Patient examination in esthetic dentistry

  • Ugur Erdemir
  • Esra Yıldız
  • Taner Yucel
Part of the following topical collections:
  1. Prosthodontics and Restorative Dentistry


A comprehensive evaluation of the patient before initiation of any therapy is important to establish a treatment plan. For a long-term success of any treatment, a detailed analysis of the patient involving medical/dental history and clinical evaluation along with dental X-rays is essential.


Esthetic dentistry Clinical examination Intra-oral examination Extra-oral examination 

Quick reference/description

A comprehensive evaluation of the patient before initiation of any therapy is important to establish a treatment plan. For a long-term success of any treatment, a detailed analysis of the patient involving medical/dental history and clinical evaluation along with dental X-rays is essential [1].

Symptoms [1, 2, 3]

  • Diastema or spaces between the teeth

  • Misalignment of teeth (especially in the anterior region)

  • Disproportioned teeth

  • Discrepancies between the tooth size and arch length

  • Discrepancy of tooth size or shape

  • Mesiodens

  • Hypodontia

  • Microdontia

  • An enlarged frenum

  • Pernicious oral habits

  • Systemic oral pathological conditions

  • Congenital tooth absence.

Clinical examination

Clinical examination includes assessment of: [1, 4, 5]
  • Dental hard tissues

  • Functional elements

  • Oral soft tissues

  • Lips

  • Patient’s facial characteristics.

Materials/instruments [1, 6]

  • Millimeter ruler

  • Calipers or compasses

  • Therabite appliances

  • Magnifier tools (i.e., × 2.5 or greater loops)

  • Air syringe

  • Dental casts

  • Blunt-edged periodontal probe


To obtain satisfactory results in esthetic dentistry, the expectations of patients and functional elements should be evaluated to obtain satisfactory results [1, 7].

A detailed evaluation, including medical history along with intraoral and extraoral examination of the patient before initiation of any therapy is necessary (Fig. 1) [1, 7, 8].
Fig. 1

Roadmap of comprehensive patient evaluation in esthetic dentistry

Medical history

A detailed history form should be filled documenting the medical and dental history of the patient. Information should be obtained regarding: [1, 8]
  • Infections or systemic disease

  • Prophylactic therapies

  • Treatment modifications

  • Allergic reactions to drugs and restorative materials

  • Physiological changes due to aging

  • Smoking

  • Plaque control

  • Pernicious habits (i.e., thumb sucking)

  • Dietary habits

  • Present and future restorative and oral care

  • Previous dental visits and treatments, past dental problems, previous conditions, and patient responses to procedures

Extraoral examination

After recording the medical and dental history, detailed clinical evaluation of all determinants of the mouth such as extraoral examination, periodontal condition, general tooth health, oral soft tissue, and occlusion is done.

The determination of the harmonious function or dysfunction and all components of the stomatognathic system should be carefully evaluated [1].

Observe for: [1, 5, 6, 7, 8]
  • Facial symmetry

  • Lip position at rest and at smile

  • Facial contours

  • Midline axis

  • Significant TMJ changes

  • Rattling noise during chewing

  • Headaches

  • Muscle tension

  • Mandibular motion

  • Switching limits

  • Mastication

Temporomandibular joint (TMJ):

Mandibular motion can be evaluated by observing maximum opening, lateral and protrusive movement of the mandible.

The clinician can evaluate minor deviations during mandibular movement and switching limits by standing at the 12 o’clock position (Fig. 2) [1, 6, 9].
Fig. 2

Evaluation of the patient from 12 o’clock position

It also allows the clinician to evaluate the pain response of the patient by pressing onto the capsule during the switching motion.

The lateral pole and interrelated surrounding structures can be evaluated by palpating the TMJ when the mandible is closed and widely open (Fig. 3a, b) [1, 9].
Fig. 3

Palpation of the TMJ (a) when mandible is closed and b mandible is opened widely

In superior compression test of TMJ, bimanual guidance is used to measure the load-bearing capacity of the TMJ (Fig. 4). If pain and tension are apparent during this test, then they arise from intracapsular or surrounding structures [9].
Fig. 4

Load-bearing capacity examination of the TMJ using bimanual guidance


Masticatory muscles can be tested by palpation. Healthy and well-functioning muscle should not show any hypertrophy, sign, or pain during examination [1, 10]. Any discomfort or pain detected on palpation indicates that muscle is in hypercondition or hypertrophy [1].

