Appendix 4 Case Summary Template Patient (Name and Date of birth): Social history Prosenting complaints Marta status Chief complaint Chikken Subsidiary complaints Occupation History of complaint Smokin Patient's expectations ° Recreational drugs Diet C Soft drinks cal Practitioner 5 Sports drinks Medical Proc B pons Respiratory o cide foods 5 Sweet foods Cardiovascular c Guest Gastrointestinal r Tea Neurclog cal o Cottee ° c Alechol Endocrine o rite foods Developmental LU Musculoskeletal Habts/hobbies o c Genitourinary 5 Oral habits Haematological other Allergies Smoking Infectious diseases Pregnancy Eon. Eated by Iven Kineberg, Diona Kingston. 2012 by Blackwell Publishing Li412 Oral Rehabilitation Dental history Date of last examination Oral hygie 2 Brushing 1 Flossing: G Mouthwash 1 Toothpaste Treatment) Restorations 1D Endodontes 1 Periodontics 1 Orthodontics a a Facial symmetry Profile Nasolabial angle Facial folds Midlines Faco/maxilary centrals Maxilary central alignment Maxilaryimancibular centrals Lip posture symmetry Upper tip Lower lip Competence Tooth display Ccelusal plane Parallel to ala vagus Ine Parallel to interpupilary line Overeruption Vertical Fws: ‘OVD assessment Smile assessment Symmetry Lip tine Gingival display Tooth display COD OOD Atrest Broad smile Phonetics Labial (rn Labiodental (th) Linguodontal(t) Interdertal is) Linguopalatal (king oDooog oooog mandibular Click Crepitus 4 Tenderness a Tomporalis a a Masseter a o Posterior mandible a o a 0 Maximal opening Fight laterotrusion Left laterotrusion Midline deviation Maximal protrusion Opening pathway Overjet Overbite Further investigation requiredSummary Template 412 Intraoral examination Saliva Soft tissues Water intake Quality Quantity Pathology re oO Mestre stecing Barvenue Cheote 58 in ’ 8 8 Orme = «Bo Periedentium Tere 8 a ra ae com Freatscnronts 8 ! Arch shape Gingiva Biotype fessor ea Pi vu Shee Tori Consistency (ezalatacnmens Pais cot Pencley Sonu Oral cleaniiness Plague D a Caleulas o a Food impaction B a Stains. o a Halitosis B antal charting Maxillary buccal Tooth no. eo % 1% 4 1 12 «1 21 2 2 2h 28 28 28 Pocket Bleeding Suppuration Recession Buccal furcation Distal fureation Mobility Maxillary palatal Tooth no. 27 1% 1% 14 13° 1 2 28 kT Pocket Ble ing Suppuration Recession (Mesial furcation Mandibular fingual Tooth no, a 47 46ST Pocket Bleeding Suppuration Furestion Mandibular buccal Toothno. 484746 SST “3 367 a8 Pocket Bleeding Suppuration Recession Fureation Mobility‘Summary Template Ocelusion Skeletal classification Dental occlusion Angle rght Angle left Anterior overbite Anterior overiet Crosstbites Operbites Curve of §; Curve of Wilson RP to P slide ws: Tooth guidance Right laterotrusion g7654s2i/12345678 87654221 12345678 Protusion g765432i/12345678 87654221 12345678 Tooth surface loss Caries g7es4s2ili2aa5678 87654221 12348678 Atttion g7e54s2ili2s45e78 Left laterotrusion g76s432 112345678 87654221 12245678 Erosion fspecity surface) g765432 112345678 87654221 12348678 ‘Abrasion (specify surface) g765432i/i2345678 87686321 12245678 Abfraction lspeci aves4s2ilize4se78 27654321 12345678 87654221 12345678416 _ Oral Rehabilitation Dental charting Provious dentures Teeth replaced 8 7654371/12325678 87654321 12945678 Type Kennedy classification Appearance LH Stability Support Retention Hygier Patient opinion Percussion Palpation Vitality Cusp loading Transilumination Selective anaesthesia Other Daooooo Radiographs Orthopantomogram (date) T™ Bone loss, Sinuses Mandibular foramen and canal Mental foramen, Retained roots PatholooyCase Summary Template 41 Study casts Treatment option 2 Treatment time Cost Artculaton Position Fave bow Total s Diagnostic wax-up OVD change Deohia eustrant Treatment option 3 Treatment time Cost rown lengthening SSS Problem list Total s Problem list Details Treatment option 4 Treatment time Cost Medical condition otal 8 Mandibl Oral hygiene aO_O | Salve Treatment option 1 Treatment time Cost Periedontal OT Egentulism ota Occlusion aS Tooth surface loss Restorative Treatment option 2 Treatment time Cost Prosthet SS Endodontic ee otal s Troatmont options Maxilla Treatment option 3 Treatment time Cost Treatment option 1 Treatment time Cost “otal s 8 Treatment plan ‘+ Maxilla: Treatment option ‘* Mandible: Treatment option Treatment phase Detail Timeline Cost Hygiene phase Presprosthetic pretreatment phase | Presprosthetc pretreatment phase Il Prosthetic prase Maintenance Total 8 allcoramie crown, MCC, metaleeramic wn: P, pontic; | implant.218 Orel Rohs tation Treatment sequence 18 Total so Troatmont discussion