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Palmer notation
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Palmer notation (sometimes called the "Military System" and named for 19th-century American dentist Dr. Corydon Palmer from Warren, Ohio[1]) is a dental notation (tooth numbering system). Despite the adoption of the FDI World Dental Federation notation (ISO 3950) in most of the world and by the World Health Organization, the Palmer notation continued to be the overwhelmingly preferred method used by orthodontists, dental students and practitioners in the United Kingdom as of 1998.[2]
The notation was originally termed the Zsigmondy system after Hungarian dentist Adolf Zsigmondy, who developed the idea in 1861 using a Zsigmondy cross to record quadrants of tooth positions.[3] Adult teeth were numbered 1 to 8, and the child primary dentition (also called deciduous, milk or baby teeth) were depicted with a quadrant grid using Roman numerals I, II, III, IV, V to number the teeth from the midline. Palmer changed this to A, B, C, D, E, which made it less confusing and less prone to errors in interpretation.
The Palmer notation consists of a symbol (⏌⎿ ⏋⎾) designating in which quadrant the tooth is found and a number indicating the position from the midline. Adult teeth are numbered 1 to 8, with deciduous (baby) teeth indicated by a letter A to E. Hence the left and right maxillary central incisor would have the same number, "1", but the right one would have the symbol "⏌" underneath it, while the left one would have "⎿".
Table of codes
[edit]Orientation of the chart is traditionally "dentist's view", i.e. patient's right corresponds to notation chart left. The designations "left" and "right" on the chart, however, nonetheless correspond to the patient's left and right, respectively.
| Permanent Dentition | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| upper right | upper left | ||||||||||||||
| 8⏌ | 7⏌ | 6⏌ | 5⏌ | 4⏌ | 3⏌ | 2⏌ | 1⏌ | ⎿1 | ⎿2 | ⎿3 | ⎿4 | ⎿5 | ⎿6 | ⎿7 | ⎿8 |
| 8⏋ | 7⏋ | 6⏋ | 5⏋ | 4⏋ | 3⏋ | 2⏋ | 1⏋ | ⎾1 | ⎾2 | ⎾3 | ⎾4 | ⎾5 | ⎾6 | ⎾7 | ⎾8 |
| lower right | lower left | ||||||||||||||
| Primary Dentition | |||||||||||||||
| upper right | upper left | ||||||||||||||
| E⏌ | D⏌ | C⏌ | B⏌ | A⏌ | ⎿A | ⎿B | ⎿C | ⎿D | ⎿E | ||||||
| E⏋ | D⏋ | C⏋ | B⏋ | A⏋ | ⎾A | ⎾B | ⎾C | ⎾D | ⎾E | ||||||
| lower right | lower left | ||||||||||||||
One advantage of Palmer notation is that it can produce a very graphical image, akin to a 'map' of the dentition; tooth transpositions or edentulous spaces can easily be depicted if desired. It would also be feasible to introduce additional alphabetic characters or other symbols, for example to denote supernumerary teeth or bridge pontics, to which a purely numerical method such as the FDI system does not lend itself easily.[4]
Computerization
[edit]With the move from written dental notes to electronic records, some difficulty in reproducing the symbols has been encountered.[4] On a standard keyboard 'slash' and 'backslash' may be used as a crude approximation to the symbols with numbers placed before or afterwards; hence 3/ is 3⏌ and /5 is ⎾5.
The Miscellaneous Technical block in Unicode provides Palmer notation symbols in U+23BE through U+23CC. The symbols are not to be confused with box-drawing characters (┘└ ┐┌), which have the horizontal line at the middle.[5] These symbols are inherited from JIS X 0213 Dentist symbols.[6]
Daniel Johnson has put together a Palmer Tooth Notation TrueType font called FreePalmer. It is covered by the GPL 3 license. This font is descended from FreeSans. It can be used in OpenOffice and other software. A "MP7" derivative which enables the grid patterns to be produced that correspond to handwritten Palmer tooth notations is available for download as well. The FreePalmer characters are placed in the Latin-1 part, overriding existing characters.[7] A more technically correct way would be to program orthographic ligatures into the font.
Victor Haderup notation (Danish variant)
[edit]The Danish dentist Victor Haderup devised a variation of the Palmer notation where the (⏌⎿ ⏋⎾) symbols are replaced by plus/minus signs, which can either be placed in front or behind the number.[8][9] A plus (+) indicates upper position while minus (−) indicates lower. When the sign is in front of the number, it indicates left while after it indicates right. For instance −6 indicates the 6th lower left tooth, i.e. first mandibular molar.
