Documente Academic
Documente Profesional
Documente Cultură
Foaie Observatie Protetica
Foaie Observatie Protetica
fi: ___________________
Medic: ____________________
Nespecialist
Specialist
Primar
FOAIE DE OBSERVAIE
- PROTETIC NUME: ________________ PRENUME: _____________ VRST: ____ SEX ___
STAREA PREZENT
Stare general:
Tipul constituional:
Postura capului i trunchiului:
Starea psihic:
Comportament psihic:
Mersul:
bun
nlime: ____
normosom
dreapt
echilibrat
reinut
fa
influenat
Greutate: ____
hiposom
modificat
neechilibrat
revendicativ
spate
hipersom
expansiv
profil
Meniuni: _____________________________________________________________________________________________________________
Indicele facial:
Simetrie:
Msurtori:
ovalar
rotund
trapezoidal
dreptunghiular
Gn - Oph
I.F. = 100 x ------------------------- = ___________
Zy-Zy
mezoprosop = 84
leptoprosop > 84
simetric
asimetric
ptrat
triunghiular
Dreapta:
Stnga:
Zy-Kdl = _____
Zy-Kdl = _____
musculare
altele
Asimetrii:
Gn-Zy = _____
Gn-Zy = _____
articulare
pri moi
Gn-Go = _____
Gn-Go = _____
osoase
ocluzale
euriprosop < 84
Meniuni: _____________________________________________________________________________________________________________
Proporionalitatea etajelor:
Coloraia tegumentelor:
Gn - Sn = _____
normal
Integritatea tegumentelor:
integre
o deformri
o nevi
Sn-Oph = _____
modificat
o palide
modificate
o tumefieri
o cicatrici
Oph-Tr = _____
o turgescente
o cianotice
o ulceraii
o plgi
o tumori
o fistule
Meniuni: _____________________________________________________________________________________________________________
Inspecia de profil:
Profil:
drept
Unghiul nazo-labial:
Valoare = ____
convex
concav
= 90
< 90
accentuat convex
accentuat concav
> 90
1
Postura buzelor:
Decalaj sagital:
Treapta labial:
an labio-mentonier:
Poziia mentonului:
Unghiul goniac:
Valoare = ____
Valoare = ____
normal
retruziv
protruziv
normal
normal
normal
accentuat
accentuat
anterioar
inversat
ters
posterioar
normal
crescut
sczut
normal
normal
normal
normal
crescut
crescut
crescut
crescut
sczut
sczut
sczut
sczut
integre
modificate
continue
discontinui
nedureroase
dureroase
Palpare
Palparea superficial:
Temperatura:
Sensibilitatea:
Umiditatea:
- tactil
- termic
- dureroas
Palparea profund:
Contururi i suprafee osoase:
Meniuni: _____________________________________________________________________________________________________________
dureros
dureros
dureros
nedureros
nedureros
nedureros
Meniuni: _____________________________________________________________________________________________________________
Grupele ganglionare:
- preauriculari
- retroauricular
- genieni
- submandibulari
- sub i retro-angulo-manidbulari
- submentonieri
- cervicali superficiali
- cervicali profunzi
- supraclaviculari
- suboccipitali
palpabili
palpabili
palpabili
palpabili
palpabili
palpabili
palpabili
palpabili
palpabili
palpabili
nepalpabili
nepalpabili
nepalpabili
nepalpabili
nepalpabili
nepalpabili
nepalpabili
nepalpabili
nepalpabili
nepalpabili
Meniuni: _____________________________________________________________________________________________________________
normal
normal
normal
patologic
patologic
patologic
Meniuni: _____________________________________________________________________________________________________________
Durere
Volum
Tonicitate
Consisten
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
inserii
masa
hipotrofie
hipertrofie
hipotonicitate
hipertonicitate
normala
patol.
Digastric
Milohioidian
Geniohioidian
SCM
Buccinator
Orbicularul
buzelor sup.
Orbicularul
buzelor inf.
Mentonieri
Narinari
Occipitali i
paracervicali
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Dr.
Stg.
Muchii mimicii
Examenul A.T.M.
Static:
Inspecie
Pretragian:
- modificri de culoare
- deformri
absente
absente
prezente
prezente
Meniuni: _____________________________________________________________________________________________________________
Menton poziie:
normal
protruzie
lateropoziie dr. ____
retruzie
lateropoziie stg. ____
Palpare
Sensibiliate:
- palpare pretragian
- compresiune menton
absente
absente
prezente
prezente
Dinamic:
Inspecie + palpare (metoda palprii pretragian / conduct auditiv extern)
Excursii:
dureroase
nedureroase
simetrice
sinergice
asimetrice
asinergice
- menton
linie median
laterodev. stg. ____
poziie intermediar suma deplasrii ____
- amplitudine maxim = ____
subluxaie
- condili
amplitudine egal
amplitudine inegal
laterodev. dr. ____
luxaie
Meniuni: _____________________________________________________________________________________________________________
Zgomote articulare:
- tip
absente
cracmente
crepitaii
- producere
- momentul apariiei zgomotului
prezente
stnga
stnga
concomitent
traiectorie deschidere
nceput
dreapta
dreapta
succesiv
traiectorie nchidere
sfrit
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
normal
Sn -St = ____
simetric
L.sup St = ____
simetric
asimetric
accentuat
nchis
Ch Ch = ____
normal
normal
normal
diminuat
St -Gn = ____
asimetric
L.inf. St = ____
continuu
discontinuu
ters
ntredeschis
inversat
micorat
modificat
n exces
bine reprezentat
aplatizat
deschis
mrit
integr
normal
absent
modificat
modificat
prezent
Canal Stenon
normal
modificat
prezeni
prezente
abseni
absente
Corpusculi Fordyce
Leziuni
o accentuat
o atenuat
o aspect
o integritate
o permeabilitate o calitatea salivei
Meniuni: _____________________________________________________________________________________________________________
MAXILAR
EXAMENUL VESTIBULULUI BUCAL
Modificri:
aspect
culoare
formaiuni patologice
integritate
o tumefieri
o formaiuni tumorale
o pierderi de substan
o fistule
o cicatrici
Meniuni: _____________________________________________________________________________________________________________
Profunzime:
adnc
mediu
micorat
dreapta
stnga
dreapta
stnga
dreapta
stnga
dreapta
stnga
dreapta
stnga
lungi
lungi
subiri
subiri
unice
unice
nalt
nalt
lat
lat
medii
medii
medii
medii
multiple
multiple
medie
medie
medie
medie
scurte
scurte
groase
groase
lungi
subiri
medii
medii
scurte
groase
joas
joas
ngust
ngust
nalt
lat
medie
medie
joas
ngust
Zone funcionale:
Zona Eisenring:
Dr.
