliding
component.
 PATH OF CLOSURE : Mandible movement from
rest position to full articulation analyzed in 3
PLANES.

A. SAGITTAL PLANE : 3 TYPES

a) Pure rotational .
b) Forward path of closure . Rotation + Anti. sliding
component .
c) Backward path of closure. Rotation + Post.
sliding component.
B. VERTICAL PLANE:
C. True deep overbite : Infraocclusion of molars
+ large free way space.
D. Pseudo deep bite : Overeruption of incisors +
small free way space

E. TRANSVERSE PALNE:
a) Laterognathy : True cross bite .
b) Laterocclusion
PATH OF CLOSURE IN SAGITTAL PLANE
Pure rotational
• In Class II malocclusions
without functional
disturbance the path of
closure from rest to
occlusion is straight up
and forward, with a
hinge movement of the
condyle in the fossa.
these are true Class II
maloccluslons
Backward path of closure

• up and backward (posterior

shift). this type of activity is
the most common,
particularly in cases of
excessive overbite. This
functional type of Class II
malocclusion appears more
severe than actually is
sagittally.
 • up and forward- This
Forward path of closure malocclusion is more severe
than it appears with the teeth
in occlusion this variation of
path of closure is least frequent
for Class II malocclusions
• Mandible may be anteriorly
displaced from initial con- tact
as the cusps guide the
mandible into a forward
position,
• Translatory movement of
condyle is downward and
forward on the posterior slope
of the articular eminence
The prognosis for Class II treatment
• Posterior displacement + horizontal growth
directions,- the prognosis very good

• Anterior displacement + vertical growth

vector - the prognosis is quite poor.

• Anterior displacement + horizontal growth

direction or posterior displacement + vertical
growth direction- the prognosis is not good.
[ it can be improved or worsened depending on the
age of the patient and his facial pattern]
 Class lll malocclusions
• The possibility of successful functional
appliance treatment of these problems exists
only if the magnitude of the sagittal dysplasia
is not too great and therapy is begun in the
early mixed dentition.

• Hinge-type condylar function is often

associated with Class III malocclusions with
straight paths of closure
• Up and back (an anterior
postural rest position) path of
closure- , the prognosis is even
poorer.

• Up and forward path of closure

-, the prognosis is much better
and treatment success is
possible , even in the permanent
dentition.
Evaluation of the path of closure from postural
rest to habitual occlusion in the vertical plane

A. True deep overbite : Infraocclusion of

molars + large free way space.

B. Pseudo deep bite : Overeruption of

incisors + small free way space
• The prognosis is good in a
true deep overbite
problem if a vertical
growth pattern is present .

• In pseudo-deep overbite
problems with horizontal
growth patterns, the
possibilities for correction
with functional appliances
are limited .
• In combined cases of
true deep overbites
and horizontal
growth patterns or
pseudo-deep bites
and vertical growth
patterns limited
success can be
expected.
• In Class II malocclusion A total of eight
functional combinations between the vertical
and sagittal relationship can be categorized
 Evaluation of the path of closure from postural
rest to habitual occlusion in the transverse plane

• Clinical examination of transverse functional

relationships is easy to perform.

• It consists of observing the behavior of the

mandibular midline as the teeth are brought together
from rest position to habitual occlusion.
laterocclusion or pseudo-crossbite
• The crossbite in which
the midline shift of the
mandible can be observed
only in the occlusal
position.

• In postural rest the

midlines are coincident
and well centered.
laterognathy • The second is a crossbite in
which the midline shift is
present in both occlusal and
postural rest positions (e.g., a
true asymmetric facial skeleton)

• Successful functional appliance

treatment is not possible in
such cases

• In severe cases surgery is the

only alternative.
• Generally in functional Class II problems with
posterior displacement and functional deep
overbite problems with large interocclusal
spaces, functional appliances have good
prognosis .