See also
[edit]References
[edit]- ^ Edward F. Harris (2005). "Tooth-Coding Systems in the Clinical Dental Setting" (PDF). Dental Anthropology. 18 (2): 44. ISSN 1096-9411. Archived from the original (PDF) on 2012-01-06.
- ^ Blinkhorn A, Choi C, Paget H (1998). "An investigon into the use of the FDI tooth notation system by dental schools in the UK". European Journal of Dental Education. 2 (1): 39–41. doi:10.1111/j.1600-0579.1998.tb00034.x. PMID 9588962.
- ^ Huszár G (1989). "[The role of the life and works of Adolf Zsigmondy and Ottó Zsigmondy in the history of dentistry]". Fogorv Sz. 82 (12): 357–63. PMID 2689240.
- ^ a b Ferguson J (2005). "The Palmer notation system and its use with personal computer applications". British Dental Journal. 198 (9): 551–3. doi:10.1038/sj.bdj.4812303. PMID 15895048.
- ^ "Unicode chart, U2300 Miscellaneous Technical" (PDF). Retrieved 22 August 2023.
- ^ "Universal Multiple-Octet Coded Character Set International Organization for Standardization" (PDF). unicode.org. Retrieved 22 August 2023.
- ^ "FreePalmer TrueType Font".
- ^ Havale, R.; Sheetal, B. S.; Patil, R.; Hemant Kumar, R.; Anegundi, R. T.; Inushekar, K. R. (2015-06-01). "Dental notation for primary teeth: a review and suggestion of a novel system". European Journal of Paediatric Dentistry. 16 (2): 163–166. ISSN 1591-996X. PMID 26147826.
- ^ "Victor Haderup". Den Store Danske (in Danish). Gyldendal.
Sources
[edit]- Bunn S (19 May 2006). "Tooth Numbering". Retrieved 2010-04-21.
External links
[edit]Palmer notation
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History
Zsigmondy System
The Zsigmondy system was developed in 1861 by Hungarian-born dentist Adolf Zsigmondy, who practiced in Vienna, as a foundational method for systematically charting tooth positions in the dental arch.[2][4] This system introduced a diagrammatic approach known as the "Zsigmondy cross" to visually represent the oral cavity, facilitating precise documentation in clinical and educational settings.[5][2] The Zsigmondy cross consisted of a horizontal line symbolizing the upper dental arch (occlusal plane) intersected by a vertical line marking the midline, forming an L-shaped or cross-like structure; tooth positions were indicated by placing numerals around this diagram to denote the four quadrants without employing quadrant-specific symbols.[2][5] For permanent dentition, Arabic numerals 1 through 8 were assigned to each quadrant, progressing from the central incisor (1) to the third molar (8).[2][4] Primary teeth were denoted using Roman numerals I to V per quadrant, with I representing the central incisor and V the second molar.[2][4] Zsigmondy detailed his system in publications within German dental journals, including the 1861 article "Grundzüge einer praktischen Methode," which emphasized its utility for practical tooth recording.[2] This work contributed to the system's early adoption in Europe, where it became a standard for visually mapping dental arches in professional practice.[2][5]Palmer Modifications
Corydon Palmer, a dentist from Ohio, United States, developed modifications to the Zsigmondy system around 1870, claiming independent invention while adapting its core numeric positioning for greater practicality in clinical use.[6] These changes replaced the original Zsigmondy cross—a diagrammatic grid for quadrant identification—with simpler line-based symbols to denote the four quadrants more efficiently in records. Palmer introduced specific symbols for the quadrants: right-angle symbols ┘ for the upper right, └ for the upper left, ┐ for the lower left, and ┌ for the lower right, often depicted as inverted L shapes for handwriting ease.[7] This simplification aimed to streamline documentation without requiring complex diagrams, making the system more accessible for daily dental practice. In a 1891 article published in The Dental Cosmos, Palmer advocated for the modified system's adoption, highlighting its utility in accurately tracking treatments and avoiding errors in patient charts. He emphasized how the line symbols and retained numbering enhanced record-keeping efficiency compared to verbose descriptions or anatomical names. For primary teeth, Palmer shifted from Zsigmondy's Roman numerals (I–V) to letters A–E, aligning the notation with permanent dentition while preventing overlap with permanent premolar and molar numbers (4–8); A denoted the central incisor, B the lateral incisor, C the canine, D the first molar, and E the second molar within each quadrant. The historical debate centers on whether Palmer's work represented true independent invention—given his unawareness of Zsigmondy's 1861 publication—or a direct adaptation, as the core sequencing remained similar; Palmer actively promoted the system at American Dental Association meetings and through journals, facilitating its spread in American and European dentistry by the early 20th century.[6]Core Principles
