Suplemen Kartu Status Klinik Ortodonsia

RSGM Universitas Jember

ANALISIS FUNGSIONAL DAN MODEL

1. Analisis Fungsional
1.1 Freeway Space

Centric Occlusion : ..................... mm

Relaxation Occlusion : ..................... mm
Value : ..................... mm

1.2 Path of Clousure : Normal / Tidak Normal (..................................... )

1.3 Sendi Teomporo Mandibular : Normal / Tidak Normal ( ........................................)

1.4 Pola Atrisi : Normal / Tidak Normal (....................................................)

2. Analisis Model
2.1 Bentuk lengkung : RA ................................ ; RB ....................................

2.2 Jumlah lebar 4 insisive : .............. mm ; (Normal / Tidak Normal)

11 : ......... mm (Normal/ Makrodonsia/ Mikrodonsia)

12 : ......... mm (Normal/ Makrodonsia/ Mikrodonsia)
21 : ......... mm (Normal/ Makrodonsia/ Mikrodonsia)
22 : ......... mm (Normal/ Makrodonsia/ Mikrodonsia)

2.3 Kurva of Spee : Positif / Datar / Negatif

2.4 Diastema

RA : ...............................................................................

RB : ...............................................................................

2.5 Pergeseran Gigi Geligi

Rahang Atas : Rahang Bawah :

1. ............................................................
2. ............................................................
3. ............................................................
4 ............................................................
5 ............................................................
1 .............................................................
2 ...........................................................
3 ...........................................................
4 ..........................................................
5 ...........................................................
2.6 Gigi-gigi yang terletak salah

Rahang Atas : Rahang Bawah :

1. ............................................................
2. ............................................................
3. ............................................................
4. ............................................................
5. ............................................................
1. .............................................................
2. ...........................................................
3. ...........................................................
4. ..........................................................
5. ...........................................................

2.7 Pergeseran Garis Median Terhadap Muka

Rahang Atas : ............. mm ke kanan/kiri

Rahang Bawah : ............. mm ke kanan/kiri

2.8 Kelainan Kelompok Gigi

Berdesakan
Anterior : Rahang atas / Rahang bawah
Posterior : Rahang atas kiri / kanan
Rahang bawah kiri / kanan
Supra Posisi : Rahang atas, regio ...............................
Rahang bawah, regio ..........................
Infra Posisi : Rahang atas, regio ..............................
Rahang bawah, regio ..........................
Protrusi : Rahang atas / Rahang bawah
Retrusi : Rahang atas / Rahang bawah

2.9 Relasi Sagital dan Vertikal

Relasi Sagital
Molar kedua sulung kanan : .........................................
Molar kedua sulung kiri : .........................................
Molar pertama permanen kanan : .........................................
Molar pertama permanen kiri : .........................................
Kaninus permanen kanan : .........................................
Kaninus permanen kiri : .........................................
 Relasi Vertikal
Overjet : .........................................
Overbite : .........................................

3. KEMUNGKINAN ETIOLOGI MALOKLUSI

Faktor keturunan : .................................................

DDM : .................................................

Kebiasaan jelek : .................................................

Kehilangan prematur gigi sulung : .................................................

Kelainan otot mulut : .................................................

Kelainan jumlah gigi : .................................................

Kelainan posisi gigi : .................................................

Persistensi : .................................................

Kelainan patologik : .................................................

Defek congenital : .................................................

Sebab-sebab yang tidak diketahui : .................................................

Lain - lain : .................................................

4. RESUME INDEKS PAR

No Skor Penilaian Skor Indeks Pasien

Model I Model II Model III Model IV
1 Segmen Anterior
2 Segmen Bukal
3 Overjet
4 Overbite
5 Midline
Jumlah
Keparahan Maloklusi