complete denture case history proforma

DEPT. OF PROSTHODONTICS AND CROWN & BRIDGE C.S.M.S.S DENTAL COLLEGE & HOSPITAL, KANCHANWADI, AURANGABAD

CASE HISTORY PROFORMA – COMPLETE DENTURE

I. Patient Da Data Name: ________________________________________________________________ Case No:

 ____________  Age: ________  Sex: __________ Race: __________________ Occupation:

 ____________________________  Address: ____________________________________________________ Contact No:

 ___________________  Cosmetic index: 1 - High cosmetic index/ 2- Mid cosmetic index/ 3- Low Cosmetic index

 _______________________  Personality: Philosophical/ Exacting /Hysterical/ Indifferent

 _____________________________________________   _______________________________________ ______  II. Medi Medica call Histor History y General health:

 ____________________________________________________________________________   _______________________________________ _____________________________________   ______________________________________________________________________________  _______________________________________ __________________________________________________  ___________   ______________________________________________________________________________  _______________________________________ __________________________________________________  ___________   __  Pathology:

 ______________________________________________________________________________  _______________________________________ _________________________________________  __  Diet habits: Veg / Non-Veg

Diet intake: Carbohydrates: Cereals, Potatoes, Sugar;

Proteins: Meat, Egg, Fish, Pulses; Fats: Oil, Butter; Minerals & Vitamins: Vegetables, Fruits, Milk & Curds ______________________________________  Unsatisfactory: Quality & Quantity of diet: Satisfactory/ Unsatisfactory:

 ______________________________________________   _______________________________________ _______  Economic/ Ignorance/ Unable Unable to chew Reason for deficient diet: Taste/ Custom / Economic/

 ____________________________  Any Habits: Pan / Tobacco chewing / Smoking / Alcoholic / Bruxism / Other:

 _________________________________ 

III. Dental History Chief complaint:

 ____________________________________________________________________________   _______________________________________ _____________________________________ 

Reason (Periodontal / Caries / Other)

Extraction history:

Year Maxillary anterior

 ________________________________________________ 

 ________________ 

Maxillary left posterior  ________________________________________________   ________________ 

Maxillary right posterior  ________________________________________________   ________________ 

Mandibular anterior

 ________________________________________________ 

 ________________ 

Mandibular left posterior ________________________________________________   ________________ 

Mandibular right posterior

 ________________________________________________ 

 ________________  What is your problem and why do you seek treatment? Lost all teeth and need

dentures / Old dentures are unsatisfactory or ill-fitting / Old dentures are Worn out / broken / lost  ___________________________________________  Age of present denture: _______________________ Duration of edentulism: Max:

 ________  Man: _________  Number and type of previous dentures:

Removable partial denture:

Maxillary: ______________________ Mandibular:

 _______________________  Complete denture:

Maxillary: ______________________ Mandibular:

 _______________________  Earlier denture experience: (Good / Poor)

 _______________________________________________________  Patient evaluation of dentures (subjective): Chewing efficiency: Good / Fair / Poor

Comfort: Good / Fair / Poor Esthetics: Good / Fair / Poor Articulation: Good / Fair / Poor

Soreness: Good / Fair / Poor

trapping: Good / Fair / Poor Dentures worn at night:  Y / N

Problem with current dentures:

 __________________________________________  Expectations: Mastication / Speech / Appearance / Comfort / Professional

 __________________________________  Understands limitations: ___________   __________________________________________________________  Pre-extraction records: Casts / Measurements / Photographs / Old Dentures

 ______________________________   __  IV.Clinical examination A] EXTRAORAL EXAMINATION 1. Facial form:

Food

Front: Square/ Tapering/ Square-tapering/ Ovoid Profile: Class 1 – Normal / Class 2 – Retrognathic / Class 3 – Prognathic Height: Normal / Decreased / Increased

2. Muscle tone: Class 1 – Normal/ Class 2 – Slightly impaired/ Class 3 – Greatly impaired 3. Muscle development: Class 1 – Heavy / Class 2 – Medium / Class 3 – Light 4. Complexion: Skin color: ________ Skin texture: _________ Eye color: _________ Hair

color: __________  5. Appearance of Cheeks: Full / Hollow

7.

6. Appearance of Skin: Firm / Loose

Lip:  Thin / Full / Tense / Active ______________________________________________________________ Vermillion border: Max: __________________________ Man:

 ____________________________  Lip contour: Adequately supported / unsupported

Max:_______________ Man:

 _________________  Mobility: Class 1 – normal/ Class 2 – reduced mobility/ Class 3 – paralysis

 _______________________________  Length: Long/ normal or medium/ short (ave. Males 22m, Females 20mm)

 ______________________________ 

8.