Quadrant Identification
Palmer notation divides the oral cavity into four quadrants based on the patient's perspective, with the upper right quadrant encompassing teeth from the upper right central incisor to the upper right third molar, the upper left quadrant covering the corresponding left-side teeth, the lower left quadrant including the lower left teeth from central incisor to third molar, and the lower right quadrant addressing the lower right equivalents.[7] This division facilitates precise localization of teeth within the dentition.[8] Each quadrant is designated by a specific L-shaped symbol derived from the corners of a diagrammatic representation of the dental arches, mimicking directional lines for intuitive visual reference aligned with the layout of the mouth.[9] The symbols are: ┘ for the upper right quadrant, └ for the upper left quadrant, ┐ for the lower left quadrant, and ┌ for the lower right quadrant.[7] These symbols provide a compact, non-numeric method to indicate laterality and arch position, enhancing quick identification during clinical documentation.[8] The quadrant symbol is conventionally placed immediately before the tooth number to denote the location, ensuring unambiguous reference within the notation system.[10] For instance, the upper right first molar would be represented as ┘6, integrating seamlessly with the sequential numbering.[7] In cases involving exact midline teeth, such as the central incisors, a quadrant symbol is typically still specified for complete clarity, though some simplified contexts may omit it when the position is evident.[8] Visually, the symbols align with the patient's facial orientation: when facing the patient, the ┘ symbol points to the upper right side (patient's right), └ to the upper left (patient's left), ┐ to the lower left (patient's left), and ┌ to the lower right (patient's right), creating a logical mapping that corresponds to the anatomical arrangement of the dental arches.[11] This patient-centered perspective aids in standardizing communication across dental records and radiographs.[7]Tooth Positioning
In Palmer notation for permanent teeth, each quadrant employs a sequential numbering scheme from 1 to 8, beginning with the central incisor designated as 1 and progressing posteriorly to the third molar as 8.[7] This arrangement reflects the anatomical order of tooth eruption and position within the dental arch.[3] The system maintains symmetry across quadrants, mirroring the numbering for corresponding teeth between the left and right sides of both the maxillary and mandibular arches, which simplifies bilateral comparisons.[12] Numbers increase away from the midline, oriented from the patient's perspective to ensure consistent identification regardless of the observer's viewpoint.[13] While the standard scheme adheres strictly to numbers 1 through 8, some extensions incorporate 9 to denote supernumerary teeth or serve as placeholders for absent ones, though this is not part of the core system. Quadrant symbols, such as ┘ for the upper right, prefix these numbers to specify location.[7] This emphasis on positional symmetry over absolute global numbering aids orthodontic planning by enabling straightforward assessment of tooth alignment and movement across symmetric arches.[12]Application to Dentitions
Permanent Teeth
In the Palmer notation system, the 32 permanent teeth are identified by combining a quadrant symbol with a number from 1 to 8, where the numbering begins at the midline and proceeds posteriorly in each quadrant. The quadrants are designated as follows: upper right with ┘, upper left with └, lower left with ┐, and lower right with ┌.[1] This approach ensures precise identification across the maxillary and mandibular arches, with numbers corresponding to specific tooth positions regardless of the quadrant. The numbering sequence is consistent: 1 for central incisor, 2 for lateral incisor, 3 for canine, 4 for first premolar, 5 for second premolar, 6 for first molar, 7 for second molar, and 8 for third molar. For instance, ┘1 refers to the upper right central incisor, └8 to the upper left third molar, ┐1 to the lower left central incisor, and ┌7 to the lower right second molar. In clinical contexts, this notation streamlines documentation; a procedure such as a filling on the upper right canine would be recorded as "filling on ┘3," while an extraction of the lower right first premolar might be noted as "extraction of ┌4." These combinations allow for quick reference in patient records, radiographs, and treatment plans.[1]| Quadrant | Symbol | Number | Tooth Type |
