FMR Data Collection FULL NAME:

DATE OF BIRTH - -
Facial analysis (for Smile design) Esthetics
Horizontal reference Use Facial Use Other
Vertical reference Use Facial Use Other
TMJ Mobility* TMJ pain*
Dentolabial analysis
Right Vertical Left
Lip length Short Long Avarage
________ _______ _______
Lip shape Thin Full
1 2 3
pain / no pain pain / no pain pain / no pain

Smile line Low Average High Gummy Smile

Labial corridor space Present Not Present
Right: 1 2 3
Anterior occlusal plane orientation Straight Inclined Right joint Left joint
Dental analysis Clicking Clicking
Left: 1 2 3
Maxillary incisal edge visibility at rest _ _ _ _ _ _ _ _ mm Early / Late Early / Late
*mark only if severe / familiar

Maxillary incisal edge position at rest Flat Reverse Convex Crepitus Crepitus
Posterior occlusal plane orientation Acceptable Modify
Maxillary central incisor width _ _ _ _ _ mm length _ _ _ _ _ mm
Supereruption Subluxation Subluxation
Muscle pain
Protrusion Masseter
Teeth colour Acceptable Modify Developmental causes _______
Temporalis:
lntra-arch analysis - select if needs modifying pain / no pain
• Right
Mildline Crowding Diastema Rotations Crossbite
*draw deflection / deviation Anterior Middle Posterior
Gingiva analysis • Left
Gingival zenith symmetry Acceptable Modify
Obstructive Sleep Apnea
Anterior Middle Posterior
Gingival scallop form Flat Normal High
Suboccipital
MALLAMPATI CLASSIFICATION Trapezius
Sternocleidomastoid
2D/3D RADIOLOGY Imaging Suprahyoid
Caries _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Lateral pterygoid area [intraoral]
Periapical lesions _ _ _ _ _ _ _ _ _ Tendon of temporalis [intraoral]
(+) Immobilization test
Periodontal bone loss
Localized _ _ _ _ _ _ _ _ _ _ _ _ _ Circle muscle causing referred pain
Generalized
class 1 class 2 class 3 class 4
Is this pain familiar? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Peri - implant bone loss _ _ _ _ _ _ _ _ _ _ _ _ _ Narrow arches

Bone dimension for prosthetically guided implants

High palatal vault
Tongue scalloping
Incisal relationship Occlusion
Class 1 Class 2 Class 3
R L Maxillary sinusitis Enlarged tonsils *PG/DISE indicated
Overbite 2-4mm >4mm Less 2mm
Other bone pathologies _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Overjet 0-3mm >3mm Less 1mm
Airway restriction _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Periodontium Positive CCP test Fremitus present
Basic periodontal examination 0-4 / *
TMJ ANALYSIS Is the bite repeatable Yes No
CBCT
Erosion of cortical bone
Dental Condition
R L
R L Narrowing of the joint space Periodontal phenotype ( THICK / THIN )
R L Significant deviation from central position Gingival recession _ _ _ _ _ _ _ _ _ _ _ _ _ _ Defective restorations
R L Abnormal size of the condyle
Violation of the supracrestal tissues Remaining tooth structure without ferrule
MRI Erosion Attrition Abrasion
Tooth hypermobility _ _ _ _ _ _ _ _ _
Disc displacement Carious Lesion
R L with reduction Oral hygiene
Periapical disease _ _ _ _ _ _ _ _
R L without reduction Attached Keratinized Mucosa (AKM) around teeth
Missing teeth
R L Effusion Attached Keratinized Mucosa (AKM) for
implant placement Hypodontia

DIAGNOSIS / BASED ON 1. INTERVIEW 2. EXAMINATION 3.IMAGING

TMD PERIODONTAL DENTAL Other common orofacial pains:
Healthy tooth structure Sinusitis
Healthy Periodontium Caries Periapical lesion Pulpal pain
Functional Disorders Gingivitis Erosion Active Stagnant Tension type headache
Acceptable function Periodontitis / Periimplantitis Attrition Active Stagnant Neuropathic pain
R L Hypermobility of the condyles Recession Abrasion Active Stagnant Migraine
Implant requires soft&hard Psychogenic pain
Restriction due to: Compromised with enamel or ferrule
tissue management Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Muscle / TMJ Compromised without ferrule
Disc displacement:
R L With reduction RISK FACTORS
R
R
L
L
With catching
Without reduction with limitation
OCCLUSION ESTHETICS Ongoing eating disorder
History of TMD problems
Stable repeatable bite Acceptable Bruxism Muscle hypertrophy
R L Without reduction without limitation Easy to improve with prosthodontics
Primary occlusal trauma Hyperdivergent profile with small condyles
Degenerative TMJ disease: Internal discoloration Contact sports
Constricted chewing pattern Lip hypermobility
R L Active Autoimmune diseases
Unrepeatable bite Altered passive eruption
R L Stable Otolaryngologic disorders
Occlusal dysesthesia Too short / Long lip Lip incompetence
Orthodontic disorder Maxillary excess Tongue thrust
Pain Disorders History of unsuccessful procedures
No pain Chronic stress / PTSD / Depression
Local myalgia (acute) Occlusal dysesthesia

TREATMENT PATHWAY
Neurologic disorders / Migraines
Myofascial pain with referral
Muscle spasm
Centrally mediated myalgia (chronic) Esthetics TMD Occlusion Dental Condition Perio/Implant
Arthralgia SIMPLE SIMPLE SIMPLE SIMPLE SIMPLE
COMPLEX COMPLEX COMPLEX COMPLEX COMPLEX
SPECIALIST SPECIALIST SPECIALIST SPECIALIST SPECIALIST

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