• In non functional true Class II malocclusions and

pseudo-deep overbite problems, therapy is
more difficult.
 Examination of T.M.J
• The objective of this aspect of functional
examination is to assess whether incipient
symptoms of TMJ dysfunction are present
• These symptoms are important for rwo reasons:
• 1. Through the early elimination of functional
disturbances, some incipient TMJ problems can
be prevented or eliminated. This is an indication
for early orthodontic treatment.
• 2. During activator therapy the condyle is displaced or
dislocated to achieve a remodeling of the TMJ
structures and a change in muscle function.
• If the temporomandibular structures are abnormal at
the start and hypersensitivity is a problem, the
possibility of further increase in the symptoms exists .
• Fortunately this seldom happens; functional appliances
often eliminate unfavorable sensory reactions in the
process of posturing the mandible forward.
• If TMJ problems are present in the deciduous
dentition, forward posturing may be better achieved in
a staged progression.
• Early symptoms of TMJ problems include the
following;
– Clicking and crepitus
– Sensitivity in the condylar region and masticatory
muscles
– Functional disturbances (e.g., hypermobility,
limitation of movement ,deviation)
– Radiographic evidence of morphologic and
positional abnormalities
EXAMINATION OF TMJ

1. Auscultation
2. Palpation
3. Functional analysis
PALPATION
 MUSCULAR EXAMINATION
• Head and neck should be inspected for soft
tissue asymmetry or evidence of muscle
hypertrophy. Patient should be observed for
signs of jaw clenching or other habits. The
muscles should be palpated for presence of
tenderness and spasms
lateral pterygoid
• Origin of lateral pterygoid
Insertion of medial pterygoid (intraorally)
Insertion of medial pterygoid (extraorally)
Temporalis
Insertion of temporalis
Masseter (extra oral)
Masseter (intra oral)
 Functional analysis
• Dislocation of the condyles and
discoordination of movements are early
symptoms of functional Disturbances.

• Premature contacts and deviations in sagittal

and transverse directions are assessed.
The direction of opening and closing
movements should be registered graphically
with curves .
 OROFACIAL DYSFUNCTIONS

• Functional examination to see dysfunctional

aspects requires an assessment of the tongue ,
lips, cheeks , and hyoid musculature.

• Examination of the swallowing function usually

involves all areas, although each muscle group
can be studied separately .
• The primary means of examination are clinical
observation and functional testing supported by
cephalometric analysis .

• More sophisticated techniques of functional

analysis are electromyography, cineradiography,
kinesiology, video imaging, magnetic resonance
imaging (MRI).
• They are helpful but not usually available in
private practice.
a. COMPUTERIZED ELECTROMYOGRAPHY(EMG): it records
the timing and magnitude of activity of the jaw muscles
which can be coordinated with the movements.
b. CINERADIOGRAPHY AND CINEMATOGRAPHY: records
the jaw movements during mastication
 KINESIOGRAPHIC REGISTRATION
It allows the mandibular position to be registered 3-dimensionally.
(Jankelson 1984)
The position of the mandible is recorded electronically by:
• a permanent magnet, which is fixed with rapid setting acrylic
to the lower anterior teeth, and
• a sensor system of six magnetometers mounted on a frames.
 EXAMINATION OF OROFACIAL DYSFUNCTIONS

• 1.SWALLOWING
– INFANTILE SWALLOWING
– MATURED SWALLOWING
• 2. EXAMINATION OF TONGUE
– TONGUE FUNCTION
– TONGUE POSTURE
– CEPHALOMETRIC EVALUATION OF TONGUE POSTURE
– TONGUE SIZE
– TONGUE DYSFUNCTION
– PALATOGRAPHIC EXAMINATION OF TONGUE
DYSFUNCTION
• 3. THUMB- AND FINGER-SUCKING EFFECTS
• 4. EXAMINATION OF THE LIPS.
– CEPHALOMETRIC EVALUATION OF LIPS
» ScHWARZ ANALYSIS
» RICKETTS LIP ANALYSIS
» STEINER LIP ANALYSIS
» HOLDAWAY LIP ANALYSIS
– DYSFUNCTION OF THE LIPS.
• 5. RESPIRATION
 SWALLOWING
• Normal mature swallowing takes place without
contracting the muscles of facial expression.
• The teeth are momentarily in contact and the
tongue remain inside the mouth.
• During first few years, infants swallow
viscerally,i.e with the tongue between the gum
pads.
• As the deciduous dentition is completed, visceral
swallowing is gradually replaced by somatic
swallowing.
 If visceral swallowing persists after fourth year of
age, it is considered as orofacial dysfunction.