|---|---|---|---|
| Upper Right | ┘ | 1 | Central Incisor |
| Upper Right | ┘ | 2 | Lateral Incisor |
| Upper Right | ┘ | 3 | Canine |
| Upper Right | ┘ | 4 | First Premolar |
| Upper Right | ┘ | 5 | Second Premolar |
| Upper Right | ┘ | 6 | First Molar |
| Upper Right | ┘ | 7 | Second Molar |
| Upper Right | ┘ | 8 | Third Molar |
| Upper Left | └ | 1 | Central Incisor |
| Upper Left | └ | 2 | Lateral Incisor |
| Upper Left | └ | 3 | Canine |
| Upper Left | └ | 4 | First Premolar |
| Upper Left | └ | 5 | Second Premolar |
| Upper Left | └ | 6 | First Molar |
| Upper Left | └ | 7 | Second Molar |
| Upper Left | └ | 8 | Third Molar |
| Lower Left | ┐ | 1 | Central Incisor |
| Lower Left | ┐ | 2 | Lateral Incisor |
| Lower Left | ┐ | 3 | Canine |
| Lower Left | ┐ | 4 | First Premolar |
| Lower Left | ┐ | 5 | Second Premolar |
| Lower Left | ┐ | 6 | First Molar |
| Lower Left | ┐ | 7 | Second Molar |
| Lower Left | ┐ | 8 | Third Molar |
| Lower Right | ┌ | 1 | Central Incisor |
| Lower Right | ┌ | 2 | Lateral Incisor |
| Lower Right | ┌ | 3 | Canine |
| Lower Right | ┌ | 4 | First Premolar |
| Lower Right | ┌ | 5 | Second Premolar |
| Lower Right | ┌ | 6 | First Molar |
| Lower Right | ┌ | 7 | Second Molar |
| Lower Right | ┌ | 8 | Third Molar |
Primary Teeth
In the Palmer notation system, primary (deciduous) teeth are designated using letters A through E within each quadrant to account for the 20-tooth dentition, which lacks premolars and thus requires a condensed scheme compared to the permanent set. The lettering begins at the midline and proceeds posteriorly: A for the central incisor, B for the lateral incisor, C for the canine, D for the first molar, and E for the second molar. This adaptation ensures unambiguous identification in pediatric dentistry, where primary teeth predominate until approximately age 6.[1][14] Quadrant symbols mirror those used for permanent teeth: ┘ for the upper right, └ for the upper left, ┐ for the lower left, and ┌ for the lower right. Simplified variants in clinical records or handwriting may employ + for upper right, - for upper left, V for lower left, and ^ for lower right. Full notations combine the symbol with the letter; for instance, ┘A (+A) denotes the upper right primary central incisor, └E (-E) the upper left primary second molar, and ┐B (VB) the lower left primary lateral incisor. These combinations facilitate precise communication in treatment planning, such as noting the extraction of ┌C (^C), the lower right primary canine, in a pediatric case.[1][5] Primary teeth are distinguished from permanent teeth primarily through the use of letters (A-E) versus numbers (1-8), preventing confusion during the mixed dentition phase. In handwritten charts, primary notations may include an underline beneath the letter or a superscript "d" (for deciduous) to emphasize their temporary nature, while digital records often rely on contextual labels or separate sections. This distinction is crucial for tracking exfoliation and eruption sequences.[14][5] The table below outlines the Palmer notation for all 20 primary teeth, specifying tooth types and approximate eruption timelines based on standard developmental patterns.| Quadrant | Tooth Type | Notation | Eruption Timeline (months) |
|---|---|---|---|
| Upper Right | Central Incisor | ┘A | 7–8 |
| Upper Right | Lateral Incisor | ┘B | 9–10 |
| Upper Right | Canine | ┘C | 16–18 |
| Upper Right | First Molar | ┘D | 13–14 |
| Upper Right | Second Molar | ┘E | 25–27 |
| Upper Left | Central Incisor | └A | 6–7 |
| Upper Left | Lateral Incisor | └B | 7–8 |
| Upper Left | Canine | └C | 16–18 |
| Upper Left | First Molar | └D | 13–14 |
| Upper Left | Second Molar | └E | 25–27 |
| Lower Left | Central Incisor | ┐A | 6–10 |
| Lower Left | Lateral Incisor | ┐B | 10–12 |
| Lower Left | Canine | ┐C | 17–21 |
| Lower Left | First Molar | ┐D | 14–16 |
| Lower Left | Second Molar | ┐E | 23–31 |
| Lower Right | Central Incisor | ┌A | 6–10 |
| Lower Right | Lateral Incisor | ┌B | 10–16 |
| Lower Right | Canine | ┌C | 17–21 |
| Lower Right | First Molar | ┌D | 14–16 |
| Lower Right | Second Molar | ┌E | 23–31 |
Variants
Victor Haderup Notation
