Clinical Examination
Extraoral examination: Within normal limit
Head and neck: Within normal limit
Lymph nodes: No palpable lymph nodes
Facial asymmetry: No facial asymmetry detectable
Intraoral Examination: Within normal limit
Dentition
Missing teeth: # 1,16,17,32
Hemisection: # 31 Mesial root hemisected.
Impaction: none
Defective restorations: #2: overhanging restoration
#4: (open margin)
#18: recurrent caries
#20: (open margin)
#29: Recurrent caries
Missing restorations: none
Open contacts: none
Diastemas: #26-27, 22-23
Malposition: none
Erosion: none
Extrusion: #3
Wear facets: #5,8, lower incisors, #20,21,22,29
Occlusal Examination
Angle classification: Class I canine on the left side
Class II canine on the right side
Centric relation: repeatable
CO/CR discrepancy:
anterior/posterior: less than 0.5mm
superior: less than a 0.5mm
right: none
Left: none
Protrusive guidance: Anterior guidance
Right lateral guidance: #29-25/ #4-8
Balancing contacts #18,19,20,21
Left lateral guidance: #21,22,23/#12,11,10
Incisal relationship: Vertical overlap 4mm
horizontal overlap 4mm
Occlusal plane: adequate; supraeruption of # 3
Vertical dimension: no abnormality
Fremitus: none
TMJ Exam: Within normal limit
Range of motion
-max opening 60mm
-protrusive 9mm
-right lateral 11mm
-left lateral 12mm
Deviation: none
Muscular tenderness: none
Periodontal Findings
Description of gingiva: mild to moderately inflamed
color: pink with localized areas reddish-blue
texture: generalized stippling
tone: generalized firm
edematous: localized
fibroedematous: none
Plaque score: 90% plaque free
location: interproximally and lingual of posterior teeth.
Inflammation: Generalized minimal with areas of moderate to severe
localized inflammation
Probing depths: Range 2-7mm
Suppuration: none
Supragingival calculus: mild/absent
Subgingival calculus: mild/absent
Mucogingival problems: none
Frenum pulls: none
Furcations: Grade I Glickman buccal # 15
Mobility: no pathological mobility is clinically detectable