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DEPARTMENT OF PROSTHODONTICS AND MAXILLOFACIAL

PROSTHETICS
Peoples Dental College & Hospital
Nayabazar, Balaju Kathmandu

FPD CASE HISTORY SHEET
PERSONAL 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:

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