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

Overbite
USIA : th P/L Open bite
Riwayat penyakit: tonsilitis, asma, alergi, epilepsy, kelainan darah dll
Kebiasaan buruk: Arch form
Lip/Nail/Pencil Bitting, Thumb Sucking, Tongue thrusting, Tongue posture, mouth Maxilla : tapering/ovoid/square
breating, Snooring, Bruxism Mand : tapering/ovoid/square

Profil Wajah Lateral Crowding

Cekung/Datar/Cembung Spacing
Analisis Jaringan Lunak: Ectopic teeth
Lip: tebal/rata-rata/tipis
Tipe gingiva: tebal/rata-rata/tipis Oklusi
Frenulum labial : …………………………………………………………………………………………………. Molar : Right……………….Left………………….
Kegoyangan gigi : ……………………………………………………………………………………………… Canine : Right……………….Left………………….
Resesi : ………………………………………………………………………………………………
Furkasi : ……………………………………………………………………………………………… Crossbite
OH Posterior:…………………………… Uni/Bil
Anterior:……………………………
Dental Analisis
Erupsi gigi Curve of spee
Reverse/normal/increase

Midline
Atrisi : Upper : ……………………….mm R/L
Diskolorisasi Lower : ……………………….mm R/L
Tambalan :
Missing/Agenisi Arch Length Diskrepansi
Non vital Maxilla : …………………………….mm
Poor prognosis gigi Mandibula : ………………………mm
Retained root
Retained tooth Diagnosis
Un-erupsi ………………………………………………………………………………………………………………………………
Alveolar on loss ………………………………………………………………………………………………………………………………
Impaksi
Supernumerary Problem List
Overjet
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Treatment Plan
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Space creation
Ekstraksi now :
Ekstraksi Later :
Stripping :
Anterior/Lateral Ekspansi:
Ancorage
Max:
Mand: