Gina

Gina’s Examination Results

PART I: Pa)ent History

PART II: Examina)on
PART III: Radiographic Examina)on
Key:
In the coming slides you will see the results of the history and clinical and radiographic examinations. 

ý indicates presence of a finding or condition,
o indicates absence or no finding.
(I) Patient History - Gina Gina

1. Chief complaint
1) Wants upper laterals to be replaced to improve appearance

2. Local symptoms
o Pain
o Infec)on, Inflamma)on
o Bleeding gums
o Food impac)on
o Bad taste
o Tooth mobility, Migra)on
o Impaired chewing func)on
ý Enough teeth o Yes ý No
ý Aesthe)c concerns Dissa6sfied with aesthe6cs offered by upper Hawley retainer
(I) Patient History - Gina Gina

3. Dental history
ý Last visit to the den)st: 6 months ago
ý Last tooth cleaning: 6 months ago
ý Periodontal therapy non-surgical periodontal treatment has been done
o Pregnancy gingivi)s
ý Orthodon)c therapy lasted lasted 3 years but is now complete
o TMJ dysfunc)on
o Pain o Clicking o Crepitus
ý Loss of teeth
o Caries o Perio ý Ortho 15, 25, 34, 44 ý Congenital 12, 22
o Tooth replacement

o Fixed o Removable o Sa)sfied
(I) Patient History - Gina Gina

4. Oral hygiene
ý Toothbrush
oSoU ý Medium o Hard
ý Nylon o Natural o Electric
ý Applica)on: 2 mins / 4 x daily
o Disclosing
ý Addi)onal aids
ý Floss o Irrigator
o Tooth picks ý Interdental brush
ý Fluoride
o Tablets o Gel ý Mouth rinse Listerine
ý Toothpaste Oral B
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(I) Patient History - Gina Gina

5. General medical risk assessment

o Allergies
o Rheuma)c fever
o Cardiovascular diseases
o Blood diseases
o Neoplasms
o Diabetes
o Pregnancy
o Hepa))s o Hep. A o Hep. B o Hep. C
o Other
(I) Patient History - Gina Gina

6. Medica)on
o Insulin
o Cor)costeroids
o Dilan)n
o An)coagulant
o An)bio)cs
o Immunosuppressives
o Others

7. Smoking history
o Smoke
ý Non-smoker
o Former smoker
(II) Examination - Gina Gina

1. Extraoral examina)on
o Skin
o Head
o Eyes
o Neck
o Hands
o Pigmenta)on
o Halitosis
o Other
(II) Examination - Gina Gina

2. Intraoral examina)on
o Lips
o Labial mucosa
o Buccal mucosa
o Alveolar mucosa
o Hard palate
o SoU palate
o Tonsils
o Floor of the mouth
o Tongue
o Salivary glands o Saliva
(II) Examination - Gina Gina
3. Clinical dental examina)on
17 16 14 13 11 21 23 24 26 27

Restoration

Abr/ Attr / Eros

CO2-Test + + + + + + + + + + + +
(II) Examination - Gina Gina
3. Clinical dental examina)on

CO2-Test + + + + + + + + + + + +
Abr/ Attr / Eros

Restoration

47 46 45 43 42 41 31 32 33 35 36 37
(III) Radiographic Examination - Gina Gina
(III) Radiographic Examination - Gina Gina
(II) Examination - Gina Gina

4. Func)onal analysis
4.
ý 1/2 Min. Test (Shore 1958): TMJ palpa)on during movements
o Pain o Crepitus
Restricted mobility: oYes ýNo Opening: 51 mm
o Lateral pterygoid muscles tender to palpa)on
o Parafunc)on o Bruxism
ý Occlusal class:
Angle I: R ý L ý Angle II: R o L o Angle III: o R o L
o Prognathism
ý Overbite: 2 mm o Deep bite: o Primary o Secondary
ý Overjet: 1 mm
(II) Examination - Gina Gina

4. Func)onal analysis (con)nued)

o Crossbite 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

o Premature contacts in CR
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

o Slide in centric: o Yes ý No

0 mm Sagibal
0 mm Lateral (right)
0 mm Ver)cal
o Posterior contacts in protrusion

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
(II) Examination - Gina Gina

4. Func)onal analysis (con)nued)

ý Working side movements
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

ý Group func)on ý R ý L
o Canine guidance o R o L
o Balancing interferences
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

o Wear facets

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
(II) Examination - Gina Gina

5. Periodontal screening

(Basic Periodontal Examina)on: BPE)

3 1 3
BPE
3 2 3
(II) Examination - Gina Gina

Examination
Periodontal charting
Pre - treatment

Ini6al
examina6on
(II) Examination - Gina Title Text Gina

Examination
Periodontal charting
Pre - treatment

4 pockets of 4-5mm

Ini6al
examina6on
(II) Examination - Gina Gina

Examination
Periodontal charting
Pre - treatment

Ini6al
examina6on
(II) Examination - Gina Gina

Examination
Periodontal charting
Pre - treatment

5 pockets of 4-5mm

Ini6al
examina6on
(II) Examination - Gina Gina

6. Periodontal indices

ý Plaque Index (O‘Leary et al. 1975): 34 %

ý Bleeding on probing (BOP): 12 %

 Summary Gina
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styles
1. Chief complaint
Impaired aesthe)cs due to congenitally missing upper lateral incisors

2. Financial situa)on
Nego)able