DEPT.

OF PROSTHODONTICS AND CROWN &

BRIDGE
C.S.M.S.S DENTAL COLLEGE & HOSPITAL,
KANCHANWADI, AURANGABAD

CASE HISTORY PROFORMA COMPLETE DENTURE

I. Patient Data
Name: ________________________________________________________________ Case No:
____________
Age: ________

Sex: __________ Race: __________________ Occupation:

____________________________
Address: ____________________________________________________ Contact No:
___________________
Cosmetic index: 1 - High cosmetic index/ 2- Mid cosmetic index/ 3- Low Cosmetic index
_______________________
Personality: Philosophical/ Exacting /Hysterical/ Indifferent
_____________________________________________

II. Medical History

General health:
____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
__
Pathology:
________________________________________________________________________________
Diet habits: Veg / Non-Veg

Diet intake: Carbohydrates: Cereals, Potatoes, Sugar;

Proteins: Meat, Egg, Fish, Pulses; Fats: Oil, Butter; Minerals & Vitamins: Vegetables, Fruits, Milk &
Curds ______________________________________

Quality & Quantity of diet: Satisfactory/ Unsatisfactory:

______________________________________________
Reason for deficient diet: Taste/ Custom / Economic/ Ignorance/ Unable to chew
____________________________
Any Habits: Pan / Tobacco chewing / Smoking / Alcoholic / Bruxism / Other:
_________________________________

III. Dental History

Chief complaint:
____________________________________________________________________________

Extraction history:

Reason (Periodontal / Caries / Other)

Year
Maxillary anterior

________________________________________________

________________

Maxillary left posterior

________________________________________________

________________

Maxillary right posterior ________________________________________________

________________

Mandibular anterior

________________________________________________

________________

Mandibular left posterior ________________________________________________

________________

Mandibular right posterior

________________________________________________

________________

What is your problem and why do you seek treatment? Lost all teeth and need
dentures / Old dentures are unsatisfactory or ill-fitting / Old dentures are Worn out / broken / lost
___________________________________________

Age of present denture: _______________________ Duration of edentulism: Max:

________ Man: _________
Number and type of previous dentures:
Removable partial denture:

Maxillary: ______________________ Mandibular:

_______________________
Complete denture:

Maxillary: ______________________ Mandibular:

_______________________
Earlier denture experience: (Good / Poor)
_______________________________________________________
Patient evaluation of dentures (subjective):
Comfort: Good / Fair / Poor

Chewing efficiency: Good / Fair / Poor

Esthetics: Good / Fair / Poor

Articulation: Good / Fair / Poor

Soreness: Good / Fair / Poor

trapping: Good / Fair / Poor

Dentures worn at night: Y / N

Problem with current dentures:

__________________________________________

Expectations: Mastication / Speech / Appearance / Comfort / Professional

__________________________________
Understands limitations: ___________
__________________________________________________________
Pre-extraction records: Casts / Measurements / Photographs / Old Dentures
________________________________

IV. Clinical examination

A] EXTRAORAL EXAMINATION
1. Facial form:

Food

Front: Square/ Tapering/ Square-tapering/ Ovoid

Profile: Class 1 Normal / Class 2 Retrognathic / Class 3 Prognathic
Height: Normal / Decreased / Increased

2. Muscle tone: Class 1 Normal/ Class 2 Slightly impaired/ Class 3 Greatly impaired
3. Muscle development: Class 1 Heavy / Class 2 Medium / Class 3 Light
4. Complexion: Skin color: ________ Skin texture: _________ Eye color: _________ Hair
color: __________

5. Appearance of Cheeks: Full / Hollow

6. Appearance of Skin: Firm / Loose

7. Lip: Thin / Full / Tense / Active

______________________________________________________________
Vermillion border: Max: __________________________ Man:
____________________________
Lip contour: Adequately supported / unsupported

Max:_______________ Man:

_________________
Mobility: Class 1 normal/ Class 2 reduced mobility/ Class 3 paralysis
_______________________________
Length: Long/ normal or medium/ short (ave. Males 22m, Females 20mm)
______________________________

8. TMJ:

Comfort: __________Crepitus: ______________

Clicking: ________________

Smoothness: _____________
Locking: ___________ Deviation: ____________

Protrusive: _____________

Lateral:

