Clinical Examination
Extraoral examination:
Head and neck: Within normal limit
Lymph nodes: Within normal limit
Facial asymmetry: No facial asymmetry detectable
Intraoral Examination: Lips, tongue, floor of the mouth, soft palate,
tonsillar fossae and pharynx appear within normal limits. Salivary flow
is within normal limits. Gingiva: localized changes in size, shape,
color, consistency and position.
Dentition
Missing teeth: #1,15
Impactions: none
Defective restorations: Fixed Partial Denture (FPD) #14-16 (delivered 12/94, patient "cannot chew
on that side at all." Bridge was adjusted many
times but still "...feels high.)"
Missing restorations: none
Open contacts: none
Diastemas: none
Malposition: #23-25 crowding
Erosion: none
Extrusion: #9
Wear facets: no
Occlusal Examination
Angle classification: Right side - Class I with Class III tendency
Left side - Class I
Centric relation:
CO/CR discrepancy: none: CO=CR
Protrusive guidance: Anterior guidance
Right lateral guidance: Group function
working: contact with the following teeth: 2/31, 3/30, 4/30, 4/29, 5/29, 6/28
non-working: none
Left lateral guidance: Group function
working: contact with the following teeth: 14/19, 13/20, 12/21, 11/22
non-working: none
Incisal relationship: Vertical overlap 4mm
horizontal overlap 2mm
Occlusal plane: normal
Fremitus: #9, 10
TMJ Exam: Within normal limit
Range of motion
-max opening 60mm
-protrusion normal
-right lateral normal
-left lateral normal
Deviation: none
Muscular tenderness: none
Periodontal Findings
Description of gingiva: mild to moderately inflamed
color: pink with localized marginal and papillary erythema or
localized marginal cyanosis
texture: smooth
tone: localized fibroedematous/edematous
Plaque score: 82% plaque free
location: distal areas interproximally, lower frontal sextant lingually
Inflammation: generalized mild to moderate
Probing depths: 2-9mm maxilla, 2-8mm mandible
Suppuration: none
Supragingival calculus: localized mild
Subgingival calculus: localized mild
Mucogingival problems:
attached gingival: 2-4mm, except facial of teeth #3, 14
vestibular depth: adequate, except area of teeth #3, 14
areas of recession: Facial- teeth #2, 3, 4, 5, 6, 8, 12, 13, 18, 19, 20, 22, 27, 28, 29, 30, 31
Lingual - teeth #2, 3, 4, 5, 6, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28
Frenum pulls:
Furcations: Grade I Glickman: teeth numbers: 5M, 18B, 19B, 20B, 30B
Grade II Glickman: teeth numbers: 3B, 3D
Mobility: teeth #3, 4, 5, 7, 12, 14, 23, 24, 25, 26, 9, 10