FIXED PARTIAL DENTURE CASE SHEET

NAME: O.P.No:

OCCUPATION:

AGE/SEX:

ADDRESS:

CHIEF COMPLAINT:

MEDICAL HISTORY:

PAST DENTAL HISTORY:

EXTRA ORAL EXAMINATION (FACE):

SHAPE:

SYMMETRY:

TOOTH EXPOSURE : VERTICAL: Incis ! T"i#$/ Mi$$!% T"i#$/ C%#&ic ! T"i#$ HORI'ONTAL: I PM/ II PM/ I M

INTRA ORAL EXAMINATION:

ORAL HYGIENE STATUS:

PERIODONTAL STATUS:

GINGIVAL COLOUR:

EXAMINATION OF DENTAL ARCH:

DMFT

()*+,-./ /.-,+*)( ()*+,-./ /.-,+*)(

AREAS OF A0RASION:

AREAS OF OCCLUSAL 1EAR:

EXAMINATION OF A0UTMENTS:
2

CRO1N ROOT RATIO:

Too2" No.

C#o3n H2(44)

Roo2 H2(44)

C:R

RESTORATIONS ON A0UTMENT:

OCCLUSAL MORPHOLOGY:

ALIGNMENT:

OPPOSING TEETH:

VITALITY OF A0UTMENTS:

VITALITY TESTS:

NON5VITAL ROOT CANAL TREATED:

ENDO POST RE6UIRED:

A0UTMENT 0UILD UP:

METAL POST:

FI0RE POST:

AMALGAM CORE:

COMPOSITE CORE:

EXAMINATION OF EDENTULOUS AREA:

EXAMINATION OF OCCLUSION:

TYPE OF OCCLUSION: G#o78 97nc2ion/ M727 !!: P#o2%c2%$/ C nin% P#o2%c2%$

OCCLUSION CLASS:

EXAMINATION OF TM;:

DEVIATION OF THE MANDI0LE:

CLIC<ING:

TENDERNESS:

MOUTH OPENING:

RADIOGRAPHIC EXAMINATION OF A0UTMENT:

TYPE:

OPG

IOPA

RESIDUAL ROOTS:

IMPACTIONS= CYSTS > GRANULOMAS:

PERIAPICAL INVOLVEMENT:

0ONE SUPPORT:

CONTINUITY > INTEGRITY OF LAMINA DURA:

ROOT LENGTH > MORPHOLOGY:

CALCULUS DEPOSITION:

VERTICAL > HORI'ONTAL 0ONE LOSS:

HEALTH OF PERIODONTAL LIGAMENT:

ASSESSMENT OF RESTORATION (IF ANY):

DIAGNOSTIC CASTS:

EVIDENCE OF SUPRA ERUPTION:

EVIDENCE OF TOOTH MOVEMENT:

AXIAL INCLINATION OF TEETH:

PRESENCE OF OCCLUSAL 1EAR FACETS:

5

OCCLUSAL RELATIONSHIP: CONTOUR OF THE EDENTULOUS RIDGE:

EDENTULOUS AREA:

NUM0ER:

LOCATION:

LENGTH > HEIGHT:

SHAPE:

PRE TREATMENT PLAN:

SELECTION OF A0UTMENTS : PRIMARY A0UTMENTS:

SECONDARY A0UTMENTS:

TYPE OF CRO1N PREPARATION:

TYPE OF 0RIDGE DESIGN:

TYPE OF PONTIC DESIGN:

CHOICE OF CERAMIC:

PFM :

METAL FREE :

GINGIVAL TISSUE MANAGEMENT:

TYPE OF CORD IMPREGNATED:

SI'E OF CORD:

SINGLE CORD TECHNI6UE:

DOU0LE CORD TECHNI6UE:

OTHERS: LASER:

CAUTERY:

GEL:

SELECTION OF IMPRESSION MATERIAL:

SELECTION OF IMPRESSION TECHNI6UE:

7

INTEROCCLUSAL RECORDS:

TEMPORI'ATION:

TECHNI6UE:

CEMENT USED:

METAL FRAME1OR< TRY IN:

CEMENTATION OF PERMANENT RESTORATION:

CEMENTATION PROCEDURE:

LUTING CEMENT:

SELF CURE RESIN CEMENT:

DUAL CURE RESIN CEMENT:

Si?n 27#% o9 2"% H.O.D.

8

Si?n 27#% o9 2"% G7i$%