DEPARTEMEN PROSTODONSIA NO.

RM:
PENDIDIKAN DOKTER GIGI FAKULTAS KEDOKTERAN
RUMAH SAKIT AKADEMIK UNIVERSITAS BRAWIJAYA
REKAM MEDIK S A M

Operator/NIM :…………………………………………................. Instruktur Klinik :...……………………………………................

Nama Pasien: Tgl Mulai Perawatan :

Jenis Kelamin: Laki-laki/Perempuan Tgl.Lahir: / / ( thn) Tgl Perawatan Selesai:
Suku/Ras/Kewarganegaraan: No.RP :
Alamat: Acc.IK Acc.IP Acc.PS

Telp/Hp: Status: Kawin/Belum Kawin

Pekerjaan: Pendidikan Terakhir :

ANAMNESIS

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1 Keluhan Utama ..................................................................................................................................................................
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2 Tujuan Pembuatan GT Perbaikan Estetik / Fungsi Kunyah / Fonetik / Lain-lain :.................................................................................

a. Penyebab kerusakan atau kehilangan gigi : Gigi berlubang / Gigi goyang / Gigi patah karena benturan /
(*)
Lain-lain :...........................................................................................................................................
b. Tindakan Pencabutan Gigi yang terakhir kali dilakukan :
Urutan pencabutan(Regio–Rahang)........................................................................................................
Riwayat Kesehatan Waktu pencabutan................................................................................................................................
3
Gigi dan Mulut
c. Kebiasaan Buruk : Kerot – kerot (Bruksism) / Bekertak gigi (Clenching) / Mendorong lidah ke depan
(tongue thrusting) / Mengunyah pada satu sisi (kanan / kiri) / Membuka tutup botol dengan giginya/
(*)
Lain-lain :.........................................................................................................................................
Dilakukan sejak....................................................................................................................................
Penyakit Sistemik/Alergi/Menular yang dahulu/saat ini diderita :.....................................................................
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Riwayat Kesehatan .................................................................................................................................................................
4
Umum
Penggunaan Obat-obatan: ..........................................................................................................................
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Pernah memakai / Sedang memakai / Tidak pernah memakai GT (*)
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5 Riwayat Pemakaian GT
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Perawatan GT yang lama :...........................................................................................................................
Problema dengan GT yang lama :.................................................................................................................
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(*)
Klasifikasi House : Philosophis / Exacting / Indefferent / Hysterical
6 Sikap Mental (*)
Untuk pasien Geriatri : Realist / Resenters / Resigned (passive)

PEMERIKSAAN KLINIS
Bentuk Kepala: Dolichocephalic / Mecocephalic / Brachycephalic / Hiperbrachycephalic(*)
Bentuk Wajah (tampak depan): Square / Square-Tapering / Tapering / Ovoid(*)
Bentuk Profil Wajah (tampak samping): Lurus-Orthognatic / Cekung-Retrognatic Mandibula
Cembung-Prognatic Mandibula(*)
Tinggi dan Lebar Wajah: Euryprosop / Mesoprosop / Leptoprosop(*)
Proporsi dan Simetris Wajah: Proporsional / Tidak proporsional(*) ; Simetris / Asimetris(*)
Mata: Simetris / Asimetris(*) ; Warna Pupil...................................................................................................
Hidung: Simetris /Asimetris(*) ; Tidak / Bernafas melalui hidung(*)

1 Ekstra Oral
Bibir:Kontur Kompeten/Inkompeten(*); Normal / Panjang / Pendek(*); Tebal / Medium / Tipis(*)
Mobilitas Bibir Normal / Menurun / Paralisis(*) ; Lateral Negative Space: Ada / Tidak(*)
Bentuk lengkung bibir atas: Straight/Moderate Arched-Upward/Maximal Arched-Downward(*)
Garis senyum: Simetris / Asimetris(*) ; Lengkung Senyum: Simetris / Asimetris(*)
Warna Kulit..............................................................................................................................................
Sendi Temporomandibular (TMJ):
Tonus Otot: Klas 1-Normal / Klas 2 / Klas 3(*)
Range of Motion (ROM) Rongga Mulut: Normal / Terbatas(*) .........................mm
Pembukaan Mulut: Deviasi / Defleksi(*) ke sisi.............................................................................................
 DEPARTEMEN PROSTODONSIA NO.RM:
PENDIDIKAN DOKTER GIGI FAKULTAS KEDOKTERAN
RUMAH SAKIT AKADEMIK UNIVERSITAS BRAWIJAYA
REKAM MEDIK S A M

Tes Beban Kunyah (Load Test): Tidak Nyeri / Intensitas nyeri bertambah / berkurang(*)
Joint Sound: Clicking / Krepitasi / Popping pada sisi....................................................................................
Dirasakan sejak...................................................................................................................
Evaluasi Neuromuscular : Normal / Tidak normal-Affected(*)
Koordinasi Neuromuscular: Baik / Cukup / Buruk(*)
Kelainan/Defek pada wajah:..................................................................................................................

