Color Atlas of Dental Medicine:

Orthodontic Diagnosis
(page.159-165)

Nadya Sri Devi, SKG

NIP : 000XXX

PRESENTASI BEDAH BUKU

PADANG, 21 FEBRUARI 2018
 Orofacial Dysfunctions - page 159

Hyperactivity of Mentalis Muscle

• The deep mentolabial sulcus (Fig. 404) is characteristic of a
hyperactive mentalis muscle.
• Cases of hyperactivity of the mentalis muscle which occur in the
same family, are usually hereditary (Fig. 404) However, this finding
may be based on an imitation of the dysfunction.
Figure 404:
Deep mentolabial sulci and
hyperactivity of mentalis
Muscle

Profile view of a female patient

with the clinical appearance of the
abnormal muscle function.

Right: The same dysfunction is

diagnosed in the sister, who is 2
years older.
 Orofacial Dysfunctions - page 159

Hyperactivity of Mentalis Muscle

• The abnormal mentalis function often occurs together with lip-
sucking or lip-thrust (Fig. 403).

Figure 403:
Cheek dysfunction
and malocclusion

Buccal nonocclusion
in the deciduous
dentition combined
with a cheek
dysfunction.
 Orofacial Dysfunctions - page 159

Hyperactivity of Mentalis Muscle (cont.)

• This habitual pattern of muscle behavior impedes the
forward development of the anterior alveolar process
in the mandible (Fig. 405).
Figure 405
Cephalometric findings in case
of hyperfunction of the mentalis
muscle and the lower lip

The dentoalveolar location of the

Class II malocclusion is
characteristic.

Right: The hyperactive mentalis

muscle pulls the lower lip upward
and rearward and presses it
against the lingual surfaces of the
upper incisors. The upper lip
remains relatively motionless. The
normal lip seal is disturbed and the
tongue displaced downward.
This type of soft-tissue morphology
aggravates the dentoalveolar
malocclusion.
 Page 160 - Functional Analysis

Mouth-Breathing
• The mode of respiration is examined to establish
whether the nasal breathing is impeded or not.
• Chronically disturbed nasal respiration represents a
dysfunction of the orofacial musculature; it can
restrict development of the dentition and hinders
the orthodontic treatment.
• The following clinical findings are typical of patients
with oronasal respiration: a high palate, persisting
"tooth germ position" of the upper incisors,
narrowness of the upper arch, cross-bite, often
accompanied by poor oral hygiene and hyperplasia
of the gingiva (Figs. 407, 408).
 Page 160 - Functional Analysis

Mouth-Breathing (cont.)

Figure 407: Figure 408:

Occlusal and dental findings in case of Configuration of the maxilla in
oronasal respiration.
oronasal respiration
The upper jaw is markedly constricted, the
"tooth germ position" of the upper incisors The high palate and narrow
has persisted, the mandibular arch is well upper arch are characteristic
formed. features.
Due to the incongruence in arch width a
bilateral cross-bite exists.
 Page 160 - Functional Analysis

Mouth-Breathing (cont.)
• The extraoral appearance of these patients is often
conspicuous, and is termed "adenoid facies" (Fig. 406)
Figure 406:
"Adenoid facies"

Frontal and profile

views of a 6-year-
old female patient
with chronically
restricted nasal
respiratory
function.
 Respiration – page 161
Pattern of Facial Morphology
• The configuration of the facial skeleton and oral respiration are correlated
to a certain degree.
• Impeded nasal breathing shows a higher frequency in facial types with
vertical growth tendency.
• Proliferation of the adenoids is more common and more pronounced in
patients with oronasal respiration. The incidence of hypertrophied tonsils is
also increased in this group (Fig. 409-411)

Classification of the Adenoids on the Lateral Cephalogram:

Figure 409:
Small-sized adenoids (+)
The radiographic images of the
adenoids on the lateral cephalogram
appear as a slight curvature on the
upper rear wall of the nasopharynx.
Left: Schematic illustration of the
morphological relationships.
 Respiration – page 161
Classification of the Adenoids on the Lateral
Cephalogram (Cont.):
Figure 410:
Medium-sized adenoids (++)
Noticeable proliferation of lymphoid
tissue on the upper rear wall of the
nasopharynx, which occupies
approximately half of the visible
pneumatic cavity in the epipharynx.
Left: Schematic illustration of the
relationships.

