NAMA PASIEN : ……………………………………………………………………………………………….

USIA : th P/L
Riwayat penyakit: tonsilitis, asma, alergi, epilepsy, kelainan darah dll
Kebiasaan buruk:
Lip/Nail/Pencil Bitting, Thumb Sucking, Tongue thrusting, Tongue posture, mouth breating, Snooring,
Bruxism

Profil Wajah Lateral

Cekung/Datar/Cembung
Analisis Jaringan Lunak:
Lip: tebal/rata-rata/tipis
Tipe gingiva: tebal/rata-rata/tipis
Frenulum labial : ………………………………………………………………………………………………….
Kegoyangan gigi : ………………………………………………………………………………………………
Resesi : ………………………………………………………………………………………………
Furkasi : ………………………………………………………………………………………………
OH

Dental Analisis