Stg.
Zona vestibular lateral:
Dr.
Stg.
Zona vestibular frontal:
Dr.
Stg.
A = ____ mm
Limite ___ - ___
A = ____ mm
Limite ___ - ___
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
A = ____ mm
Limite ___ - ___
A = ____ mm
Limite ___ - ___
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
A = ____ mm
Limite ___ - ___
A = ____ mm
Limite ___ - ___
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
semielipsa
simetric
hiperbol
asimetric
semicerc
trapez
W
Dini prezeni
Dentiie:
Cod (D)
0
0.1
0.2
0.3
1
2
2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.1.7
2.1.8
2.2
2.2.1
2.2.2
2.3
2.3.1
2.3.2
2.3.3
2.4
2.4.1
2.4.1.1
2.4.1.2
2.4.1.3
2.4.2
2.4.3
2.4.4
temporar
mixt
permanent
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
DINTE ABSENT
Extracie
Anodonie
Inclus
DINTE INDEMN
DINTE AFECTAT PRIN:
ANOMALII DE FORM
d. Turner
d. clape de pian / cuneifomi
taurodontism
bigeminatie
dens-in dente
fuziune
hipercementoza
tuberculi dentari
ANOMALII DE VOLUM
hipodonie
hiperdonie
ANOMALII DE CULOARE
hiperpigmentaii
white-spot
brown-spot
PIERDERI DE SUBSTAN
abrazii ocluzale
grd. 1
grd. 2
grd. 3
abrazii cervicale
eroziuni
abfracii
2.4.5
2.4.5.1
2.4.5.2
2.4.5.3
2.4.5.4
2.4.5.5
2.4.5.6
2.4.6
2.4.6.1
2.4.6.2
2.4.6.3
2.4.7
2.4.7.1
2.4.7.2
2.4.7.3
2.5
2.5.1
2.5.2
2.5.3
2.5.4
2.6
2.6.1
2.6.1.1
2.6.1.2
2.6.1.3
2.6.1.4
2.6.2
2.6.3
2.6.3.1
2.6.3.2
2.6.3.3
2.6.4
2.6.4.1
2.6.4.2
2.7
2.7.1
2.7.2
2.8
2.8.1
2.8.2
2.8.3
3
3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.2
3.2.1
3.2.1.1
3.2.1.1.1
3.2.1.1.2
3.2.1.1.3
3.2.1.1.4
3.2.1.1.5
leziuni carioase
clasa I
clasa a II-a
clasa a III-a
clasa a IV-a
clasa a V-a
resturi radiculare
fracturi
coronar
radicular
corono-radicular
complicaii pulpare
reversibile
ireversibile
leziuni periapicale
ANOMALII DE SEDIU
transpoziie
heteropoziie
ectopie
entopie
ANOMALII DE POZIIE
versie:
vestibulooromeziodistotranslaie
infra-/suprapoziie:
intruzie
extruzie
egresie
rotaie:
vestibular
oral
ANOMALII DE NUMR
hipodonii
hiperdonii
ANOMALII DE STRUCTURA
amelogeneza imperfecta
dentinogeneza imperfecta
displazia dentar
RESTAURRI CORONARE
Obturaii
amalgam
compozit
ciment
glassionomer
obturaie provizorie
Restaurri protetice
Elemente de agregare
- tip:
faet
inlay
onlay
coroan de nveli
coroan de substituie
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Parodoniu
Indice de sntate a papilei inter-dentare:
Cod (P)
1
Indici de sngerare a papilei
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
1.0
1.1
1.2
Absena sngerrii
Sngerare punctiform
Sngerare liniar
1.3
V hemoragic
1.4
2
2.0
2.1
2.2
2.3
3.