 Abnormal swallowing is caused by tongue-thrust

either as a simple thrusting or as “tongue-thrust
syndrome(complex tongue thrust)”.
 COMPLEX TONGUE THRUST
The following symptoms distinguish this syndrome:
 Protrusion of tip of tongue(tongue thrusting during
swallowing)
 No tooth contact
 Contraction of the perioral muscles during the
deglutition cycle.(excessive buccinator
hyperactivity)

• Elimination of the problem is usually more difficult

and a long period of retention is necessary.
 SIMPLE TONGUE THRUST
• This is largely a localized anterior tongue posturing
forward during rest and active function with
localized anterior open bite.

• Attendant muscle abnormalities are more adaptive

than primary in such cases .

• The prognosis for functional therapy is usually good,

and autonomous improvement can often be seen.
 THE DEGLUTITIONAL CYCLE
• Divided into four stages:
• Stage 1
– The anterior third of the superior
surface of the tongue is flat or retracted

– The food bolus is collected on the flat

anterior part of the tongue or in the
sublingual area in front of the retracted
tongue.
– The posterior arched part of the
dorsum is in contact with the soft
palate.
– The posterior seal is closed; swallowing
Stage 2
• -The soft palate moves in a cranial and
posterior direction.
– The palatolingual and palatopharyngeal
seals are now open.
– The tip of the tongue moves up as the
dorsum drops, creating a groove or
depression in the middle third and
permitting posterior transport of the bolus.
– Simultaneously a slight contraction of the
lip muscles occurs while the lips are in
contact.
– the anterior teeth approximate at the end
of this stage.
• Stage 3
– The superior constrictor muscle ring in
the epipharyngeal wall starts to
constrict.

– The soft palate assumes a triangular

form, both tissues together form the
palatopharyngeal seal.

– With the closing of the nasopharynx

the posterior part of the dorsum of the
tongue drops more, this allows the
bolus of food to pass through the
isthmus faucium.
– Simultaneously the anterior part of
the tongue is pressed against the
hard palate which helps manipulate
the bolus in a posterior direction.

– The teeth are in contact (usually

slightly forward of full contact), and
the lips are together.

– If tongue thrusting is present, the

tongue is not retracted but narrowed
with the tip pressed forward to help
in the anterior lip seal.
• Stage 4
– The dorsum of the tongue
now moves posteriorly and
superiorly as the
palatopharyngeal tissues
move down and forward.

– The tongue pushes against

the tensed soft palate,
squeezing the residual food
bolus out the oropharyngeal
area.
 EXAMINATION OF THE TONGUE.

• Not only the function but also the posture,

size, and shape of the tongue are significant.
such potential etiologic factors should be
considered before any form of therapy is
prescribed.
 TONGUE FUNCTION
• The object of the tongue function assessments to
make a differential diagnosis possible and
determine the tongue's role in malocclusion

• Abnormal tongue posture and function can be

primary factors as consequences of retained
infantile deglutitional patterns or other abnormal
oral habits, but they also may be strictly secondary
or adaptive to unfavorable morphologic patterns .
• Functional appliance therapy is indicated if
the role of tongue malfunction is considered a
primary etiologic factor.

• If tongue function is adaptive to morphologic

disorders, its secondary role does not take
priority in treatment considerations.
 TONGUE POSTURE
• The posture and shape can be flat or arched,
protracted or retracted, narrowed and long, or
spread laterally and shortened.

• Tongue posture is examined clinically with the

mandible in postural rest position. Sagittal
cephalometric registration of this relationship also
is possible.