TMJ:

Comfort: __________Crepitus: ______________

Clicking: ________________ 

Smoothness: _____________  Locking: ___________ Deviation: ____________

Protrusive: _____________

Lateral:

 _________________ 

9.

Neuromuscular evaluation:

Coordination: Class 1 – Excellent/ Class 2 – Fair/

Class 3 – Poor Speech: Normal / Affected

 __________________________________________________________________  B] INTRAORAL EXAMINATION:

1.

Arch size: (Class 1 – Large/ Class 2 - Medium/ Class 3 – Small)

Max: ___________ 

Man: ______________ 

2.

Arch form: (Class 1 – Square / Class 2 – Tapering / Class 3 – Ovoid) Max: ___________ 

Man: ______________ 

3.

Ridge form: Max: Class 1 – Square to gently rounded/ Class 2 - Tapering or “V” shaped/

Class 3 – Flat __________  _______________________________________________________________________________

Man: Class 1 – medium to tall Inverted “Ü” shaped/ Class 2 - short inverted “U” shaped/ Class 3 – unfavourable : inverted “W” (or) short inverted “V” (or) tall thin inverted “V” ______________________ 

 _______________________________________________________________________________  4. Residual alveolar ridge Height:

Maxillary: Anterior: Excessive / Deficient / Normal Normal

Posterior right: Excessive / Deficient / Normal

Posterior left: Excessive / Deficient /

Mandibular: Anterior: Excessive / Deficient / Normal Posterior left: Excessive / Deficient / Normal

Posterior right: Excessive / Deficient / Normal

5.

Residual alveolar ridge Width:

Maxillary: Anterior: Excessive / Deficient / Normal

Posterior left: Excessive / Deficient /

Normal

Posterior right: Excessive / Deficient / Normal Mandibular: Anterior: Excessive / Deficient / Normal Posterior left: Excessive / Deficient / Normal

Posterior right: Excessive / Deficient / Normal

6.

Severe undercuts:

 _______________________________________________________________________ 

7.

Sharp bony projections:

 __________________________________________________________________ 

8.

Hypermobile tissue:

 _____________________________________________________________________ 

9.

Tori: (Class 1 – minimal or absent/ Class 2 – moderate/ Class 3 – Large) Max: ___________ 

Man: ____________ 

10. Genial tubercles: Not seen / Prominent

11. Retained Root piece:

 ___________________________________ 

12. Interach space: Class 1 – Ideal / Class 2 – Excessive/ Class 3 – Insufficient 13. Ridge parallelism: Class 1 – both ridges parallel to occlusal plane / Class 2 – Mandibular ridge is divergent anteriorly from occlusal plane / Class 3 – Maxillary ridge or both ridges are divergent anteriorly from occlusal plane

14. Ridge relationship: Class 1 – Normal / Class 2 – Retrognathic / Class 3 – Prognathic Posterior: Normal / Crossbite

15. Bone quantity (radiographic; according to Branemark et al) (A/B/C/D/E) Max: _______  Man: __________ 

16. Bone quality (radiographic; according to Branemark et al) (1/2/3/4)

Max:

 ________ Man: __________ 

17. Floor of the mouth: Sublingual gland area: ___________________ Mylohyoid area:  _________________ 

18. Retromylohyoid area / Lateral throat form (according to Neil): Class 1 / Class 2 / Class 3

19. Mylohyoid ridge: Average / Sharp / Undercut 20. Tongue size and function: Class 1 – Normal / Class 2 – Changed form and function / Class 3 – Excessively large and abnormal

21. Tongue Position: Normal / Class 1 – Retracted / Class 2 – Retracted and pulled backward and upward

22. Gagging: Normal / Exaggerated

23. Palatal throat form (according to House): Class 1 – Large size, ends 5 to 12 mm distal to line / Class 2 – Medium size, ends 3 to 5 mm distal to line / Class 3 – Small size, abruptly ends 3 to 5mm anterior to line

24. Hard Palate: High vault / Medium vault / Flat / U shaped / V shaped 25. Soft Palate: Class 1 – Horizontal, little movement / Class 2 – Turns downward 45o from hard palate / Class 3 – Turns downward 70o from hard palate

Active / Passive

26. Palatal sensitivity: Class 1 – Normal / Class 2 – Hyposensitive / Class 3 – Hypersensitive 27. Incisive papilla: Normal / Tender / Prominent

28. Rugae: Normal /

Prominent / Faint 29.Palatal mucosa compressibility: Median area: Rigid / Compressible

Lateral

area: Rigid / Compressible 30.Mucous gland openings: Sparse / Numerous

31. Fovea: Seen / Not seen 32. Ah

line: Sharp / Gradual / Medium

33. Posterior palatal seal area: Width: Wide / Narrow / Average

Displaceability:

Marked / Average / Slight 34. Alveolar tubercle/ Maxillary tuberosity: Normal / Undeveloped / Bulbous / Pendulous / Undercut