3.0
3.1
3.2
3.3
4
4.0
4.1
4.2
4.3
5
5.1
5.2
5.3
5.4
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Spaiul protetic potenial (numerotarea spaiilor se face n sensul acelor de ceasornic / a cadranelor)
SPP1:
crescut
crescut
o
o
L = ____
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
o
o
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
crescut
crescut
o
o
L = ____
redus
redus
infraalveolodonia antagoniti
resorbia crestei edentate
o
o
crescut
o
o
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
Clasa
infraalveolodonia antagoniti
resorbia crestei edentate
crescut
o
o
SPP2:
redus
redus
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
Aspect clinic
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
SPP1
SPP2
SPP3
SPP4
SPP5
SPP1
SPP2
SPP3
SPP4
SPP5
Fibomucoasa:
Indicii pentru aprecierea fibromucoasei
0
1
2
3
Fibromucoas sntoas
Inflamaie uoar
Inflamaie medie cu nceput de mobilitate n plan orizontal
Inflamaie sever, mucoas intens congestiv, papilomatoas
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
SPP3:
crescut
crescut
o
o
L = ____
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
o
o
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
crescut
crescut
o
o
L = ____
redus
redus
infraalveolodonia antagoniti
resorbia crestei edentate
o
o
crescut
o
o
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
Clasa
infraalveolodonia antagoniti
resorbia crestei edentate
crescut
o
o
SPP4:
redus
redus
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
Aspect clinic
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
SPP1
SPP2
SPP3
SPP4
SPP5
SPP1
SPP2
SPP3
SPP4
SPP5
Fibomucoasa:
Indicii pentru aprecierea fibromucoasei
0
1
2
3
Fibromucoas sntoas
Inflamaie uoar
Inflamaie medie cu nceput de mobilitate n plan orizontal
Inflamaie sever, mucoas intens congestiv, papilomatoas
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
10
Tuberoziti maxilare:
Dreapta:
- form
tears
medie
plonjant
o
o
- retentivitate versani
- mucoas
verstibular
nerezilient
palatinal
rezilient
distal
- form
tears
medie
plonjant
Stnga:
o
o
- retentivitate versani
- mucoas
proliferare osoas
proliferare mucoas
verstibular
nerezilient
palatinal
rezilient
distal
H = ____
roman
plat
simetric
simetrice
nr. perechi ____
pe creasta
rafeu median ____
L = ____
gotic
medie
adnc
asimetric
asimetrice
distana de creasta ____
la distan de creast
rugi palatine ____
zone Schroder ___
A = ____
vertical
L = ____
oblic
BOLTA PALATIN
A = ____
Form
Adncime
Simetrie
Rugi palatine
Papila bunoid
Rezilien mucozal
Zona Ah:
Limite ____ ____
Poziia vlului palatin
orizontal
Dr.
Stg.
Pe rafeul median
1
2
3
4
Creast nalt, rotunjit, bolt adnc, tuberoziti proeminente, distan mare ntre sinus i creast
II
III
Creast diminuat, bolt medie spre plan, tuberoziti terse, sinus apropiat de muchia crestei
Atrofie marcat a crestei, tuberoziti absente, bolt plan i sinus apropiat de muchia crestei
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
11
MANDIBULAR
EXAMENUL VESTIBULULUI BUCAL
Modificri:
aspect
o tumefieri
culoare
o formaiuni tumorale
o fistule
integritate
formaiuni patologice
o pierderi de substan
o cicatrici
Meniuni: _____________________________________________________________________________________________________________
dreapta
stnga
dreapta
stnga
dreapta
stnga
dreapta
stnga
dreapta
stnga
lungi
lungi
subiri
subiri
unice
unice
nalt
nalt
lat
lat
medii
medii
medii
medii
multiple
multiple
medie
medie
medie
medie
lungi
subiri
nalt
lat
medii
medii
medie
medie
scurte
groase
joas
ngust
scurte
scurte
groase
groase
joas
joas
ngust
ngust
Zone funcionale:
Zona Fish:
Dr.
Stg.
Zona vestibular frontal:
Dr.
Stg.
A = ____ mm
Limite ___ - ___
A = ____ mm
Limite ___ - ___
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
A = ____ mm
Limite ___ - ___
A = ____ mm
Limite ___ - ___
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
semielipsa
simetric
hiperbol
asimetric
semicerc
trapez
W
Dini prezeni
Cod (D)
0
0.1
0.2
0.3
1
2
2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
3.8 3.7 3.6 3.5 3.4 3.3 3.2 3.1 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8
DINTE ABSENT
Extracie
Anodonie
Inclus
DINTE INDEMN
DINTE AFECTAT PRIN:
ANOMALII DE FORM
d. Turner
d. clape de pian / cuneifomi
taurodontism
bigeminatie
dens-in dente
12
2.1.6
2.1.7
2.1.8
2.2
2.2.1
2.2.2
2.3
2.3.1
2.3.2
2.3.3
2.4
2.4.1
2.4.1.1
2.4.1.2
2.4.1.3
2.4.2
2.4.3
2.4.4
2.4.5
2.4.5.1
2.4.5.2
2.4.5.3
2.4.5.4
2.4.5.5
2.4.5.6
2.4.6
2.4.6.1
2.4.6.2
2.4.6.3
2.4.7
2.4.7.1
2.4.7.2
2.4.7.3
2.5
2.5.1
2.5.2
2.5.3
2.5.4
2.6
2.6.1
2.6.1.1
2.6.1.2
2.6.1.3
2.6.1.4
2.6.2
2.6.3
2.6.3.1
2.6.3.2
2.6.3.3
2.6.4
2.6.4.1
2.6.4.2
2.7
2.7.1
2.7.2
2.8
2.8.1
2.8.2
2.8.3
3
3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
fuziune
hipercementoza
tuberculi dentari
ANOMALII DE VOLUM
hipodonie
hiperdonie
ANOMALII DE CULOARE
hiperpigmentaii
white-spot
brown-spot
PIERDERI DE SUBSTAN
abrazii ocluzale
grd. 1