_________________

9. Neuromuscular evaluation:

Coordination: Class 1 Excellent/ Class 2 Fair/

Class 3 Poor

Speech: Normal / Affected

__________________________________________________________________
B] INTRAORAL EXAMINATION:

1. Arch size: (Class 1 Large/ Class 2 - Medium/ Class 3 Small)

Max: ___________

Man: ______________

2. Arch form: (Class 1 Square / Class 2 Tapering / Class 3 Ovoid) Max: ___________
Man: ______________

3. Ridge form: Max: Class 1 Square to gently rounded/ Class 2 - Tapering or V shaped/
Class 3 Flat __________

_______________________________________________________________________________
Man: Class 1 medium to tall Inverted shaped/ Class 2 - short inverted U
shaped/ Class 3 unfavourable : inverted W (or) short inverted V (or) tall thin
inverted V ______________________

_______________________________________________________________________________
4. Residual alveolar ridge Height:
Maxillary: Anterior: Excessive / Deficient / Normal
Normal

Posterior right: Excessive / Deficient / Normal

Posterior left: Excessive / Deficient /

Mandibular: Anterior: Excessive / Deficient / Normal Posterior left: Excessive / Deficient /

Normal

Posterior right: Excessive / Deficient / Normal

5. Residual alveolar ridge Width:

Maxillary: Anterior: Excessive / Deficient / Normal

Posterior left: Excessive / Deficient /

Normal

Posterior right: Excessive / Deficient / Normal

Mandibular: Anterior: Excessive / Deficient / Normal Posterior left: Excessive / Deficient /
Normal

Posterior right: Excessive / Deficient / Normal

6. Severe undercuts:
_______________________________________________________________________

7. Sharp bony projections:

__________________________________________________________________

8. Hypermobile tissue:
_____________________________________________________________________

9. Tori: (Class 1 minimal or absent/ Class 2 moderate/ Class 3 Large) Max: ___________
Man: ____________

10. Genial tubercles: Not seen / Prominent

11. Retained Root piece:

___________________________________

12. Interach space: Class 1 Ideal / Class 2 Excessive/ Class 3 Insufficient

13. Ridge parallelism: Class 1 both ridges parallel to occlusal plane / Class 2 Mandibular
ridge is divergent anteriorly
from occlusal plane / Class 3 Maxillary ridge or both ridges are divergent anteriorly
from occlusal plane

14. Ridge relationship: Class 1 Normal / Class 2 Retrognathic / Class 3 Prognathic

Posterior: Normal / Crossbite

15. Bone quantity (radiographic; according to Branemark et al) (A/B/C/D/E) Max: _______
Man: __________

16. Bone quality (radiographic; according to Branemark et al) (1/2/3/4)

Max:

________ Man: __________

17. Floor of the mouth: Sublingual gland area: ___________________ Mylohyoid area:
_________________

18. Retromylohyoid area / Lateral throat form (according to Neil): Class 1 / Class 2 /
Class 3

19. Mylohyoid ridge: Average / Sharp / Undercut

20. Tongue size and function: Class 1 Normal / Class 2 Changed form and function / Class
3 Excessively large and abnormal

21. Tongue Position: Normal / Class 1 Retracted / Class 2 Retracted and pulled backward
and upward

22. Gagging: Normal / Exaggerated

23. Palatal throat form (according to House): Class 1 Large size, ends 5 to 12 mm distal
to line / Class 2 Medium
size, ends 3 to 5 mm distal to line / Class 3 Small size, abruptly ends 3 to 5mm
anterior to line

24. Hard Palate: High vault / Medium vault / Flat / U shaped / V shaped
25. Soft Palate: Class 1 Horizontal, little movement / Class 2 Turns downward 45o from hard
palate / Class 3 Turns
downward 70o from hard palate

Active / Passive

26. Palatal sensitivity: Class 1 Normal / Class 2 Hyposensitive / Class 3 Hypersensitive

27. Incisive papilla: Normal / Tender / Prominent

28. Rugae: Normal /

Prominent / Faint

29.Palatal mucosa compressibility: Median area: Rigid / Compressible

Lateral

area: Rigid / Compressible

30.Mucous gland openings: Sparse / Numerous

31. Fovea: Seen / Not seen 32. Ah

line: Sharp / Gradual / Medium

33. Posterior palatal seal area: Width: Wide / Narrow / Average

Displaceability:

Marked / Average / Slight

34. Alveolar tubercle/ Maxillary tuberosity: Normal / Undeveloped / Bulbous /
Pendulous / Undercut

35. Space between coronoid process and tuberosity: Adequate / Restricted /

Inadequate

36. Mucosa thickness: Class 1 Normal / Class 2 Thin / Class 3 Excessively thick
37. Mucosa condition: Class 1 Healthy/ Class 2 Irritated / Class 3 Pathologic
38. Oral Mucosa: Normal resiliency/ Hard unyielding/ Displaceable/ Spongy/ Hyperemic/
Hyperplastic_____________