• Tongue posture was compared at rest position and

in habitual occlusion.
• At rest position an assessment of three regions-
root, dorsum, and tip-was made; this assessment
disclosed the following:
• 1. The root
– in cases of mouth breathing and deep overbite caused
by a small tongue- The root is usually flat
– in all other cases - slight contact of the tongue usually
occurs with the soft palate.
• 2. the dorsum
– In Class II, division 1 malocclusions and deep
overbite -the dorsum of the tongue is arched and
high;
– in all other malocclusions a tendency exists for
the tongue to flatten in accordance with the
length of the interocclusal space.
• 3. The tip
– in Class II, division 1 malocclusions- usually retracted
– in other malocclusion categories a slight anterior
gliding of the tongue tip occurs as the mandible moves
into postural rest position.

• Changes in the position of the tongue tip relate directly

to mandibular malformations.
• Nasal and pharyngeal blockage and compensatory
tongue posture also may be potent factors in the
development of malocclusions.

• In the presence of excessive epipharyngeal

lymphoid tissue, the tongue naturally postures
forward to maintain an open airway.

• If the nasal passages are closed, mouth breathing

with its attendant drop in mandibule and tongue
posture must be practiced.
 CEPHALOMETRIC EVALUATION OF TONGUE
POSTURE

• Cephalometric analysis is exact, reproducible, and

simple and can be employed in private practice.
• Use of a radiopaque coating (such as barium
paste) on the tongue enhances visualization during
palatography.
• Assessment of tongue posture is made from a
lateral cephalogram taken in postural rest and
habitual occlusion .
• The size of the tongue can be measured on the
occlusal film.
Assessment of tongue size from
occlusal cephalograms requires
measurement of the distance
between the superior tongue
surface and the roof of the
mouth.

If the entire oral cavity is filled

then only a diagnosis of
macroglossia can be made. This
diagnosis also must be
supported by clinical evidence.
• Measurements made from tongue
templates can be expressed by graphs .
The palatal vault may be represented by a
horizontal line and the seven single
measurements by a curve.
• To assess the posture and mobility of the
tongue, the clinician can calculate the
differences between rest and occlusal positions.

• The occlusal position is taken as zero, with

changes in rest position expressed as positive or
negative figures (positive if the tongue is higher
in rest position, negative if it is lower).
 TONGUE SIZE.

• The size and shape of the tongue have many

variations-bulky and short, narrow and long,
and wide and long.
• In macroglossia the oral cavity is filled by the tongue
mass. The mouth does not seem to have enough space,
and the epipharynx is narrow.

• Indentations are evident on the tongue periphery. The

tongue is protuded, and usually an open bite is evident.

• True macroglossia often occurs with certain pathologic

conditions such as Down’s syndrome.

• In children a definitive diagnosis of macroglossia cannot

be made without cephalometric analysis
• The obvious characteristic of microglossia, or
hypoglossia, is a very small tongue.

• The protruded tongue tip reaches the lower

incisors at best. The floor of the mouth is
elevated and visible on each side of the tongue.

• The dental arch reflects the small tongue size

when it is collapsed and reduced, with extreme
crowding in the premolar area.

• A severe Class II relationship is usually evident.

 TONGUE DYSFUNCTION
• The most common tongue dysfunctions involve
selective outer pressure (pressing) and tongue
biting.

• The recognition of areas of excessive tongue

pressure is important for not only determining the
etiology of the associated malocclusion but also
providing information needed to construct the
screening or functional appliance.
 Tongue thrust

- Anterior - Primary
- Lateral - Secondary
- Complex
The consequences of tongue posture and function
abnormalities in the dentoalveolar region also
depend on the skeletal pattern.