Figure 411:
Large-sized adenoids (+++)
The lymphatic tissue occupies most
of the nasopharyngeal pneumatic
cavity.
Left: Schematic illustration of the
relationships.
 Page 162 - Functional Analysis

Tongue Posture
Two different tongue postures are possible in case of
oronasal respiration:

• Type I: The tongue is flat and its tip is behind the

lower incisors. This type is often encountered in
conjunction with an anterior cross-bite (Figs. 412,
414).
• Type II: The tongue is flat and retracted. This type
of abnormal tongue posture is common in cases
with oral respiration and distoclusion (Fig. 413)
 Page 162 - Functional Analysis

Tongue Posture (cont.)

Figure 412:
Type I tongue position

Class III malocclusion with a

flat, protruding tongue posture.
The downward forward
position of the tongue has
been marked with contrast
medium on the lateral
cephalogram.

Figure 413:
Type II tongue position

Class II malocclusion with

flat, retracted tongue
posture.
The downward backward
position of the tongue has
been marked with contrast
medium
 Page 162 - Functional Analysis

Tongue Posture (cont.)

Figure 414: Tongue position and oral respiration

These lateral cephalograms show the position of the tongue in a patient with
restricted oral respiration prior to (left) and after (right) removal of the adenoids.
After ENT surgery and change to nasal breathing the initially flat positioned ton
 Respiration – page 163

Examination of Breathing Mode

• The case history (e.g. details regarding recurrent diseases of the upper air passages,
sleeping habits) and evaluation of tongue and lip posture as well as lip function, provide
certain keys concerning the breathing mode.
• The following are various clinical methods of examination which permit a crude check of
the degree of nasal obstruction: the cotton pledget test, the mirror test (Fig. 415), and
observation of the nostrils (Fig. 416).
Figure 415: Mirror test
The mirrors are held in front of both nostrils.
In nasal-breathers the mirror will cloud with
condensed moisture during expiration as
shown on the right.

Examination of alar musculature

Figure 416: Nasal respiration

The size and shape of the external nares of a
patient with nasal respiration during inspiration
(left) and expiration (right).
The very noticeable changes in the cross-section
of the nasal orifices are typical for nasal-breathers
 Respiration – page 163

Examination of Breathing Mode (cont)

Figure 417: Oronasal respiration

The cross-section of the external

nares of a patient with prevailing
oral respiration during inhaling (left)
and exhaling (right).
The alar muscles are inactive
nares do not change their size,
which is a clinical feature of
increased oral respiration.

• When interpreting the findings, it must be taken into account that the
respiratory mode is controlled by the nasal cycle which changes approximately
every 6 hours. This is a physiologic protective mechanism which prevents the
nasal membranes from drying out (Eccles,1978; Masing and Wolf 1969).
• Due to the nasal cycle, one nasal airway is always more constricted than the
other, i.e. an apparent unilaterally obstructed nasal passage during the crude
clinical examination is not necessarily a pathologic finding.
 Page 164 - Functional Analysis

Differential Diagnosis
• Differential diagnosis must be used to determine
whether the problems in nasal respiration are due
to an obstruction of the upper nasal passages or to
habitual oral respiration (Fig. 418).
Figure 418:
Differential diagnosis of
restricted nasal respiration

The orthodontic treatment

planning for patients with
restricted nasal respiration must
be related to the d iag nosis of
the ENT-specialist.
Otorhinologic determination of
the nasal resistance appears to
be an important paramete
 Page 164 - Functional Analysis

Differential Diagnosis (cont.)

• In the first case, an operation by an ENT-specialist is
indicated; i.e. in the case of allergic rhinopathy,
edication should be applied.
• Should the nose not be obstructed, pre-orthodontic
therapy should be carried out to treat the restricted
nasal breathing.
• This may include breathing exercises (Fig. 419) or
incorporation of a perforated oral screen (Fig. 420)
 Page 164 - Functional Analysis

Differential Diagnosis (cont.)

Figure 419:
Myofunctional exercises for
patients with habitual oral
respiration
Lip exercises with a piece of
cardboard to improve the lip seal
are indicated.
Right: The cardboard should be
held loosely in a horizontal position
with the lip

Figure 420:
Changing habitual oral respiration

The custom-made, perforated oral

screen is placed in the vestibule.
The air holes in the appliance are
sealed off one after the otherto
convert patients who breathe throu
Record Sheet – Page 165

Functional Analysis –
Record Sheet
 THANK YOU

Color Atlas of Dental Medicine – The Series