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space-maintainer-2

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SPACE MAINTAINER
SUBMITTED BY:
ZIPPORAH J. MATILING
DDM 6B
SUBMITTED TO:
REY CACHERO DMD
PATIENT’S WORK-UP:
NAME:
ADDRESS:
AGE:
BIRTHDAY:
GENDER:
Fathers Name:
Occupation:
Mothers Name:
Occupation:
CASE HISTORY:
I.
CHIEF COMPLAINT:
II.
HISTORY OF PRESENT ILLNESS:
III.
PAST MEDICAL HISTORY:
IV.
PAST DENTAL HISTORY:
V.
INTRAORAL EXAMINATION:
VI.
FACIAL PHOTOGRAPHS:
VII. INTRAORAL PHOTOGRAPHS:
VIII. PANORAMIC RADIOGRAPH:
IX.
TREATMENT PLAN:
MDI: is the measurement from the distal surface of permanent mandibular right lateral incisor to the distal
surface of permanent mandibular left lateral incisor.
Available space: is the measurement from the distal surface of permanent mandibular lateral incisor (R/L) to the
distal surface of primary mandibular second molar or the mesial surface of the permanent mandibular first
molar.
Space Required:
MdCB - MDI/2 + ___mm
____+ ____m
____mm
Space Discrepancy:
Mandibular left:
____mm – ____mm = ____mm
Mandibular right:
____mm – ____mm = ____mm
Md Left
Available space
Required space
Space discrepancy
Treatment
Md Right
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