STATUS PERAWATAN IKGA Spesialis

I.

II.

III.

DATA UMUM
IdentitasPenderita
Nama
: .
Jenis Kelamin
: .
Tgl Lahir
: .
Usia
: .
Alamat
: .
Berat badan / tinggi badan : ..
No. Status IKGA : .
KELUHAN UTAMA
.
.
ANAMNESIS
A. Medical History :
Tonsisilitis
Asthma
Allergy
Epilepsi
Blood disease
Others

:....................................................................................................
:....................................................................................................
:....................................................................................................
:....................................................................................................
:....................................................................................................
:....................................................................................................

B. Relevant Dental History :

Perio Problem
:....................................................................................................
Endo Problem
:....................................................................................................
Prosto Problem
:....................................................................................................
Oral Surgery Problem :....................................................................................................

C. Family History of DentoSceletal Problem :

Hereditary manifestation :
Father
:....................................................................................................
Mother
:....................................................................................................
Brother / Sister
:....................................................................................................
Others
:....................................................................................................
D. Bad Habits
Lip biting
Nail biting
Thumb sucking
Tongue thrusting
Tongue posture
E. Growth Status

:
:
:
:
:

Mouth breathing :...

Lisping :
Snoring :..
Brusixm:..
Others :.

Pre pubertal
Pubertal
Post pubertal
IV.

:
:
:

PEMERIKSAAN KLINIS
A. Pemeriksaan Klinis Ekstra Oral
Foto Klinis Ekstra Oral

Profile Photometry Analysis:

Frontal view : Symetry/asymetri Facial third portion :
Lateral view :Profile convex / straight / concave

Face shape

Skeletal I / II / III
Vertical low angle / average / high angle
:Dolichofacial / Mesofacial / Brachifacial

B. Pemeriksaan Klinis Intra Oral

Odontogram
Intra Oral Examination
Soft tissue analysis
:
Lip thickness
: Thick / average / thin
Upper lip shows :..mm I at rest &. mm smiling
Lower lip covers : .mm I / behind I

Upper labial frenalattachment :

Oral hygiene
: good / fair / poor
Gingiva type
: thick / N / thin
Tooth mobility
: ..
Furcation
: ..
Recession
: ..

Dental Analysis
Panoramic finding :
Teeth Erupted
:

Elektra Oral.

Pembesaran Kelenjar Submandibula:.

TMJ
:..
Atrition
:..
Discoloration
:..
Fracture
:..
Poor prognosis teeth :...
Filling
: ..
Missing / agenesis : ..
Non vital
: ..
Retained root
: ..
Retained tooth
: ..
Un-erupted
: ..
Alveolar on loss : ..
Impaction
: ..
Supernumerary teeth :
Overjet
Overbite
Complete
Incomplete
Traumatic

: ..
: ..
: ..
: ..
: ..

Arch from
Maxilla
Mandibular

:Tapering / ovoid / square

: tapering / ovoid / square

Arch symetry :
Maxilla
Mandibular

: ..
: ..

Crowding
Spacing
Ectopic teeth

: ..
: ..
: ..

Occlusion :
Molar relationship : Right : Left :

Canine relationship :Right :

Left :

Crossbite

:Posterior
Anterior ..

Unilateral / bilateral

Curve of spee

: Reverse / N / Increase

Midline

V.

:Upper : Lower:
Shifting: mm R / L

PEMERIKSAAN PENUNJANG
A. Pemeriksaan Radiografi
Foto panoramic

Panoramic findings:
Tampak benih gigi pada gigi:
Fotosefalometri
Cephalometricfindings :
Skeletal : ...........................................................................
Dental
: ...........................................................................
Soft tissue : ...........................................................................

Parameter
SNA
SNB
ANB
A M line
B M line
Wits
Go Gn Sn
FMA
I SN
I MP
II
Naso labial angle
Lower lip to E line
B. Analisis Model

(N)

Patient

Keterangan

Arch length discrepancy :

Total M-D 11 ;12;21;22 = mm (A)
Total M-D 31;32;41;42 = mm (B)
Maxilla ALD (dari 16-26)
Total predicted toothmass : {(B.2) + 11 mm} x 2 + A =mm
Total measured arch length : mm, difference = mm
Mandibular ALD (dari 16-26)
Total predicted totohmass : {(B.2) + 10,5 mm} x 2 + B = mm
Total measured arch length :mm, difference =.mm
VI.

DIAGNOSIS
..
..
..

VII.

Problem List
1..
2..
3..
4..

VIII.

Treatment objectives:
..
..
..
..
Space Creation:
Extraction Now
:
Extraction Later
:

IX.

X.
XI.
XII.

Stripping
:
Anterior/ lateral expansion:..
Anchorage
: Max:
Mand:
Mechanic:
..
Exercise (Certain Habits):
..

XIII.

Treatment sequence:
Step

Upper

Lower

Time

XIV.
XV.
XVI.

Retention:
Upper:
Lower:
Estimation (Length of Treatment): (Moonths)
Informed consent
Patient/Parent

Doctor,

()

()
Instructor,

()
XVII. Free Arrangement