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Case Sheet

Case sheet

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Dr K Siva
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24 views5 pages

Case Sheet

Case sheet

Uploaded by

Dr K Siva
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Dr V Vidyashree Nandini

Professor and HOD


Dept of Prosthodontics & Implantology
SRM Kattankulathur Dental College &
Hospital

Case Sheet
Completely Edentulous Patients

I. Patient Data

Nam e
Age
Sex
Race
Addre ss :

Phone N o :
O ccupat i on :
Mari t al st at us:
II. Chief Complaint

III. Systemic Status

Di abet e s:
Hypert en si on:
O t her CVS di sea se s:
Art hri t i s:
Anem i a:
Epi l epsy:
Al l ergy:
T hyroi d:
T ubercul o si s:
Syphi l i s:
Ki dney dysf unct i on:
Medi cat i on:
Radi at i on:
Any ot her:
IV. Pe rsonal History
Di et :
Habi t s:
1. Sm oki ng:
2. Pan che wi ng:
3. Al cohol :
4. Cl enchi ng :
5. Brux i sm :

V. De ntal History
i . Hi sto ry o f d en tal extracti o n
Max ill ary:
Rea so n f or ext ract i on -
Durat i on of edent ul i sm -
Mandi bul ar:
Rea so n f or ext ract i on -
Durat i on of edent ul i sm -
i i . Nu mb er an d typ e o f p revi o u s d en tu re
a) RPD :
b) CD :
c) Ex am i nat i on of prev i ous dent ure
i ii . Earl i er d en tu re exp eri en ce:
iv . Pre-extracti o n Reco rd s :

VI. Mental Attit ude:

VII. Ext ra Oral Exa minatio n


i . F aci al f orm :
O ut li ne f orm :
i i . Prof il e :
i ii . Li ps (St at i c Posi t i on)
a) Lengt h :
b) T hi c kness :
c) Support :
d) Mobi l i t y :
e) I nt er comm i ssural wi dt h: Passiv e – mm , Activ e – mm
iv . Com pl ex i on :
v . T em porom andi bul ar j oi nt
a) T ender n e ss :
b) Mout h ope ni ng:
c) Dev i ati on :
d) Cl i cki ng :
v i. Neuro m uscul ar ev al uat i on:
a) Speech :
b) Co-ordi n at i on :

VIII. Intra oral Examination


i . Arch f orm :
ii . Resi dual Ri dge F orm :
Maxi ll ary :
Mandi bul ar :
ii i. I nt er arch spac e :
iv . Ri dge Paral l eli sm :
v . Ri dge Rel at i onshi p :
v i. Lat eral T hroat f orm :
v ii . Sof t Pal at e :
v iii . Pal at al Sensi t iv i t y :
ix . Mucosa Con di t i on :
x. At t achm ent
Mucosal :
Max ill a : Mandi bl e :
F renal :
Max ill a : Mandi bl e :
xi . Saliv a :
Q uali t y : Q uant i t y :
xi i . T ongue:
Si ze :
Posi t i on :

VIII. Investigations
Radi ogra ph s :
1. O . P.G - Mandi bul ar hei ght –
2. Lat eral ceph. - Angl e’ s Cl ass
Rout i ne bl ood i nv est i gat i ons:

IX. Diag nosis


Accordi ng t o PDI pat i ent bel ong s t o Cl a ss becau se
a. Resi du al m andi bul ar bone hei ght i s
b. T he m axi ll om andi bul ar rel ati onshi p i s
c. T he m axi ll ary ri dge m orphol ogy i s
d. Muscl e at t achm ent l ocat i on i s

XI. T reatment Plan


Prepro st het i c surgery :
I m pressi on p roce dure :
Prim ary im pressi on :
F i nal im pressi on :

Ja w rel at i ons a nd Art i cul at or:


F ace bo w t ran sf er:
Art i cul at or:
0
Cont rol set t i ngs - hori zont al condyl ar gui dance
0
- l at eral condyl a r gui dance
0
- i nci sal gui de angl e
T oot h sel ect i on: Shade –
Mol d:
Mat eri al :
No. of t eet h:
Dent ure b a se m at eri al :

XII. Prognosis:

Doct or s’ Si gnat ur e
SOAP Summary

A 74 year ol d m al e pat i ent nam ed Mr . Vij aya Vi t t al report ed t o t he cl i ni c wi t h t he

chi ef com pl ai nt of repl acem ent of ol d f ract ured dent ur e wi t h ne w d ent ure s . Pat i ent

ha s n o si gni f i cant m edi cal hi st ory. He ha s bee n com pl et el y edent ul ou s i n bot h

m ax ill a and m andi bl e si nce 3 y ear s wi t h hi st ory of ex t ract i on of t eet h due t o

t raum a. Ex t raoral ex ami nat i on rev eal s squar e t aperi ng f aci al f orm , wi t h prognat hi c

prof il e. I nt ra oral ex ami nat i on rev eal s ov oi d arch f orm , Cl ass I m axi ll ary and Cl ass

I m andi bul ar ri dge f orm , Cl ass I I ri dge rel at i onshi p, i nt erarch sp ace – 35m m ,

Cl ass I ri dge paral l e li sm , Cl ass I pal at e , Cl ass I I I f renal and cl ass I I m ucosal

at t achm ent s i n t he m andi bl e , Cl ass I m ucosal an d Cl a ss I I f renal at t achm ent s i n

t he m axi ll a, Cl ass I Lat eral t hroat f orm . O PG rev eal s bone i s of adequat e quant i t y

and i s l oo sel y packed t ra bacul ae. Sal iv a i s of adequat e qu ant i t y and sero u s i n

nat ure. T he P at i ent bel ong s t o ACP Cl a ss I I de al or m i nim al l y com promi sed.

I nf orm ed consent i s o bt ai ned af t er ex pl ai ni ng t he t reat m ent proce dure and i s al so

i nf orm ed about t he v ari ous t reat m ent opt i ons i nc l udi ng im pl ant s. T reatm ent

pl anni ng i nv olv es pr im ary im pressi on wi t h put t y f or - upper and l ower, f or t he f i nal

im pressi on b orde r m ol di ng wi l l be done wi t h put t y and i m pressi on wi t h l i ght bod y.

F ace bo w t ran sf er wi l l be done u si ng H ana u Arbi t rary Spri ng bo w earpi ece t yp e

f ace bow a nd wi l l be t ransf erred t o a sem i adj ust abl e, Arcon t ype, Ha nau wi d e v eau

Art i cul at or. T he m ol d of art if i ci al t eet h t hat i s sel ect ed i s 25 a nd sh ade A 2.

Progno si s i s f ai r.

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