grd. 2
grd. 3
abrazii cervicale
eroziuni
abfracii
leziuni carioase
clasa I
clasa a II-a
clasa a III-a
clasa a IV-a
clasa a V-a
resturi radiculare
fracturi
coronar
radicular
corono-radicular
complicaii pulpare
reversibile
ireversibile
leziuni periapicale
ANOMALII DE SEDIU
transpoziie
heteropoziie
ectopie
entopie
ANOMALII DE POZIIE
versie:
vestibulooromeziodistotranslaie
infra-/suprapoziie:
intruzie
extruzie
egresie
rotaie:
vestibular
oral
ANOMALII DE NUMR
hipodonii
hiperdonii
ANOMALII DE STRUCTURA
amelogeneza imperfecta
dentinogeneza imperfecta
displazia dentar
RESTAURRI CORONARE
Obturaii
amalgam
compozit
ciment
glassionomer
obturaie provizorie
13
3.2
3.2.1
3.2.1.1
3.2.1.1.1
3.2.1.1.2
3.2.1.1.3
3.2.1.1.4
3.2.1.1.5
3.2.1.2
3.2.1.2.1
3.2.1.2.2
3.2.1.2.3
3.2.1.3
3.2.1.3.1
3.2.1.3.2
3.2.1.3.3
3.2.1.3.4
3.2.1.3.5
3.2.1.3.6
3.2.1.3.7
3.2.1.4
3.2.1.4.1
3.2.1.4.2
3.2.1.4.2.1
3.2.1.4.2.2
3.2.2
3.2.2.1
3.2.2.1.1
3.2.2.1.2
3.2.2.1.3
3.2.2.2
3.2.2.2.1
3.2.2.2.2
3.2.2.2.2.1
3.2.2.2.2.2
3.2.2.3
3.2.2.3.1
3.2.2.3.2
3.2.2.3.3
3.2.2.3.4
3.2.2.3.5
3.2.2.3.6
3.2.2.3.7
3.2.2.4
3.2.2.4.1
3.2.2.4.2
3.2.2.4.3
3.2.2.4.4
3.2.2.4.5
4
4.1
4.2
Restaurri protetice
Elemente de agregare
- tip:
faet
inlay
onlay
coroan de nveli
coroan de substituie
- gradul de refacere fizionomic:
fizionomic
semifizionomic
nefizionomic
- material:
acrilic
metalic
metalo-acrilic
metalo-compozit
metalo-ceramic
compozit
ceramic
- corectitudinea realizrii:
conceptual
execuie tehnologic
- morfologie
- adaptare
- ocluzal
- cervical
- transversala
- axial
Corp de punte - intermediari
- gradul de refacere fizionomic:
fizionomic
semifizionomic
nefizionomic
- corectitudinea realizrii:
conceptual
execuie tehnologic
- morfologie
- adaptare
- ocluzal
- cervical
- transversala
- axial
- material:
acrilic
metalic
metalo-acrilic
metalo-compozit
metalo-ceramic
compozit
ceramic
- contact cu creasta edentata
supendat
punctiform
talgential
semisa
sa
Punct de contact
absent
n suprafa
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
14
Parodoniu
Indice de sntate a papilei inter-dentare:
Cod (P)
1
Indici de sngerare a papilei
3.8 3.7 3.6 3.5 3.4 3.3 3.2 3.1 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8
Papil inflamat
Papil inflamat i inel periodontal inflamat
Inflamaie, secreie i pungi
Indici de recesiune ginigival
3.0
3.1
3.2
3.3
Normal
Recesiune egal cu din lungimea rdcinii
Recesiune egal cu din lungimea rdcinii
Recesiune peste din lungimea rdcinii
4
4.0
4.1
4.2
4.3
5
5.1
5.2
5.3
5.4
1.0
1.1
1.2
1.3
Absena sngerrii
Sngerare punctiform
Sngerare liniar
V hemoragic
1.4
2
2.0
2.1
2.2
2.3
3.
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
15
Spaiul protetic potenial (numerotarea spaiilor se face n sensul acelor de ceasornic / a cadranelor)
SPP1:
crescut
crescut
o
o
L = ____
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
o
o
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
crescut
crescut
o
o
L = ____
redus
redus
infraalveolodonia antagoniti
resorbia crestei edentate
o
o
crescut
o
o
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
Clasa
infraalveolodonia antagoniti
resorbia crestei edentate
crescut
o
o
SPP2:
redus
redus
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
Aspect clinic
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
SPP1
SPP2
SPP3
SPP4
SPP5
SPP1
SPP2
SPP3
SPP4
SPP5
Fibomucoasa:
Indicii pentru aprecierea fibromucoasei
0
1
2
3
Fibromucoas sntoas
Inflamaie uoar
Inflamaie medie cu nceput de mobilitate n plan orizontal
Inflamaie sever, mucoas intens congestiv, papilomatoas
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
16
SPP3:
crescut
crescut
o
o
L = ____
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
o
o
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
crescut
crescut
o
o
L = ____
redus
redus
infraalveolodonia antagoniti
resorbia crestei edentate
o
o
crescut
o
o
Creasta alveolar:
A = ____
H = ____
L = ____
- profil
- orientare
- forma pe seciune
- versant
- muchia crestei
Clasa
infraalveolodonia antagoniti
resorbia crestei edentate
crescut
o
o
SPP4:
redus
redus
redus
crescut
crescut
crescut
regulat
ascendent
triunghiular
neutru
rotunjit
Aspect clinic
o
o
redus
redus
redus
neregulat
descendent
semicerc
retentiv
tears
semielips
neretentiv
ascuit
SPP1
SPP2
SPP3
SPP4
SPP5
SPP1
SPP2
SPP3
SPP4
SPP5
Fibomucoasa:
Indicii pentru aprecierea fibromucoasei
0
1
2
3
Fibromucoas sntoas
Inflamaie uoar
Inflamaie medie cu nceput de mobilitate n plan orizontal
Inflamaie sever, mucoas intens congestiv, papilomatoas
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
17
balant
- retentivitate versani
- mucoas
verstibular
nerezilient
- form
balant
tears
medie
o
o
modificai
pe seama suportului osos
pe seama suportului mucos
distal
o
o
modificai
pe seama suportului osos
pe seama suportului mucos
distal
palatinal
rezilient
Stnga:
- retentivitate versani
- mucoas
tears
verstibular
nerezilient
medie
palatinal
rezilient
Dr.
