Examination, Diagnosis and Treatment Plan form
King Saud University
College of Dentistry
Fixed Prosthodontics
Examination, Diagnosis and Treatment Plan form
Patient's Name : ____________________ File No. : ___________
Clinician's Name : ____________________
Part I Examination
A. Clinical Examination
- 1. Periodontal Examination
- OH Condition - good - fair - poor
- Gingivitis - localized - generalized
- Periodontitis- - localized - early
- generalized - moderate - severe
- 2. Abutment Examination
Criteria of Examination | Abutment | |||||
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- Periodontal pockets (if ≥ 4 mm) |
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- Mobility (grade I, II, III) |
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- Caries (S, simple; E, extensive) |
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- Restorations |
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- Pulp status sensitivity pulp involvement pulp extirpated RCT |
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Pier abutment |
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- 3. Occlusal Examination
Type of centric occlusion Angle Class I II III
Type of working side contacts - canine- guidance - group function
Anterior guidance - yes - no
Bruxism - yes - no
Type of opposing dentition - natural teeth - acrylic
- ceramic - metal
Reduced interarch space - yes - no
- 4. Evaluation Existing FPD (if any)
B. Radiographic Examination
Criteria of Examination | Abutment | |||||
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- Crown-to-root ratio (1:2 – 2:3 – 1:1 – 1 :1) |
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- Caries |
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- Periapical lesions |
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- proximity of destruction (if any) to alveolar bone
- < 2 mm - ≥ 2 mm
- RCT quality (if any) - acceptable - not acceptable
C. Mounted Diagnostic Cast Examination
- 1. Edentulous space
Span length : _____ mm ( missing tooth/teeth # )
Reduced interarch space - yes - no
Edentulous ridge deformities - yes - no - Class I(loss of ridge)
- Class II(height)
- Class III(combination)
- 2. Abutments
- OG length
- Malposition
- MD drifting (# )
- Rotation (# )
- Faciolingual displacement (# )
- Common path of insertion - yes - no
- 3. Occlusal Evaluation
- Supra-eruption of abutment tooth/teeth - yes(# ) - no
- Supra-eruption of opposing tooth/teeth - yes - uneven
Part II Pre-Prosthetic Preparation
- Restoration
- Endodontic treatment/retreatments # ________
- Periodontal therapy
- Orthodontic treatment
- Gingivectomy # ________
- Crown lengthening procedure # ________
- Occlusal analysis and correction
- Customized incisal guide table
- Diagnostic wax-up
Part III FPD Treatment Plan
A. Restoration of Abutment Foundation
- Dental retentive feature retained build-up
- Pin retained build-up
- Prefabricated post retained build-up
- Cast post and core
B. Restoration Design
- 1. Material
- Metal Ceramic (MC)
- All Metal
- All Ceramic
2. Retainer/crown - Full - Partial
3. Pontic Design
- Bullet (conical) - Hygienic
- Ridge lap - Modified ridge lap
4. Pontic Tissue Contact - Metal - Ceramic
5. Occlusal Contact - Metal - Ceramic
6. Labial Margin - Metal - Ceramic
7. Surveyed Restoration - yes ( # ) - No
- 8. Type of FPD
- Rigid connectors - Non-rigid connectors
- Resin-bonded - Cantilever
- other specify ………..
- 9. Ceramic material shade __________
Date : __________________
Student Name : _______________ Student No. : ________ Signature : _______
Faculty Name : _______________ Faculty Code: ________ Signature : _______