• In a horizontal growth
pattern the forward
tongue thrust or posture
can result in bimaxillary
protrusion.
• In a vertical growth pattern the tongue thrust
can open the bite, and the lower incisors may be
tipped lingually.
• During the abnormal
functional and postural
forward positioning, the tip
of the tongue lies between
the dental arches in
contact with the lower lip,
which the patient
constantly sucks. Thus the
incisors are tipped
lingually.
PALATOGRAPHIC EXAMINATION OF TONGUE
DYSFUNCTION
• Palatography ,a technique that permits
tongue function to be observed during
swallowing and speaking ,also allows the
influence of various functional orthodontic
appliances on the tongue to be evaluated.

• Palatography may be applied in both direct

and indirect methods.
• The direct method - described by Oakley Coles
in 1872, gum arabic and flour were mixed and
painted on the tongue. After selected
functional exercises had been performed, the
contacts on the palate and teeth were
transferred on to the cast of the upper jaw
with red ink.
• The indirect palatographic technique was first
used by Kingsley (1880). He prepared an
upper plate of black india rubber and covered
the tongue with a mixture of chalk and
alcohol.
The contacts seen on the palatal
rubber plate were then transferred onto the
cast .
• In the current direct method the superior
surface of the tongue is covered with a precise
impression material (e.g.Imprex).
• After functional exercises an instant polaroid
print is made of the palatal region with the
help of a surface mirror.
• Evaluation of the
palatogram is possible
by direct
measurements on the
picture.
 THUMB- AND FINGER-SUCKING EFFECTS
• Finger sucking can cause an open bite with
simultaneous narrowing of the maxillary arch.
Adaptive tongue function aggravates and
prolongs the malocclusion.

• The patient often compensates for bilateral

narrowing with a lateral shift to one side to gain
maximal chewing surface contact. This functional
type of crossbite or convenience crossbite is not
skeletal in the initial stages but adaptive.
• Before functional appliance therapy begins, the
maxillary arch should be expanded with a split
palate jackscrew type of active plate.

• Sometimes a small wire crib can be incorporated

to block the tongue in the crossbite area to
create a normal tongue habit.
 Examination of the lips
• The configuration of the lips should be studied
in the relaxed position.

• The lip relationship that commonly occurs

• 1. THE COMPETENT LIPS.- If only a slight contact

or a very small gap is evident between the upper
and lower lips.
• 2.INCOMPETENT LIPS -If a wide gap is present or
the lips (primarily the upper lip) are too short,
• 3. Potentially incompetent lips -If the lips
seem normally developed but the upper
incisors are labially tipped, making closure
difficult.

• 4.Everted lip-If the lower lip is hypertrophic,

everted, and with an excess of tissue, Iittle can
be done to improve the situation by
orthodontic therapy.
• CEPHALOMETRIC EVALUATION OF
LIPS
– SChWARZ ANALYSIS
– RICKETTS LIP ANALYSIS
– STEINER LIP ANALYSIS
– HOLDAWAY LIP ANALYSIS
 Schwarz analysis (1961)
• Three reference lines are constructed
• H line-corresponding to the Frankfort
horizontal plane
• Pn line-perpendicular to the H line at
soft tissue nasion
• Po Line-perpendicular from orbitale
to the H line
• Between the two constructed
perpendicular lines is an area termed
as the gnathic profile field(GPF).
• In normal proportions the upper lip
touches the Po line, and the lower
lip lies one third the width of the
GPF posterior to it.

• The oblique line (T) is constructed

by joining subnasale to soft tissue
pogonion.

• In the ideal case the T line bisects

the vermilion border of the upper
lip and touches the anterior
vermilion curvature of the lower lip.
Ricketts lip analysis
• The reference line used by
Ricketts(l958) is similar to
the Schwarz T line but is
drawn from the tip of nose
to soft tissue pogonion.

• In a normal relation- the

upper Iip is 2 to 3 mm and
the lower lip 1 to 2 mm
behind this line
Steiner lip analysis • The upper reference point
for the Steiner analysis at
the center of the S-shaped
curve between the tip of
the nose and subnasale
and soft tissue pogonion.
• If the lips lie behind the
reference line,they are too
flat
• If they lie in front, they are
too prominent
Holdaway lip analysis 1983
• The Holdaway lip analysis is
a quantitative assessment of
lip configuration .