Stg.
Pe rafeul median
Pe muchia crestei i pe versanii vestibulari i orali n 2/3 dinspre muchie
2
3
I
II
0
1
III
IV
Meniuni: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
PLANEUL LINGUAL
Inseria planeului
Palpare
nalt
suplu
indurat
medie
nedureros
dureros
joas
Zone funcionale:
Zona retromilohioidian (Ney i Bowen):
Dr.
A = ____ mm
Limite ___ - ___
Stg.
A = ____ mm
Limite ___ - ___
Zona lingual lateral:
Dr.
A = ____ mm
Limite ___ - ___
Stg.
A = ____ mm
Limite ___ - ___
Zona lingual central (Slack):
Dr.
A = ____ mm
Limite ___ - ___
Stg.
A = ____ mm
Limite ___ - ___
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
H = ____ mm
scurtat
H = ____ mm
scurtat
L = ____ mm
ntrerupt
L = ____ mm
ntrerupt
Glande salivare:
normal
modificare volum
saliva modificat
Meniuni: _____________________________________________________________________________________________________________
18
Limb:
Aspect
Coloraie
Integritate
Distribuie zone papilare
Volum
Consisten
Poziia n repaus
Mobilitate
Tonicitate
normal
normal
normal
normal
normal
normal
normal
normal
normal
modificat
modificat
modificat
modificat
hipotrofic
modificat
anterior
hipokinetic
hopoton
hipertrofic
posterior
hiperkinetic
hiperton
Meniuni: _____________________________________________________________________________________________________________
EXAMENUL OCLUZIEI
Parametri ocluzali
Arii ocluzale
Cuspizii de sprijin
Cuspizii de ghidaj
prezente
naturale
continui
normale
absente
artificiale
discontinui
scurtate
mixte
integri
desfiinai
naturali
artificiali
cuspidare accentuat medie
micti
tears
integri
desfiinai
naturali
artificiali
cuspidare accentuat medie
panta medie
accentuata
micti
tears
tears
mofologie primar
profunzime redus
naturale
secundar
medie
artificiale
crescut
continu
natural
nlime accentuat
nclinare vertical
cingulum accentuat
discontinu
mixt
medie
medie
ters
artificial
redus
orizontal
continu
medie
regulat
ntrerupt
orizontal
neregulat
scurtat
inversat
continu
medie
regulat
ntrerupt
orizontal
neregulat
scurtat
inversat
Curbura frontal
continu
accentuat
ntrerupt
medie
drept
armonios
uniform
nclinat
nearmonios
denivelat
Panta retroincisiv
Planul de ocluzie
aplatizat
19
Ocluzia static
Rapoartele ocluzale interarcadice (Angle):
Plan sagital:
Zona lateral - ____ mm
Zona frontal - ____ mm
normal
overjet negativ
mezializat
overjet normal
distalizat
pozitiv
Plan transversal:
Zona lateral - ____ mm
normal
lingualizat
cap la cap
invers
corespondena planurilor sagitale
laterodeviaie dr.
laterodeviaie st.
vestibularizat
Plan vertical:
Zona lateral - ____ mm
Zona frontal - ____ mm
normal
openbite
infraalveolodonie
cap la cap
supraalveolodonie
overbite
o
o
o
clasa I
fals
Clasa Angle:
clasa a II-a
adevrat
normal
ocluzie adnc
ocluzie prbuit
clasa a III-a
stabile
multiple
uniform repartizate
instabile
reduse ca numr
neuniform repartizate
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
instabile
reduse ca numr
neuniform repartizate
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
20
instabile
reduse ca numr
neuniform repartizate
instabile
reduse ca numr
neuniform repartizate
wide centric
long-centric
freedom n centric
Ocluzia dinamic
Traiectoria de nchidere n relaie centric:
traiectoria: liber
scurtat (contacte premature nedeflective)
continu
deviat (contacte deflective - interferene)
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
corectat
necorectat
contacte stabile
contacte multiple
contacte uniform repartizate
contacte instabile
contacte reduse ca numr
neuniform repartizate
poziia test:
traiectoria: liber
scurtat (contacte premature nedeflective)
continu
deviat (contacte deflective)
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
poziia test:
corectat
necorectat
contacte stabile
contacte multiple
contacte uniform repartizate
contacte instabile
contacte reduse ca numr
neuniform repartizate
21
traiectoria test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
dezocluzie _____
amplitudine _____
poziia test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
traiectoria test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
dezocluzie _____
amplitudine _____
poziia test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Micarea de protruzie:
traiectoria test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
dezocluzie _____
amplitudine _____
poziia test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
22
traiectoria test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
dezocluzie _____
amplitudine _____
poziia test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
traiectoria test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
dezocluzie _____
amplitudine _____
poziia test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Micarea de protruzie:
traiectoria test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
dezocluzie _____
amplitudine _____
poziia test:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
23
da
da
da
da
da
da
da
nu
nu
nu
nu
nu
nu
nu
Meniuni: _____________________________________________________________________________________________________________
RELAIA CENTRIC
Repere:
Articular
Muscular
Osos
Dentar
Labial
Lingual
da
da
da
da
da
da
da
da
nu
nu
nu
nu
nu
nu
nu
nu
Meniuni: _____________________________________________________________________________________________________________
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Meniuni: _____________________________________________________________________________________________________________
24
EXAMENE PARACLINICE
EXAMENUL STRII GENERALE (REZULTATE)
Tensiunea arterial
Electrocardiograma
Glicemia
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
Hemoleucograma
Colesterol
Transaminaze
Timpi de sngerare
da
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Examenul alergologic
da
_________________________________________________
Sumar urin
Urocultur
Glicozurie
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
Termografie
da
