DEPT. OF PROSTHODONTICS AND CROWN & BRIDGE

C.S.M.S.S DENTAL COLLEGE & HOSPITAL, KANCHANWADI, AURANGABAD

CASE HISTORY PROFORMA – COMPLETE DENTURE

I. Patient 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. Medical History

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 ______________________________________

Quality & Quantity of diet: Satisfactory/ Unsatisfactory: ______________________________________________

Reason for deficient diet: Taste/ Custom / Economic/ Ignorance/ Unable to chew ____________________________

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

III. Dental History

Chief complaint: ____________________________________________________________________________

Extraction history: Reason (Periodontal / Caries / Other) 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):

Comfort: Good / Fair / Poor Chewing efficiency: Good / Fair / Poor Esthetics: Good / Fair / Poor

Articulation: Good / Fair / Poor Soreness: Good / Fair / Poor Food 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:

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 6. Appearance of Skin: Firm / Loose

7. 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 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

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: _________________

Posterior teeth: Shade: ___________ Mold: _______________ Material: _________________

Esthetics: Good / Fair / Poor Phonetics: Good / Fair / Poor Retention: Good / Fair / Poor

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 Midline: Acceptable / Unacceptable

Buccal vestibule: 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

Trays selected

Impression material used

Impression technique used

Important observations & Special

Problems

Final impression:

Maxillary Mandibular

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 Comfort: Good / Fair

Mastication: Good / Fair Speech: 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)