35. Space between coronoid process and tuberosity: Adequate / Restricted / Inadequate

36. Mucosa thickness: Class 1 – Normal / Class 2 – Thin / Class 3 – Excessively thick 37. Mucosa condition: Class 1 – Healthy/ Class 2 – Irritated / Class 3 – Pathologic 38. Oral Mucosa: Normal resiliency/ Hard unyielding/ Displaceable/ Spongy/ Hyperemic/  ___________  Hyperplastic__  39. Border attachments height: Class 1 – 0.5 inches distance / Class 2 – 0.25 to 0.5 inches distance / Class 3 – less than 0.25 inches distance

40. Frenum attachments height: Class 1 – High in maxilla or low in mandible / Class 2 – Medium / Class 3 – encroach on ridge crest

41. Saliva: Quantity: Class 1 – Normal / Class 2 – Excessive / Class 3 – Xerostomia  _______________________________  Quality: Watery / Viscous / Normal

 ___________________________________________________________ 

V. Existing dentures Anterior teeth:

Shade: ___________

Mold: _______________

Material:

Shade: ___________

Mold: _______________

Material:

 _________________  Posterior teeth:

 _________________  Esthetics: Good / Fair / Poor

Fair / Poor

Phonetics: Good / Fair / Poor Retention: Good /

Stability: Good / Fair / Poor

Extensions: Good / Fair / Poor

Contours:

Good / Fair / Poor CR: Acceptable / Unacceptable VDO: Acceptable / Inadequate / Excessive Occlusal Plane orientation:

 _______________________________________________________________  Palate: ____________________ 

Post Dam: Acceptable / Unacceptable

Adaptation: Acceptable / Unacceptable Buccal vestibule: Acceptable / Unacceptable

Midline: Acceptable / Unacceptable Crossbite: None / Unilateral /

Bilateral Characterization: Characterized / Uncharacterized Comfort: Acceptable / Unacceptable

Hygiene: Good / Fair / Poor

Wear: Minimal

/ Moderate / Severe Attachments and Hardware:

 _____________________________________________________________________ 

VI. Radiographic examination:  _____________________________________________________________  _____________________________________________________________________________________   __  VII.

Treatment plan

a) PREPROSTHETIC PHASE: Corrective measures for general health: _____________________________________________________ Corrective measures for oral health: ________________________________________________________ Tissue conditioning:

 _____________________________________________________________________  Preprosthetic surgery:

 Teeth for extraction: Max:

R – 8-7-6-5-4-3-2-1

L- 1-2-3-4-5-6-7-8

Man:

R – 8-7-6-5-4-3-2-1

L- 1-2-3-4-5-6-7-8

Roots: ____________________________________

Unerupted teeth:

 ____________________________  Alveoloplasty:  __________________________________________________________________________  Exostosis:  ______________________________________________________________________________  Soft tissue:  _____________________________________________________________________________  Special considerations:

 ___________________________________________________________________   ______________________________________________________________________________________ 

Special investigations:

 ___________________________________________________________________ 

b)

PROSTHETIC PHASE:

Preliminary impression:

Maxillary

Mandibular

Maxillary

Mandibular

 Trays selected Impression material used Impression technique used Important observations & Special Problems Final impression:

Custom tray fabrication Spacer design Border moulding material used Impression material used Impression technique used Important observations & Special Problems Maxiilomandibular relation: Orientation relation: Technique used:

 _______________________________________________________  Vertical Relation: Technique used:

 _________________________________________________________  Centric relation: Technique used:

 __________________________________________________________  Important observations & Special Problems:

 _________________________________________________  Articulator: ____________________________________________________________________________ Teeth selection: Shade: ___________________ Mold: ___________________ Material:

 ______________  Occlusal scheme: ________________________________________________________________________ Try in: _________________________________________________________________________________ Anatomic palate: __________________________ 

Characterization:

 ____________________________  Denture base:

Shade: _________________________ Material:

 ________________________________  List of items to correct in new denture:

 _____________________________________________________ 

List of items to preserve from existing denture:

 _______________________________________________  Recall & Follow up:

 ______________________________________________________________________ 

VIII.

Prognosis:

Retention: Good / Fair

Stability: Good / Fair

Mastication: Good / Fair

Speech: Good / Fair

Comfort: Good / Fair Aesthetics: Good / Fair

Reason:

 ___________________________________________________________________________________ 

Operator’s Signature & Date PATIENT’S AGREEMENT

I agree to the above treatment plan. Patient’s Signature & Date Home address & Phone number:  ________________________________________________________  Office address & Phone number:  _________________________________________________________ 

ATTESTATIONS BY PATIENT:

a) I am satisfied with trial dentures (Signature & Date) b) Received upper and lower complete dentures (Signature & Date)