DEPARTMENT OF PROSTHODONTICS AND MAXILLOFACIAL PROSTHETICS

Peoples’ Dental College & HospitalNayabazar, Balaju Kathmandu

FPD CASE HISTORY SHEETPERSONAL INFORMATION

Name : Raju Maharjan Case No: _____

Age /Sex: 41yr/M O.P No: __6203

Address: makhan,kathmandu Phone No:_________

Occupation: social worker Mobile No:_984134997

Marital Status: married Email Address:

CASE HISTORY Chief Complaint :wants to replace missing upper front teeth

History of Presenting Illness:

Medical History:

Drug History:

Allergy History:

Past Dental History:Surgical History:

Restorative / Endodontic History:

Periodontal History:

Prosthodontic History:

Orthodontic History:

Others:

Personal History:Diet:

Oral Hygiene Habit:

Other Habits:

Family History:

EXPECTATION OF PATIENT:

1. Appearance

2. Function

3. Comfort

4. Psychosocial

CLINICAL EXAMINATIONS:General Examination:

Extra oral Examination:Face:

Symmetry: Symmetry / Asymmetry

Profile: Normal / Prognathic / Retrognathic

Tempromandibular Joint:

Status: Normal / Pain / Discomfort

Coding: Grade ____

Sound: Click / Cripitus

Mandibular Opening: ________ mm Adequate / Inadequate / Excessive

Mandibular Movement: Normal / Deviation / Deflection

Lateral Movement: ______mm Adequate / Inadequate / Excessive

Muscles of Mastication:Status: Normal / Pain / Discomfort

Muscle involved

Masseter Temporalis Med Pterygoid

Lat Pterygoid

Other

Coding

Smile Analysis:

Lip Line: High/ Mid / low

Smile Line: Parallel / Anterior divergent / Posterior divergent

Upper Lip Curvature: straight / upward curvature / downward curvature

Negative Space: present / absent

Smile Symmetry: symmetry / asymmetry

Smile Type: tooth / papillary/ gingival / mucosal

Facial Midline: Coincide with dental midline / deviated to right / left by _______mm

Lymph Node:Status: Palpable / Non Palpable

Area:

Tenderness: Tender / Non Tender

Mobility: Mobile / Fixed

Intra oral examination:

Hard Tissue Examination:

Teeth missing:

Dental caries:

Restored teeth:

Teeth alignment: Crowding / Rotation / Supra-eruption / Spacing / Tilting / Drifting

Tooth wear: Abrasion /Erosion / Abfraction / other

Occlusal Analysis: Jaw Relation :

Ant – Posterior: R Class I / Class II / Class III

L Class I / Class II / Class III

Vertical: Over jet ____ mm / Overbite _____ mm

Transverse: Crossbite i.r.t

Occlusal plane: straight / curved / reversed

Type of occlusion:

Centric Tooth Contact:

Ecentric Tooth Contact

Latrusive Contacts:

Protrusive Contacts:

Edentulous space: Mesiodostal Space:

Occluso-gingival Space:

Sebert’ ClassificationClass-I defect / Class-II defect / Class-III defect

Soft tissue Examination:Mucosa:

Gingiva:

Periodontium:

PROVISIONAL DIAGNOSIS:

RADIOGRAPHIC ASSESSMENT:

OPG:

IOPA X-RAY:Bone status:

Endodontic / restoration status:

Periapical status:

Root stumps:

ABUTMENT EVALUATION:

Number of Abutment Teeth:

Type of Abutment: ____________Primary / _________ Secondary / ___________Pier Abutment

Mobility :

Crown Root Ration :

Root Shape and Morphology:

Root Surface Area:

Periodontal Support:

Root Proximity:

Condition of Abutment Tooth:

TREATMENT PLAN: Type of Fixed Partial Denture/ Crown:

Number of abutment:

Tooth preparation:

Provisional restoration:

Tissue retraction:

Final impression:

Permanent restoration:

Type of pontic:

Planned occlusion:

Shade:

LAB WORK EVALUATION:

Impression:

Cast and Die:

Marginal fit:

Contacts:

Contours:

Connector:

Occlusion :

Ethetics:

Other comments: