COMPLETE DENTURE

CASE RECORD
DIAGNOSTIC AND TREATMENT PLAN CHART

General Information:

Patients Name: OP No :
Age/ Sex : Occupation :
Address : Tel No :

Patient’s Chief Complaint:

(a) Inability to chew (b) Poor Appearance

(c) Impaired Speech (d) Others

Systemic Health Status:

Medical history
1. Rheumatic Fever 6. Anaemia
2. Tuberculosis 7. Epilepsy
3. Deficiency Status 8. Neuromuscular Disorder
4. Diabetes 9. Allergy
5. Radiation Treatment 10. Others

Dental History:

(a) Reasons for loss of teeth

i. Periodontal iii. Congenital
ii. Caries iv. Others
(b) Sequence of tooth loss :
(c) Duration Of Edentulousness :
(d) Previous Denture Experience :
(e) Operators Opinion on Existing Denture : 1. Esthetics
2. Phonetics
3. Occlusion
4. V. D
5. Retention, Support & Stability
6. Attrition
7. Maintenance

Mental Attitude

(a) Exacting (c) Philosophical

(b) Hysterical (d) Indifferent
Patient’s Expectations

Understands Limitations :
(a) Esthetics (b) Functions (c) Phonetics

Nutritional Status
(a) Vegetarian (b) Mixed

Habits
(a) Pan Chewing (b) Smoking (c) Others

Extra Oral Examination

(a) Facial Symmetry : Symmetrical / Asymmetrical

(b) Face Form : Square / Tapering / Ovoid
(c) Face Profile : Straight / Prognathic / Retrognathic
(d) Skin Colour : Dark / Fair / Medium
(e) Eye Colour : Black / Brown / Green / Grey
(f) Lip Length : Normal / Short / Long
(g) Temperomandibular joint : Normal / Abnormal
(h) Mandibular Movements : Normal / Impaired
(i) Neuromuscular Control : Normal / Poor

Intra Oral Examination

(a) Residual Ridge Contour

Maxillary Mandibular

Smooth

Irregular

Well Formed

Atrophic

Massive

U Shaped

Knife Edge

Undercut
 (b) Residual Ridge Mucosa : Maxillary Mandibular

Resilient

Thin Non Keratinized

Inflammed

Hyperplastic

Displacable

Other Abnormalities

(c) Maxillary Tuberosity : Normal / Enlarged / Pendulous

(d) Mylohyoid Ridge : Normal / Sharp

(e) Genial Tubercle : Normal / Prominent

(f) Vault Of Palate : Medium /High / Flat

(g) Soft Palate : Cl I / Cl II / Cl III

(h) Tori Palatinus or Mandibularis : Present / Absent

(i) Cheek Mucosa : Normal / Abnormal

(j) Tongue Size : Normal / Small / Large

Position : Cl I / Cl II / Cl III

(k) Floor Of Mouth : Normal / Abnormal

(l) Palatal Mucosa : Normal / Abnormal

(m) Frenal Attachments : Maxillary Mandibular

Normal

Close to Crest

Broad
 (n) Saliva

Quality : Serous / Mucous / Normal

Quantity : Normal / Scanty / Abundant

(o) Interarch Space : Adequate / Inadequate / Excessive

(p) Interarch Relation : Normal / Retrognathic / Prognathic

Treatment Plan

(a) Motivation / Patient Education

(b) Systemic / Local Treatment

(c) Surgical / Non-Surgical / Preparation Of Tissues

Diagnosis :

Prognosis :

(a) Favourable (b) Unfavourable

Articulator Values :

(a) Condylar Guidance Right Left

Horizontal

Lateral

(b) Incisal Guidance Horizontal Lateral

(c) VD at Rest :
VD at Occlusion :
VD at Rest (Average) :
VD at Occ (Average) :

Teeth Set Used :

Mould Shade

(a) Maxillary Anteriors

(b) Mandibular Anteriors
(c) Maxillary Posteriors
(d) Mandibular Posteriors