Esthetics Function - Structure Biology 11.20.

15
Complete right side for each segment check Change on left if required

MAXILLARY ESTHETICS
Display of Centrals
qChange

Display of Central at REST ____mm Display of Central FULL SMILE ____mm

qAcceptable Do NOT Change

Lip Mobility ____mm

qExcessive - shorten ____mm qInadequate - lengthen____mm

Angulation of Centrals
qChange
Midline Location
qChange
Midline Alignment
qChange
Incisal / Occlusal Plane
Incisors to Interpupillary Line

qChange
Incisors to Lower Lip

qChange
Incisors to Posterior Teeth

qChange
Gingival Levels
Amount of Gingival Display

qChange
Free Gingival Margin Level

qChange
Papilla Level Symmetry

qAcceptable Do NOT Change qProclined

qRetroclined

Correction Required ____________________________________________

qNot centered but acceptable

qCentered

Correction Required ____________________________________________

qCorrect

qCanted

Correction Required ____________________________________________

---------------------qLevel with interpupillary line qNot level but acceptable qNOT level
Correction Required ____________________________________________
qFollow lip qDo not follow lip but acceptable qDo NOT follow lip
Correction Required ____________________________________________
qLevel

qNot level but acceptable

qIncisors coronal qIncisors apical

Correction Required ____________________________________________

---------------------qAcceptable display

qExcessive display

Correction Required ____________________________________________

qAcceptable symmetry qAcceptable W/L ratio qUnacceptable Symmetry or W/L
Correction Required ____________________________________________
qAcceptable

qUnacceptable

qAcceptable after changes to incisal edge and free gingival margin

qChange
Buccal Corridor
qChange

Correction Required ____________________________________________

qAcceptable qUnacceptable
Correction Required ____________________________________________

MANDIBULAR ESTHETICS
Display of Centrals
qChange

Display of Teeth at REST ____mm

qAcceptable Do NOT Change

Display of Teeth with speech____mm

qExcessive - shorten ____mm

Correction Required ____________________________________________

Angulation of Centrals

qCorrect

qRetroclined

Correction Required ____________________________________________

qChange
Incisal / Occlusal Plane

qLevel with posterior teeth qIncisors coronal qIncisors apical

Correction Required ____________________________________________

qChange
Gingival Levels

qAcceptable

qUnacceptable

Correction Required ____________________________________________

qChange

FUNCTION

qProclined

---- Check appropriate boxes in each section --------------------------------------------------------

Joints qPain/Tenderness

qNo pain/tenderness qNo Crepitus qNo Joint Sounds

q+Lateral Palpation-qRqL
q+Load Test-qRqL

qCrepitus/Click

qR qL

qLimited Movement

Therapy Required

q+Retrodiscal Palpation-qRqL

q+Translation-qRqL
_________________________________________

qNo pain or tenderness to palpation or hypertonicity

Muscles

qPain / Tenderness
Dentition

qWear

qOther pathology

Therapy Required ______________________________________________

qNo wear

qPhysiologic wear within normal limits

qAnterior

qPosterior

qPathway

qEnd-to-end

qCross-over

qAttrition

qErosion

qAbrasion

qUnknown

qSensitivity

qCrack

qMobility

qFracture

Function Step 4 is evaluation of mounted casts

Function step 5 is developing occlusion on the mounted casts

STRUCTURE / POSITION
Teeth Requiring Treatment

qNone

TREATMENT REQUIRED
qFor Structure

qRestore #________________________________________________________

qFor Esthetics

qRestore #________________________________qOrtho__________________

qFor Function

qRestore #________________________________qOrtho__________________

qInadequate Structure qBuild-up # _______________ qCrown Lengthen # ______________ note in Perio

qFor Missing Teeth

qReplace #________________________________________________________

qRemove Teeth

qRemove #_____________________________________________ note in Surgery

---------------- Treatment Modality Preferred

qReplacement Concerns

qImplants qFPD qRPD

qOsseous Levels

qGingival Levels

qEsthetics

qStructural

BIOLOGY
Teeth Requiring Treatment

qNone

qEndo

_________________________________________________________________

qPerio

______________________ qElective perio______________________________

qOral surgery

______________________ qElective surgery____________________________

_________________________________________________________________