_________________________________________________
Meniuni: _____________________________________________________________________________________________________________
da
da
da
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
Teste salivare:
Rata fluxului salivar de repaus
Rata fluxului salivar stimulat
pH salivar
da
da
_________________________________________________
_________________________________________________
da
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Examenul gnatofotostatic:
da
_________________________________________________
da
da
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
da
_________________________________________________
Examenul ATM:
Artrografie
Tomografie
CT
Combi CT
Rezonana magnetic nuclear
Examenul musculaturii:
Tonometrie
25
Electromiografia
da
_________________________________________________
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
da
da
da
_________________________________________________
_________________________________________________
_________________________________________________
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
DIAGNOSTIC
A. DIAGNOSTICUL DE STARE GENERAL
favorabil
nefavorabil
Cod
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
26
1.2.1
1.2.2
1.3
1.3.1
1.3.2
1.3.3
2
2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.3
2.3.1
2.3.2
2.4
2.4.1
2.4.2
2.4.3
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.4
Microdonie
Macrodonie
Modificri de culoare
White-spot
Brown-spot
Pigmentaii
Topografie
Fee
ocluzal
margine incizal
mezial
distal
vestibular
oral
Zone
incizal
ocluzal
1/3 medie
cervical
Unghiuri
mezial
distal
Profunzime
superficial
mediu
profund
Etiologie
Microbian
Teren
Alimentaie
Traumatic
Genetic
Iatrogenic
Plurifactorial
Tulburri funcionale
Masticatorii
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
corect
incorect
complet
incomplet
27
Integritatea pulpar
Cadranul I
Cod
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Integritatea pulpar
1 Anatomo-clinic + forma clinic
1.1 Hiperemie pulpar
1.1.1 Pulpit acut
1.1.1.1
Pulpit seroas parial
1.1.1.2
Pulpit seroas total
1.1.1.3
Pulpit purulent parial
1.1.1.4
Pulpit purulent total
1.1.2 Pulpit cronic
1.1.2.1
Pulpit cronic nchis
1.1.2.2
Pulpit cr. deschis polipoas
1.1.2.3
Pulpit cr. deschis ulceroas
1.1.3 Necroz
1.1.4 Gangren
1.1.5 Parodontit acut
1.1.5.1
Parodontit apical hiperemic
1.1.5.2
Parodontit apical seroas
1.1.5.3
Parodontit apical purulent
1.1.6 Parodontit apical cronic fibroas
1.1.7 Granulom periapical
1.1.8 Chist
3 Etiologie
3.1 Microbian
3.2 Teren
3.3 Alimentaie
3.4 Traumatic
3.5 Genetic
3.6 Iatrogenic
3.7 Plurifactorial
4 Tulburri funcionale
4.1 Masticatorio
4.2 Fizionomice
4.3 Fonetice
4.4 Deglutiie
5 Evoluie
5.1 Stabilizat
5.2 Lent
5.3 Rapid
6 Complicaii
6.1 Locale
6.2 La distan
6.3 Imediate
6.4 Tardive
7 Prognostic
7.1 Favorabil
7.2 Rezervat
7.3 Nefavorabil
8 Tratament
8.1 Netratat
8.2 Tratat
8.2.1
corect
8.2.2
incorect
8.2.3
complet
8.2.4
incomplet
28
Integritatea parodontal
Cod
1
1.1
1.1.1
1.1.2
1.2
1.3
1.3.1
1.3.2
1.3.3
1.3.3.1
1.3.3.2
1.3.3.3
1.3.4
1.3.5
1.3.6
2
2.1
2.2
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.4
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Integritatea parodontal
Anatomo-clinic + forma clinic
Gingivita
necomplicata
modulata
Gingivita ulcero-necrotica
Parodontita
juvenila
rapid progresiva
a adultului
superficiala
medie
profunda
refractara
din SIDA
ulcero-necrotica
Topografie
Localizat
Generalizat
Etiologie
Microbian
Teren
Stri fiziologice
Alimentaie
Medicaie
Traumatic
Genetic
Iatrogenic
Plurifactorial
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
corect
incorect
complet
incomplet
29
Integritatea arcadei
Cadranul I
Cod
1
1
1.1
1.1.1
1.1.1.1
1.1.1.2
1.1.2
1.1.3
1.2
1.2.1
1.2.2
2
2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.2
2.2.1
2.2.2
2.2.3
2.2.4
3
3.1
3.2
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
5
5.1
5.2
5.3
5.4
6
6.1
6.2
6.3
7
7.1
7.2
7.3
7.4
8
8.1
8.2
8.3
9
9.1
9.2
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Integritatea arcadei
Anatomo-clinic + forma clinic
Edentaie
parial
redus
ntins
subtotal
total
Dizarmonie dento-alveolar
prin nghesuire
prin spaiere
Forma clinic
Clasa Kennedy - Aplegate
clasa I
clasa a II-a
clasa a III-a
clasa a IV-a
clasa a V-a
clasa a VI-a
Subclasa Lejoyeau
clasa A
clasa B
clasa C
clasa D
Topografie
Maxilar
Mandibular
Etiologie
Carie
Parodontopatie
Traumatisme
Tumori
Ortodontic
Iatrogenii
Plurifactorial
Obiceiuri vicioase
Tulburri scheletale
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
30
9.2.1
9.2.2
9.2.2.1
9.2.2.2
9.2.2.3
9.2.2.4
9.2.3
9.2.4
9.2.5
9.2.5.1
9.2.5.2
9.2.5.3
9.2.5.4
protezare fixa
protezare mobil
acrilic
scheletat
elastic
total
protezare mixt
protezare compozit
protezare pe implante
corect
incorect
complet
incomplet
Integritatea ocluziei
Cod
1
1
1.1
2
2.1
2.2
2.3
2.4
2.5
3
3.1
3.2
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
5
5.1
5.2
5.3
5.4
6
6.1
6.2
6.3
7
7.1
7.2
7.3
7.4
8
8.1
8.2
8.3
9
9.1
9.2
9.2.1
9.2.2
9.2.3
9.2.4
Integritatea ocluziei
Anatomo-clinic
Malocluzie
Forma clinic
Clasa Angle
adevrat
fals
clasa I
clasa a II-a
clasa a III-a
Topografie
Maxilar
Mandibular
Etiologie
Obiceiuri vicioase
Malpoziii
Anomalii dento-alveolare
Tulburri scheletale
Ortodontic
Iatrogenii
Plurifactorial
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
corect
incorect
complet
incomplet
Integritatea ATM
Anatomo-clinic + forma clinic
Artrit
Artroz
Luxaie
Subluxaie
Anchiloz
parial
total
fals (pseudo)
adevrat
Forma clinic
secific
nespecific
Topografie
Dreapta
Stnga
Etiologie
Malocluzii
Traumatisme
Edentaii
Modificri morfologice articulare
Reumatism poliarticular
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
fizioterapic
medicamentos
protezat
31
corect
incorect
complet
incomplet
9.2.3.1
9.2.3.2
9.2.3.3
9.2.3.4
Integritatea muscular
Cod
1
1
1.1
1.2
1.3
1.4
2
2.1
2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
3
3.1
3.2
3.3
3.4
3.5
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.3.1
8.2.3.2
8.2.3.3
8.2.3.4
Integritatea osoas
Dr.