• Measures the angle between

the tangent to the upper lip
from soft tissue pogonion
and the N-B line, which he
calls the H angle.
• Holdaway defines the ideal profile as follows:
• A-N-B angle of 2 degrees H angle of
7 to 8 degrees
• Lower lip touching the soft tissue
line that connects pogonion and
the upper lip extended to S-N.
• Relative proportions of nose and
upper lip balanced (soft tissue line
bisecting subnasal S curve)
• Tip of nose 9 mm anterior to the
soft tissue line (normal at age 13
years)
• No lip tension on closure.
 Dysfunction of the lips
• A number of lip muscle abnormalities have
been identified and characterized.
• The most common is sucking or biting of the
lower lip, known as mentalis habit because of
the crinkling "golf ball" appearance of the
symphyseal tissue with excessive mentalis
activity
• In this type of dysfunction, contact usually
occurs between the tongue and lower lip and
can be observed during swallowing .
• Consequences of the combined muscle
abnormality include
– the opening of the bite anteriorly
– the Lingual tipping of the lower incisors with
crowding
– labial malpositioning of the upper incisor.

• Upper lip biting is a habit frequently seen in

school children, It is a stress-strain relief
syndrome . Tongue function can be normal.
• lip sucking can be either a primary or a
secondary factor.

• In cases in which it is the primary causative

factor, overjet with labial tipping of the upper
and lingual tipping of the lower incisors is
evident, and only a slight skeletal sagittal
discrepancy occurs.
• The lip habit enhances the original slight-to-
moderate overjet.

• Functional therapy is successful only in cases

of primary dysfunction .In the case of
secondary dysfunction, functional therapy is
less important to other orthopedic,
orthodontic, or surgical methods.
 Respiration

• Mouth breathing and disturbed nasal

breathing can be considered etiologic factors
or at least predisposing causes for some
malocclusion symptoms.
• In 1968, Ricketts described the "respiratory
obstruction syndrome”,consisting of the
following symptoms
– visceral type swallowing,
– predisposition to open bite,
– unilateral or bilateral crossbite,
– slight deflection of the head.
• In examinations a significantly high frequency
of the following symptoms has been observed
in patients with disturbed nasal respiration:

– Class II, division1 malocclusion

– Narrowness of the upper arch
– crowding of the upper and lower arches
– vertical growth patterns
• If the tonsils and adenoids are enlarged with a
compensatory anterior tongue posture the
patient cannot tolerate a bulky acrylic
appliance in the oral cavity .

• Other appliances are available for use in cases

of habitual mouth breathing (e.g.. Clark twin
block. )
• In mouth-breathing patients the lip seal is
usually inadequate . The tongue has a low
posture and disturbed function.

• If this condition persists after treatment , the

result is not likely to be stable ,with relapse as
a consequence.
• If at all possible establishing normal nasal
respiration before orthodontic therapy is most
advantageous .

• Unfortunately in some patients with allergies

or deviated nasal septums , this is not possible
during the growth period.
• The scope of functional therapy with respiratory
problems can be summarized as follows:

• 1. In habitual mouth breathing with small

respiratory resistance, functional therapy is
indicated. Exercises can be prescribed.
• 2. If structural problems occur with excessive
adenoid tissue and allergies, otolaryngologic
consultation and possible treatment should be
seen.

• If the structural conditions are unalterable,

Functional appliance therapy cannot be
instituted.
 References

• Dentofacial orthopedics with functional appliances ( Thomas -

M.Graber, Thomas Rakosi, Alexander petrovic)
• Removable Orthodontic appliances (T.M.Grater Bedrich
Neumann)
• Current orthodontic concepts and Techniques (T.M.Graber,
Brainerd .F.Swain)
• Orthodontics - Current Principles and Techniques (T.M.Graber,
Robert L.Vanarsdall)
• Orthodontic and Orthopedic Treatment in the mixed dentition
(James -A. Mc.Namara, William L.Brudon).