Refleks Muntah: Rendah / Tinggi(*) Sensitivitas Palatal: Klas 1-Normal/ Klas 2/ Klas 3(*)
(*)
Saliva: Klas 1-Normal / Klas 2 / Klas 3-Xerostomia
Mukosa: Kondisi Klas 1-Normal / Klas 2-Iritasi / Klas 3-Patologis(*)
Ketebalan Klas 1/ Klas 2A/ Klas 2B/ Klas 3(*) ; Resiliensi Mukosa Normal / Tidak Normal(*)
Lidah:Klasif.House Klas 1/ Klas 2/ Klas 3(*); Posisi Lidah (Klasif. Wright) Klas 1/ Klas 2/ Klas 3(*); Mobilitas.................
Frenulum: klasifikasi perlekatan Klas 1-Rendah/ Klas 2-Sedang/ Klas 3-Tinggi(*)
RA Bukalis Kanan............. Bukalis Kiri.............. Labialis...............
RB Bukalis Kanan............. Bukalis Kiri.............. Labialis............... Lingualis..............
Vestibulum: klasifikasi Deep/Dalam (D) ; Shallow/Dangkal (S)
RA Anterior.......... Posterior Kanan.......... Posterior Kiri...............
RB Anterior.......... Posterior Kanan.......... Posterior Kiri...............
Ukuran Lengkung Rahang: RA Klas 1-Besar/ Klas 2-Sedang/ Klas 3-Kecil(*)
RB Klas 1-Besar/ Klas 2-Sedang/ Klas 3-Kecil(*)
Bentuk Lengkung Rahang: RA Klas 1-Square/ Klas 2-Tapering/ Klas 3-Ovoid(*)
RB Klas 1-Square/ Klas 2-Tapering/ Klas 3-Ovoid(*)
(*)
Bentuk Dalam Palatum Keras: U-Shaped atau Square / V-shaped (Tapering) / Flat (Datar)
(*)
Bentuk Palatum Lunak: Klas 1-Ideal / Klas 2-sudut 45º / Klas 3-sudut 70º
(*)
Bentuk dan Relasi Palatal – Tenggorokan (Throat): Klas 1 / Klas 2 / Klas 3
Tinggi Residual Ridge: RA Anterior Klas 1/ Klas 2 / Klas 3(*); Posterior Klas 1/ Klas 2 / Klas 3(*)
RB Anterior Klas 1/ Klas 2 / Klas 3(*); Posterior Klas 1/ Klas 2 / Klas 3(*)
Kontur Residual Ridge: RA Square / Square Ovoid (U-shaped) / V-shaped / Flat / Unfavorable(*)..................

2 Intra Oral RB Square / Square Ovoid (U-shaped) / V-shaped / Flat / Unfavorable(*).................

Kesejajaran Residual Ridge: Klas 1-Sejajar/ Klas 2 / Klas 3(*)
Relasi Ridge Maksilomandibular pada rahang tidak bergigi:
(*)
Sagital Normal-Orthognathic / Retrognathic / Prognathic ; Transversal sudut ≥ 80º / ≤ 80º(*)
Ruang antar-rahang: Klas 1-Ideal / Klas 2-Excessive / Klas 3-Insufficient(*)
Undercut tulang/Eksostosis: Klas 1/ Klas 2/ Klas 3(*) pada regio...............................................................
Torus Palatina:Klas 1/ Klas 2/ Klas 3(*); Torus Mandibularis:Klas 1/ Klas 2/ Klas 3(*)
Genial Tubercles Normal/Prominen ; Ridge Mylohyoid Normal / Tajam-Prominen / Iregular-Prominen(*)
Tuberositas Maksilaris: Normal / Terdapat pembesaran : Bony enlargement / Fibrous enlargement(*)
(*)
Ruang Retromylohyoid: Kanan Klas 1-Dalam / Klas 2-Sedang / Klas 3-Dangkal
(*)
Kiri Klas 1-Dalam / Klas 2-Sedang / Klas 3-Dangkal
(*)
Ruang Dasar Mulut: Dangkal / Dalam
Gigi Insisivus Rahang Atas (bila ada) : Bentuk...................................... Warna.........................................
(*)
Fraktur Gigi pada elemen ...... Arah Horisontal / Vertikal / Diagonal ; Luas ≥ 1/3 mahkota / ≤ 1/3 mahkota
(*)
Relasi Rahang Bergigi: Anterior Klas 1-Normal / Klas 2- Retrognathi / Klas 3- Prognathi
(*)
Posterior Kanan Gigitan Terbuka / Gigitan Silang / Gigitan Terbalik
(*)
Posterior Kiri Gigitan Terbuka / Gigitan Silang / Gigitan Terbalik
(*)
Oklusi: Tidak ada oklusi / Terdapat oklusi yang Stabil / Tidak stabil
Kontak Prematur Tidak / Ada pada gigi................................ Overbite/TG ......... mm - Overjet/JG..........mm
Hubungan gigi posterior (cusp to fossa): Kanan.......................................Kiri..............................................
Hubungan gigi posterior (cusp to marginal ridge):Kanan...................................Kiri......................................
(*)
Artikulasi: UBO / MPO / BBO / Tidak dapat ditentukan