Factors provoking muscle discomfort or pain include: [1, 6, 9, 10]
  • Pathological condition (atypical facial pain, migraine)

  • Parafunctional conditions (clenching, grinding, bruxism)

  • Musculoskeletal disorders.

Extraoral muscles are evaluated first, followed by the intraoral muscles. During extraoral examination the masseter muscle, temporalis muscles, occipital muscle, sternocleidomastoid muscles, medial pterygoid muscle, and digastric muscles should be palpated in sequence [1, 6, 9].

If there is any painful response or discomfort during palpation of these muscles, evaluation of non-dental problems such as migraines and atypical facial pain should be made [1, 6].

If there is a positive response to palpation of occipital muscles, a possible cervical component problem should be considered (Fig. 5a) [1, 6]. An intraoral examination of medial pterygoid muscles should be done in addition to the extraoral examination (Fig. 5b) [1, 9].
Fig. 5

a Palpation of occipital muscle. b Palpation of medial pterygoid muscle. c Palpation of lateral pterygoid area on the superior maxillary tuberosity

The lateral pterygoid (Fig. 5c) is examined by positioning in front of the patient and placing his or her thumbs on the tip of the chin and asking the patient to move the mandible forward [1, 6, 9].

Intraoral examination

After the entire extraoral examination is complete, intraoral examination involving dental status, periodontal status, periapical condition, occlusion, and esthetic analysis should be done.


A tooth-by-tooth examination should be done for a complete functional and esthetic evaluation. Evaluate for: [1, 4]
  • Teeth alignment

  • Tooth–tooth relationships

  • Tooth–gingival relationships

  • The tooth surface

  • Caries lesions,

  • Defective restorations

  • Mechanical and/or chemical tooth defects such as erosion, abrasion, and attrition.

The teeth should also be evaluated by percussion on different directions for any sign or symptom of periapical pathology.

Periodontal Examination:

During periodontal examination evaluate for: [1, 4, 6, 9]
  • Gingival levels

  • Symmetry or asymmetry

  • Gingival embrasures

  • Esthetics of the gingival tissue

  • Bone support

  • Any furcation defects

  • Gingival bleeding

  • Gingival recession

  • Periodontal pockets

  • Plaque

  • Calculus

  • Mobility of a tooth.

Examination of Labial Frenum:

During intraoral examination, an abnormal frenum attachment can be directly visualized. The blanching of interdental gingival tissue (blanching test) should be checked when the upper lip is lifted and the frenum is pulled (Fig. 6) [1].
Fig. 6

a, b Blanching test

Examination of the Tongue:

The position of the tongue at rest should be observed while the patient is unaware that the clinician is examining [1]. Patient is instructed to calmly and slowly open the mouth to such an extent that the clinician can see the tongue position [1].

For examining the lingual frenum, the patient is asked to contact the tip of the tongue to the palate while the mouth is wide open.

Evaluate for: [1]
  • Shape, size and function of the tongue

  • Indentations on the lateral borders of the tongue

  • Lingual frenum attachment

Radiographic Evaluation:

Full-mouth periapical radiography should be considered if the clinician suspects any periapical pathology for a tooth or dentition. Radiovisiography (RVG) can be used to protect the patient from radiation [1].

In orthodontics, lateral cephalometric radiographs are required to evaluate skeletal relationships, incisor inclinations, lip positions, and overall soft-tissue facial profile [1].

Computed tomography and magnetic resonance imaging can be used for soft- and hard-tissue evaluation [1, 9].

Examination of Occlusion:

Examination of Occlusion includes evaluation of: [1, 6]
  • Overjet

  • Overbite

  • Amount and localization of the diastema

  • Crowding

  • Maxillary and mandibular relationships (both transversal and sagittal)

Dental casts can be used to visualize interarch and tooth-to-tooth relationships, and can show the current condition (Fig. 7). They are also used to perform tooth–arch size analysis [1].
Fig. 7

Analyzing and visualizing interarch and tooth-to-tooth relationships on study models mounted on an articulator

Esthetic evaluation:

The planned restorations need to be functional, biocompatible with the soft tissue, and esthetically pleasing for patients.

