FUNCTIONAL ANALYSIS

Patient’s Name_________________________ Date_________________

1. Muscle Examination
Muscle Palpation (0 – 10) Right Left
Negative  (0-10)____  (0-10) ____
Anterior Temporalis  (0-10)____  (0-10) ____
Posterior Temporalis  (0-10)____  (0-10) ____
Masseter  (0-10)____  (0-10) ____
Anterior Digastric  (0-10)____  (0-10) ____
Lateral Pterygoid (Provocation test)  (0-10)____  (0-10) ____
Diagnosis _______________________________________________
Comments_______________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

2. Range of Motion Measurements

Excursion Right ______mm Excursion Left_____mm
Deviation Right ______mm Deviation Left _____mm

Full Opening _______________mm

Comfortable Opening_________mm
Protrusion_________________mm
Diagnosis _______________________________________________
Comments_______________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

Copyright © 2012 Phelan Dental Seminars - All Rights Reserved

 FUNCTIONAL ANALYSIS

3. Joint Examination
Palpation Tenderness  Right  Left
Opening Click  Right  Left
Closing Click  Right  Left
Grating / Crepitus  Right  Left
Pain with Movement: Opening  Yes  No
Protrusive  Yes  No
Lateral  Yes  No

Manipulation  Easy  Moderate  Difficult

Load Test For Tension Or Tenderness Present

 Right  Left

Point of Initial Contact In Centric Relation ______________________

Number of Leafs at Point of Initial Contact______________________
Diagnosis _______________________________________________
Comments_______________________________________________
_______________________________________________________
_______________________________________________________

4. Dental Examination
Tooth Mobility
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
R 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
L

Fractured Teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
R 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
L

Sensitive Teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
R 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
L

Diagnosis _______________________________________________
Comments_______________________________________________
_______________________________________________________
_______________________________________________________

Copyright © 2012 Phelan Dental Seminars - All Rights Reserved

 FUNCTIONAL ANALYSIS

5. Periodontal Examination

Gingival Recession 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
R 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
L

Periodontal Involvement
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
R 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
L

Diagnosis _______________________________________________
Comments_______________________________________________
_______________________________________________________
_______________________________________________________

6. Esthetic Evaluation

Maxillary Midline Centered  Yes  No

If deviated direction  Right ___mm  Left _____mm
Maxillary Occlusal Plane Level  Yes  No
If canted, direction _______________________________________
Maxillary Incisal Edge Position  Acceptable  Alteration Planned
Mandibular Incisal Edge Position  Acceptable  Alteration Planned

Lip Dynamics:  Low  Medium  High

Gingival Tissue Scallop  Low  Medium  High

Present Tooth Shade Maxillary Centrals _____ Maxillary Cuspids ____

Current Size of Maxillary Centrals__________Length_________Width

Esthetic Diagnosis_________________________________________
Comments _______________________________________________
_______________________________________________________
_______________________________________________________

Copyright © 2012 Phelan Dental Seminars - All Rights Reserved