3 Odontogram

Kanan RAHANG ATAS Kiri

 DEPARTEMEN PROSTODONSIA NO.RM:
PENDIDIKAN DOKTER GIGI FAKULTAS KEDOKTERAN
RUMAH SAKIT AKADEMIK UNIVERSITAS BRAWIJAYA
REKAM MEDIK S A M

Kanan RAHANG BAWAH Kiri

Keterangan Gambar:
At Atrisi S Stain La Labial Arsir warna hitam pada mahkota utk Restorasi
Indirek (Onlay/Inlay/Full cast crown/Full Veneer
Er Erosi VVVV Kalkulus Pal Palatal Crown/Dowel Crown/ Bridge/Partial Veneer Crown/
Ab Abrasi Ds Diastema Dis Distal Laminate Veneer, Implant) dan beri kode
Abf Abfraksi M & gbr Migrasi dan Mes Mesial Arsir warna biru pada mahkota utk Restorasi Direk
panah arah (Amalgam/ GIC/ Resin komposit) dan beri
_º Goyang _ derajat Li Lingual kode.
X Gigi hilang = pergerakan
Tidak ada oklusi O Oklusal Blok warna hitam pada sisi mahkota gigi yang
TE Tidak/Belum Ob Open Bite Am Amalgam mengalami karies, akar gigi non vital dan beri
Interpretasi SA Sisa Akar
erupsi Cb Cross Bite GIC GIC kode.

Odontogram I Impaksi Ee Edge to edge RK Resin FCC Full Cast Crown

Pe Partial Eruption It Intrusi Komposit FVC/PVC Full Veneer Crown/Partial Veneer Crown
A Anomali Gigi E Ekstrusi On Onlay LV Laminate Veneer
F Fraktur Gigi Ve Versi In Inlay DC Dowel Crown
KS Karies Sekunder # Tilting Im Implant BR / BP Bridge Retainer / Bridge Pontic
Df Defek R Rotasi Ob Obturator PD / CD Partial Denture/ Complete Denture
OD Overdenture

Kondisi jaringan lunak dan keras yang tidak tercantum dalam odontogram: ..........................................................

Lain-Lain ........................................................................................................................................................................
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Radiografik Panoramik:
(*)
Ketinggian Puncak Alveolar Ridge (Klasif.Wical & Scope) Klas 1 / Klas 2 / Klas 3
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Radiografik Intra Oral:
Pemeriksaan
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Penunjang
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Lain-lain (Darah Lengkap, Biopsi/Patologi Klinik, Kejiwaan dll):
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5 Diagnosis .........................................................................................................................................................................
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Perawatan Pendahuluan/Rujukan:
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Rencana
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Perawatan
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7 Prognosis Baik / Meragukan / Buruk (*)

 DEPARTEMEN PROSTODONSIA
PENDIDIKAN DOKTER GIGI FAKULTAS KEDOKTERAN
RUMAH SAKIT AKADEMIK UNIVERSITAS BRAWIJAYA
REKAM MEDIK
DESAIN GIGI TIRUAN
UTAMA
Klasifikasi Kehilangan Gigi:
RA ....................................................................................................
RB ....................................................................................................
Keterangan Desain Gigi Tiruan Rahang Atas :
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Keterangan Desain Gigi Tiruan Rahang Bawah :
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PROBLEMA PASCA INSERSI
No Tgl/Bln/Thn Pemeriksaan Ulang
NO.RM:
S A M
ALTERNATIF
Klasifikasi Kehilangan Gigi:
RA ..................................................................................................
RB ..................................................................................................
Keterangan Desain Gigi Tiruan Rahang Atas :
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Keterangan Desain Gigi Tiruan Rahang Bawah :
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Tindakan Operator
 DEPARTEMEN PROSTODONSIA NO.RM:
PENDIDIKAN DOKTER GIGI FAKULTAS KEDOKTERAN
RUMAH SAKIT AKADEMIK UNIVERSITAS BRAWIJAYA
REKAM MEDIK S A M

PEMBAYARAN BIAYA PERAWATAN

No Kuitansi Tgl Tindakan/Perawatan Jumlah Paraf IK

CATATAN TAHAPAN PEKERJAAN

NO TGL TAHAPAN PEKERJAAN PARAF.IK KET
 DEPARTEMEN PROSTODONSIA NO.RM:
PENDIDIKAN DOKTER GIGI FAKULTAS KEDOKTERAN
RUMAH SAKIT AKADEMIK UNIVERSITAS BRAWIJAYA
REKAM MEDIK S A M

NO TGL TAHAPAN PEKERJAAN PARAF.IK KET