39. Border attachments height: Class 1 0.5 inches distance / Class 2 0.25 to 0.5
inches distance / Class 3
less than 0.25 inches distance

40. Frenum attachments height: Class 1 High in maxilla or low in mandible / Class 2
Medium / Class 3
encroach on ridge crest

41. Saliva: Quantity: Class 1 Normal / Class 2 Excessive / Class 3 Xerostomia

_______________________________

Quality: Watery / Viscous / Normal

___________________________________________________________

V. Existing dentures
Anterior teeth:

Shade: ___________

Mold: _______________

Material:

Shade: ___________

Mold: _______________

Material:

_________________
Posterior teeth:
_________________
Esthetics: Good / Fair / Poor
Fair / Poor

Phonetics: Good / Fair / Poor Retention: Good /

Stability: Good / Fair / Poor

Extensions: Good / Fair / Poor

Contours:

Good / Fair / Poor

CR: Acceptable / Unacceptable VDO: Acceptable / Inadequate / Excessive

Occlusal Plane orientation:
_______________________________________________________________
Palate: ____________________

Post Dam: Acceptable / Unacceptable

Adaptation: Acceptable / Unacceptable

Buccal vestibule: Acceptable / Unacceptable

Midline: Acceptable / Unacceptable

Crossbite: None / Unilateral /

Bilateral

Characterization: Characterized / Uncharacterized

Comfort: Acceptable / Unacceptable

Hygiene: Good / Fair / Poor

Wear: Minimal

/ Moderate / Severe

Attachments and Hardware:

_____________________________________________________________________

VI. Radiographic examination:

_____________________________________________________________
_____________________________________________________________________________________
__

VII.

Treatment plan

a) PREPROSTHETIC PHASE:
Corrective measures for general health:
_____________________________________________________
Corrective measures for oral health:
________________________________________________________
Tissue conditioning:
_____________________________________________________________________
Preprosthetic surgery:
Teeth for extraction: Max:

R 8-7-6-5-4-3-2-1

L- 1-2-3-4-5-6-7-8

Man:

R 8-7-6-5-4-3-2-1

L- 1-2-3-4-5-6-7-8

Roots: ____________________________________

Unerupted teeth:

____________________________
Alveoloplasty:
__________________________________________________________________________
Exostosis:
______________________________________________________________________________
Soft tissue:
_____________________________________________________________________________
Special considerations:
___________________________________________________________________
______________________________________________________________________________________

Special investigations:
___________________________________________________________________

b) PROSTHETIC PHASE:
Preliminary impression:
Maxillary

Mandibular

Maxillary

Mandibular

Trays selected
Impression material used
Impression technique used
Important observations &
Special Problems
Final impression:
Custom tray fabrication
Spacer design
Border moulding material
used
Impression material used
Impression technique used
Important observations &
Special Problems
Maxiilomandibular relation:
Orientation relation: Technique used:
_______________________________________________________
Vertical Relation: Technique used:
_________________________________________________________
Centric relation: Technique used:
__________________________________________________________
Important observations & Special Problems:
_________________________________________________
Articulator:
____________________________________________________________________________
Teeth selection: Shade: ___________________ Mold: ___________________ Material:
______________
Occlusal scheme:
________________________________________________________________________
Try in:
_________________________________________________________________________________
Anatomic palate: __________________________

Characterization:

____________________________
Denture base:

Shade: _________________________ Material:

________________________________
List of items to correct in new denture:
_____________________________________________________

List of items to preserve from existing denture:

_______________________________________________
Recall & Follow up:
______________________________________________________________________

VIII.

Prognosis:

Retention: Good / Fair

Stability: Good / Fair

Mastication: Good / Fair

Speech: Good / Fair

Comfort: Good / Fair

Aesthetics: Good / Fair

Reason:
___________________________________________________________________________________

Operators Signature & Date

PATIENTS AGREEMENT
I agree to the above treatment plan.
Patients Signature & Date
Home address & Phone number:
________________________________________________________
Office address & Phone number:
_________________________________________________________

ATTESTATIONS BY PATIENT:
a) I am satisfied with trial dentures
(Signature & Date)
b) Received upper and lower complete dentures
(Signature & Date)