The Victor Haderup notation was developed between 1887 and 1891 by Danish dentist Victor Haderup as a Scandinavian adaptation of the Palmer notation system.[17][14] This variant aimed to simplify dental recording in the region by retaining core elements of the original while introducing modifications suited to local practices. It shares the quadrant identification symbols with the core Palmer system, using plus (+) and minus (-) signs or directional brackets to denote upper and lower arches, respectively.[2] For permanent teeth, the Haderup notation is identical to the Palmer system, employing the same symbols combined with numbers 1 through 8 to indicate tooth position from the midline outward, such as 1+ for the upper right central incisor or 8- for the lower left third molar.[14] The primary distinction arises in the notation for primary teeth, where a "0" prefix is added to the numerical identifiers to differentiate them from permanent dentition. This results in designations like 01+ for the upper right primary central incisor, 02+ for the upper right primary lateral incisor, 03+ for the upper right primary canine, 04+ for the upper right primary first molar, and 05+ for the upper right primary second molar; similarly, +05 denotes the upper left primary second molar.[14] These prefixed numbers maintain the sequential logic of the Palmer system but enhance clarity in mixed dentition scenarios by avoiding overlap with permanent tooth numbers. The Haderup notation is predominant in Denmark and other Nordic countries, where it promotes consistency in clinical records, particularly for mixed dentition cases involving both primary and emerging permanent teeth.[18] Its adoption in these regions stems from Haderup's emphasis on practical, unambiguous charting that facilitates communication among dental professionals.[17]| Tooth Description | Standard Palmer Notation (Primary) | Haderup Notation (Primary) |
|---|---|---|
| Upper right central incisor | 4+ | 01+ |
| Upper right lateral incisor | 5+ | 02+ |
| Upper right canine | 6+ | 03+ |
| Upper right first molar | 7+ | 04+ |
| Upper right second molar | 8+ | 05+ |
| Upper left second molar | +8 | +05 |
| Lower left central incisor | 4- | 01- |
| Lower right second molar | -8 | -05 |
Frykholm and Lysell System
The Frykholm and Lysell system was introduced in 1962 by Swedish dentists K.O. Frykholm and L. Lysell to enhance the recording of both teeth and their surfaces in dental documentation.[14] This variant builds on the standard primary numbering principles of Palmer notation by retaining its quadrant symbols—such as the plus sign (+) for the upper right quadrant and the minus sign (–) for the lower left—while incorporating numbers 1 through 5 for primary teeth.[14] To distinguish primary (deciduous or milk) teeth from permanent ones, a lowercase "m" suffix is appended to these numerals, ensuring unambiguous identification in mixed dentition without overhauling the foundational structure.[14] The system's primary purpose is to facilitate clear differentiation in international dental records, particularly for pediatric cases where primary and permanent teeth coexist, thereby improving communication across diverse notation practices.[19] It also extends to surface notations, using symbols like "v" for vestibular (buccal/labial), "o" for oral (lingual/palatal), "d" for distal, and "m" for mesial, applied after the tooth identifier (e.g., +1mv for the buccal surface of the upper right primary central incisor).[14] This approach maintains compatibility with existing Palmer-based systems while addressing ambiguities in primary tooth charting. Adoption of the Frykholm and Lysell system has remained limited, primarily within certain European contexts of pediatric dentistry, where it supports research and interoperability with multiple notation frameworks.[19] It is occasionally referenced in surveys of global dental practices but has not achieved widespread use beyond specialized applications.[19] For illustration, the following table compares notations for select primary teeth in the Frykholm and Lysell system against a standard numbered Palmer variant (without suffix or letters):| Tooth Description | Quadrant Symbol | Standard Palmer (Primary) | Frykholm and Lysell |
|---|---|---|---|
| Upper right central incisor | + | +4 | +1m |
| Upper right lateral incisor | + | +5 | +2m |
| Upper right canine | + | +6 | +3m |
| Upper right first molar | + | +7 | +4m |
| Upper right second molar | + | +8 | +5m |
| Lower left central incisor | – | –4 | –1m |
| Lower left lateral incisor | – | –5 | –2m |