Universitatea de Medicină şi Farmacie „Gr. T.

Popa” Iaşi
Departamentul – Odontologie-Parodontologie, Proteza fixă
Disciplina – Proteza fixă

FIȘĂ OBSERVAȚIE – EDENTAŢIE PARŢIALĂ REDUSĂ

Nr. _____ Data _______ Medic ____________________________ Student ___________________

Nume __________________________ Prenume ______________________ Vârstă _____ Sex ___

Adresa ________________________________________________________ U / R Telefon _______________

ANAMNEZĂ

Motivele prezentării ____________________________________________________________________________

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Istoric ________________________________________________________________________________________
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AHC _________________________________________________________________________________________
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AP ___________________________________________________________________________________________
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Condiţii de viaţă şi muncă ________________________________________________________________________
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EXAMEN FACIAL (EXTRAORAL)

INSPECŢIE
Tegumente ____________________________________________________________________________________
Forma ___________________ Profil ____________________
_________________________ Postura buzelor ___________
Simetria _________________ _________________________
_________________________ Treapta labială ____________
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Etaje ____________________ Unghiuri _________________
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Observaţii ________________ Observaţii ________________
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PALPARE
Superficială
Temperatura ___________________ Sensibilitate TTD _____________________ Umiditate ___________________

Profundă
Structuri osoase ________________________________________________________________________________
Puncte Valley __________________________________________________________________________________
Ganglioni _____________________________________________________________________________________
Glande salivare ________________________________________________________________________________

1
Muşchi _______________________________________________________________________________________

Examen subiectiv: ____________________________________________________________________________

Examen obiectiv:
Dr. Stg.

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Concluzii:
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Observaţii _____________________________________________________________________________________
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NOTĂ:
Folosiți următoarele notații: Durere inserție / masa (Di / Dm), Volum hipo- / hipertrofie (V- / V+), Tonicitate hipo- / hipertonicitate (T- / T+)

EXAMINAREA ATM
Examen subiectiv: ____________________________________________________________________________
Examen obiectiv: inspecție ____________________________________________________________________
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palpare ____________________________________________________________________
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ascultație ____________________________________________________________________
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Mobilitate ATM: deschidere _________________________ mm propulsie _________________________mm
lateralitate dr. ______________________ mm retropulsie ________________________mm
lateralitate stg. _____________________ mm
Concluzii: ____________________________________________________________________________
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EXAMEN INTRAORAL
Orificiul bucal
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Mucoasa labio-jugală
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Vestibulul bucal
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2
Arcada dento-alveolară

NOTĂ:
Folosiți următoarele notații: c – carie, o – obturație, a – abrazie, p – pupită, g – gangrenă, a - parod. apicală, √ - rest radicular, X - absent
- r. prot. Fizionomică, - r. prot. semifiz., - r. prot. nefiz.

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Bolta palatină
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Planşeul bucal
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Parodonţiul marginal
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RELAȚIA DE POSTURĂ
Postura generală ______________________________________________________________________________

DVO = __________ mm Factori perturbatori:

abrazii ________________________________________
Metoda de determinare __________________________
migrări ________________________________________
Concluzie: există / nu există modificări interferențe (lucrări, obturații etc.) ___________________

DVP = __________ mm DV "a" = __________ mm

Evaluarea reperelor: se păstrează / nu se păstrează DV "s" = __________ mm

Spațiul liber DVP – DVO = ____________ mm

PM dr. = ________ mm PM stg. =________ mm
Concluzie: valoarea se încadrează / nu se încadrează

RELAȚIA DE OCLUZIE

Traseu închidere în IM _____________________________________________

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Zgomot ocluzal __________________________________________________________________________

Mobilitate dentară __________________________________________________________________________
Parametrii ocluziei:
1. ariile ocluzale: Mx _______________________________________________________________________________
Mb _______________________________________________________________________________
2. curbele sagitale ______________________________
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3. curbura transversală _________________________
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4. cuspizii de sprijin _____________________________
- gr. 1 _________________________________________
- gr. 2 _________________________________________
- gr. 3 _________________________________________
5. cuspizii de ghidaj _____________________________
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6. curbura frontală: aplatizată / medie / accentuată
7. ghidaj anterior: ineficace / N / excesiv

Rapoarte ocluzale statice:

Repere Molar Premolar Canin Incisiv

Planuri Dr. Stg. Dr. Stg. Dr. Stg.
Sagital
Transversal
Vertical
Concluzii _______________________________________________________________________________________________

Ocluzograma:
Caracterizarea contactelor stabilitate_____________________________
distribuție_____________________________
localizare_____________________________
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număr ________________________________
întindere ______________________________
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tripodalitate __________________________

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OCUZIA DINAMICĂ
Protruzia: Lateralitatea: Dr. Stg.
Poziția test ___________________________________ Poziția test ________________ ___________________
Mișcarea test ___________________________________ Mișcarea test ________________ ___________________
Interferențe ___________________________________ Interferențe ________________ ___________________
Fațete de uzură ___________________________________ Fațete de uzură ________________ ___________________

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

Ocluzia terminală în IM: Ocluzia terminală în RC:

Traiectorie ___________________________________ Traiectorie _____________________________________
Contacte ___________________________________ Contacte _____________________________________
Interferențe ___________________________________ Interferențe _____________________________________
Zgomot ocluzal ___________________________________ Zgomot ocluzal _____________________________________

Traiectoria IM - RC:
Traseu IM - RC ___________________________________
Interferențe ___________________________________ Long-centric = ______ mm / point-centric / freedom in centric

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
Legendă:
               
 Interferențe în IM - albastru
                 Interferențe în RC - roșu
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  Interferențe pe traseul IM -RC - verde

RELAȚIA CENTRICĂ
Repere: 1. ________________________________________________________________ Tipul contactelor:
2. ________________________________________________________________ ________________________
3. ________________________________________________________________ ________________________
4. ________________________________________________________________ ________________________

Evaluarea tipului de contact: - long centric - point centric

- cuspid - ambrazură - cuspid – fosetă
- funcție grup - funcție canină

CONCLUZII FINALE
RP ______________________________________________________________________________________
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RO ______________________________________________________________________________________
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RC ______________________________________________________________________________________
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EXAMENE PARACLINICE
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DIAGNOSTIC
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PLAN DE TRATAMENT
Pregătire generală __________________________________________________________________________
Educație sanitară __________________________________________________________________________
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Pregătire nespecifică __________________________________________________________________________
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Pregătire specifică __________________________________________________________________________
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Tratament protetic
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6
Dispensarizare _________________________________________________________________________________
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Dată Leziune Tratament

ACCEPTUL PACIENTULUI

Subsemnatul _____________________________ posesor a ________ seria ____ nr. _____________ menţionez că

mi-au fost explicate pe înţelesul meu diagnosticul, planul de tratament şi costul estimativ, ca urmare mă angajez să
îmi asum şi însuşesc tratamentele propuse şi să respect indicaţiile date. Am luat la cunoştinţă despre eventualele
riscuri, accidente şi complicaţii care pot interveni pe parcursul tratamentului şi după finalizarea lui şi declar în
cunoştinţă de cauză că mi le însuşesc în totalitate, aşa cum mi-au fost explicate de dr. _______________________

Data Semnatura,

7
OCLUZOGRAMA