Integritatea muscular
Anatomo-clinic
Miozit
Miastenie
Distrofie
Torticolis
Forma clinic
Meniuni.
Topografie
Muschi maseter
Temporal
Maseter
Pterigoidian. intern / ext.
Digastric
Milohioidian
Geniohioidian
SCM
Buccinator
Orbicularul buzelor sup. / inf.
Mentonieri
Narinari
Occipitali i paracervicali
Etiologie
Infecioas
Traumatic
Degenerativ
Congenital
Polifactorial
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
Stg.
Cod
1
1
1.1
1.2
1.3
1.4
1.5
2
2.1
3
3.1
3.2
3.3
3.4
3.5
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.3
Integritatea osoas
Anatomo-clinic
Osteoporoz
Osteit
Osteomielit
Proces malign
Fractur
Forma clinic
Meniuni.
Etiologie
Infecioas
Traumatic
Endocrin
Metabolic
Polifactorial
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
corect
incorect
complet
incomplet
fizioterapic
medicamentos
protezat
corect
incorect
complet
incomplet
32
1
1
1.1
1.2
1.3
1.4
1.5
1.6
2
2.1
3
3.1
3.2
3.3
3.4
3.5
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.4
Stomatit
Glosit
Adenit
Obstrucia glandelor salivare
Leziuni precanceroase
Formaiuni tumorale
Forma clinic
Mentiuni
Etiologie
Traumatic
Alergic
Microbian
Medicamentoas
Idiopat
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
corect
incorect
complet
incomplet
33
Diagnostic chirurgical
Cod
Cod
1
1
1.1
1.2
1.3
2
2.1
2.2
2.2.1
2.2.1
2.3
2.3.1
2.3.2
2.3.3
2.3.4
2
2.1
3
3.1
3.2
3.3
3.4
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.4
Chirurgical
Anatomo-clinic
Leziune tumoral
Leziune trauamatic
Leziune infecioas
Topografic
Odontal
Pri dure
os
articulaie
Pri moi
ligamente
muchi
glande
mucoase
Forma clinic
Meniuni
Etiologie
Traumatic
Tumoral
Microbian
Idiopat
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
corect
incorect
complet
incomplet
1
1
1.1
1.2
2
2.1
2.1
2.2
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
3
3.1
3.2
3.2
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.4
8.2.5
8.2.6
Homeostazie normal
Dishomeostazie
Forma clinic
Homeostazie
ideal
normal
Dishomeostazie
de compensare
susceptibilitate
preclinic
de debut
de decompensare
Etiologie
Local
Loco-regional
General
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
provizoriu
definitiv
corect
incorect
complet
incomplet
nesatisfctoare
34
Nr. edine
1 2 3 4 5 6 7 8
Manopere
Consultatia in cadrul dispensarizarii (include si educatia pentru sanatatea
bucodentara, determinarea indicelui de placa bacteriana si a indicilor de inflamatie
parodontali)
Educatia pentru individualizarea tehnicilor de indepartare a placii bacteriene / sedinta
Periaj dentar profesional / sedinta
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Fluorizri
Clatiri bucale cu solutii fluorurate
/ sedinta
Fluorizari locale cu solutii /
arcada
Fluorizari locale cu lacuri /
arcada
Fluorizari locale cu geluri in
conformatoare / arcada
Sigilri
Sigilari ale santurilor si fosetelor
cu glassinomeri / dinte
Sigilari ale santurilor si fosetelor
cu materiale compozite / dinte
Tratamente de re-educare funcional
Educatie pentru deconditionarea obiceiurilor vicioase / sedinta
Exercitii de reeducare functionala / sedinta
Exercitii de miogimnastica / sedinta
Tratament anti-inflamator
gingival fizioterapic
Control oncologic preventiv confirmat
Manopere
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
35
6
6.1
6.2
Manopere
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
36
8.1
8.2
8.3
8.4
8.5
hipersteziei dentinare
cariilor necavitare prin aplicatii
topice
eroziunilor dentare
fracturilor nepenetrante
discromiilor dentare
Manopere
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Pansament calmant
Pulpectomie vitala cu obturatie canal la monoradiculari (include anestezia)
prin tehnici manuale
prin tehnici mecanice
prin tehnici neconventionale
Pulpectomie vitala cu obturatie canale la pluriradiculari (include anestezia)
prin tehnici manuale
prin tehnici mecanice
prin tehnici neconventionale
Amputatie vitala
Pulpectomie devitala cu obturatie canale la pluriradiculari
prin tehnici manuale
prin tehnici mecanice
prin tehnici neconcentionale