Following points should be considered in esthetic dentistry: [1, 3, 9]
  • The midline

  • Smile line

  • Gingival exposure at rest and smile

  • Tooth-to-tooth relationships

  • Tooth–soft-tissue relationships

  • Relationships of teeth with the lips and face of the patients on the esthetic reconstruction area

  • How the planned restoration will fit on this framework

Differential diagnosis

When the differential diagnosis is considered, photographs of the patients obtained from different angles, study models and occlusion analysis records (static or dynamic) both obtained from directly patients and from the study models that were mounted on an articulator or computerized systems (e.g., T-Scan) would be quite important assistant for clinicians [1, 4]. In this way, substantial details on the final restoration and relationship with surrounding pink and white tissues, as well as patient’s lips and face will be analyzed in detail and all these records will create esthetic and functional restorations that are balanced with the TMJ and supporting muscles [1, 4, 9].

Pitfalls and complications

  • Panoramic radiography exhibits a lower sensitivity than periapical radiography [1].

  • Traditional radiography exposes the patient to radiations [1].

  • Lateral pterygoid muscle is difficult to examine due to its anatomical location [1, 6, 9].

  • Evaluation of patient from twelve o’clock position not only important for mandibular movement but also for facial symmetry and smile line [1].

  • Habits of the patients such as diet, smoking, and other pernicious habits (i.e., thumb sucking) could contraindicate, complicate or alter the treatment procedure [1, 8].

  • In general routine dental restorative treatment procedure facial symmetry, lip position at rest and at smile, facial contours, and midline axis may not be major evaluation criteria but are important parts in esthetic restorative dentistry [1, 6].

  • Saliva, bacterial plaque, stains, and food deposits may complicate the visual examination of the tooth surface [1].

  • The use of magnification tools (e.g., × 2.5 or greater loops) can help better visualization and evaluation of the dentition for decay, defective restorations and other kind of defects [1, 6].

  • The differential diagnosis of macroglossia is very difficult because it is not always possible to evaluate its true size and adaptation capability to the space available in the oral cavity [1, 11].

  • Occlusion analysis of a patient is difficult and not enough with single visual analysis [1].

  • Non-carious tooth defects such as erosion, abrasion and attrition can cause occlusal/incisal surface damage leading to decreased occlusion [1].

Further Reading

  1. 1.
    Erdemir U, Yildiz E, Yucel T (2016) Initial consultation and/or clinical considerations (patient history). In: Erdemir U (ed) Esthetic and functional management of diastema: a multidisciplinary approach. Springer International, Basel, pp 17–37CrossRefGoogle Scholar
  2. 2.
    Chu CH, Zhang CF, Jin LJ (2011) Treating a maxillary midline diastema in adult patients: a general dentist’s perspective. J Am Dent Assoc 142(11):1258–1264CrossRefPubMedGoogle Scholar
  3. 3.
    Oquendo A, Brea L, David S (2011) Diastema: correction of excessive spaces in the esthetic zone. Dent Clin North Am 55:265–281CrossRefPubMedGoogle Scholar
  4. 4.
    Goldstein RE (1998) Esthetics in dentistry, 2nd edn. B.C. Decker Inc., Hamilton, pp 17–49Google Scholar
  5. 5.
    Ahmad I (2006) Protocols for predictable aesthetic dental restorations. Blackwell Munksgaard, Oxford, pp 1–16Google Scholar
  6. 6.
    Santucci E, Santuscci N (2010) The initial patient examination. In: Geissberger E (ed) Esthetic dentistry in clinical practise, 1st edn. Wiley-Blackwell, Ames, pp 29–41Google Scholar
  7. 7.
    Italian Academy of Conservative Dentistry (2012) Restorative dentistry, 1st edn. Elsevier Mosby, St. Louis, pp 3–48Google Scholar
  8. 8.
    Heymann HO, Swift EJ Jr, Ritter AV (2013) Sturdevant’s art and science of operative dentistry, 6th edn. Elsevier Mosby, St. Louis, pp 89–112Google Scholar
  9. 9.
    Tarantola GJ (2010) Clinical cases in restorative and reconstructive dentistry, 1st edn. Wiley-Blackwell, Ames, pp 5–25Google Scholar
  10. 10.
    Okeson JP (2008) Management of temporomandibular disorders and occlusion, 6th edn. Elsevier Mosby, St. Louis, pp 216–284Google Scholar
  11. 11.
    Attia Y (1993) Midline diastemas: closure and stability. Angle Orthod 63:209–212PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Restorative Dentistry, Faculty of DentistryIstanbul UniversityCapa-IstanbulTurkey
  2. 2.Private PracticeAbide-i Hurriyet Cad. Pay AptŞişli-IstanbulTurkey

Personalised recommendations