prin tehnici manuale
prin tehnici mecanice
prin tehnici neconcentionale
Tratamentul gangrenei pulpare cu obturatie canal la monoradiculari
prin tehnici manuale
prin tehnici mecanice
prin tehnici neconventionale
Tratamentul gangrenei pulpare cu obturatie canal la pluriradiculari
prin tehnici manuale
prin tehnici mecanice
prin tehnici neconventionale
Dezobturarea canalelor radiculare
Indepartarea corpilor straini
Indepartarea DCR
Pansament medicamentos intracanalar
cu Walkoff
cu Ca(OH)2
cu alte asocieri medicamentoase
Tratamentul parodontitei apicale acute
prin drenaj endodontic
prin drenaj endodontic si incizie
Tratamentul parodontitei apicale cronice, plus obturatie canal
la monoradiculari
la pluriradiculari
Obturatie la dintii devitali
cu amalgam
cu materiale compozite
cu materiale compozite hibride
cu materiale nanocompozite
cu glassionomeri
cu compomeri
Obturare canal monoradicular
prin tehnica conventionala
prin condensare laterala
prin condensare verticala la cald
cu sistem Termafil
Obturare canal pluriradiculari
prin tehnica conventionala
prin condensare laterala
prin condensare verticala la cald
cu sistem Termafil
Albirea dintilor tratati endo
37
16
16.1
16.2
16.3
16.4
16.5
E. TRATAMENT PARODONTAL
Manopere
Cod (E)
1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
2
2.1
2.2
2.3
2.4
2.5
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Manopere
Tratament medicamentos
Reechilibrare psihic
Tratamentul durerii
Tratament medicamentos miorelaxant
Fizioterapie
Hidrotermoterapia
Masoterapia
Ultrasonoterapia
Fototerapia
Terapia cu laser
Tratamentul de echilibrare ocluzal
Utilizarea gutierelor
Tratament ortodontic
Tratamentul protetic
proteazare fix acrilic
protezare mobil acrilic
protezare mixt acrilic
DA
NU
38
Manopere
Cadranul I
Cadranul II
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
39
1.7.3
1.7.4
2
2.1
2.2
2.2.1
2.2.2
2.2.3
2.3
3
3.1
3.1.1
3.1.2
3.2
3.2.1
3.3
3.3.1
3.3.2
3.3.3
4
4.1
4.1.1
4.1.2
4.2
4.2.1
4.2.2
4.2.3
4.3
4.3.1
4.3.2
4.3.3
4.3.4
5
5.1
5.1.1
5.1.2
5.1.3
5.1.4
5.1.5
5.2
5.2.1
5.2.2
5.2.3
5.2.3.1
5.2.3.2
5.2.4
6
6.1
6.2
7
7.1
7.2
7.2.1
7.2.2
7.3
8
9
9.1
9.2
10
Culisa intracoronar
Lca intraradicular
Protejarea structurilor odonto-parodontale
Mijloace chimice
Mijloace mecanice
cape prefabricate
restaurari extemporanee
restaurri acrilice
Mijloace mecano-chiimice
Etalarea sulcusului
Mijloace mecanice
fir retractor
materiale expansive
MIjloace mecano-chimice
fir impregnat
MIjloace chirurgicale
Electrocauter
Laser
Frezaj mecanic
Amprenta substructurilor organice preparate
Tip
segmentar
global
Tehnic
1 timp
2 timpi
3 timpi
Tip de material
polieteri
polisulfii
siliconi de adiie
siliconi de condensare
Inregistrarea relaiilor mandibulo-craniene
Inducerea relaiei centrice
Metoda Dawson
Dawson
Ramfjord
Lauritzen-Barell
Jankelson
nregistrarea relaiei centrice
Material de amprent
siliconic
Plas + eugenol de zinc
Machete de ocluzie
val de cear
termoplastic + silicon
Arc facial
nregistrarea culorii
Cheie culori
Easy Shade
Verificarea i adaptarea scheletului metalic
Verificarea realizrii tehnologice
Verificare i adaptare cervical
axial
transversal
Verificare i adaptare axial
Verificarea i adaptarea lucrrii comjuncte
Amprentare preliminar
Adaptarea portamprentelor standard
Amprenta cu alginat
Amprenta funcional
Verificarea i adaptarea
10.1
portamprentelor individuale
10.2 Amprenta periferic
10.3 Amrpenta central
11 Inregistrarea relaiilor mandibulo-craniene
40
41
PLANUL DE TRATAMENT
I. TRATAMENTUL NESPECIFIC
NR. CRT.
1
2
3
4
5
6
7
8
9
10
MANOPER (COD)
TARIF
SUBTOTAL
TARIF
SUBTOTAL
MANOPER (COD)
42
NR. CRT.
1
2
3
4
5
6
7
8
9
10
MANOPER (COD)
TARIF
SUBTOTAL
TARIF
SUBTOTAL
MANOPER (COD)
DATA
MANOPER (COD)
TARIF
MATERIAL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
43
DIAGNOSTIC FINAL
A. DIAGNOSTICUL DE STARE GENERALA
favorabil
nefavorabil
______________________________________________________________________________________
______________________________________________________________________________________
Caz terminat
Medic,
Pacient,
44