This document presents a case of an 18-year-old female patient who frequently bites her cheek. She has mild gingivitis and Angle's Class I malocclusion with unilateral crossbite. Her treatment plan involves non-surgical therapy like scaling and root planing followed by corticotomy to assist rapid maxillary expansion between teeth 14-17 and 24-27. Proper oral hygiene instructions and maintenance therapy are also included.
2. PERSONAL HISTORY:
• Name: Akshya warrior
• Age: 18yrs.
• Sex: Female
• Occupation: Student
• Address: Aakashdeep society,
Near Chandkheda Bus stand
Chandkheda
• O.P.D. No: 14921
3. CHIEF COMPLAINT:
• Patient came with chief complaint of frequently biting her
cheek.
HISTORY OF PRESENT ILLNESS:
• Pt. was relatively asymptomatic before 3 months. she
frequently biting her cheek, she, so she came to the Karnavati
school of dentistry for further treatment.
4. • No relevant dental history
PAST DENTAL
HISTORY:
• No relevant medical history.
MEDICAL
HISTORY
• No significant family history
FAMILY
HISTORY
5. PERSONAL HISTORY:
DIET:
Pt. consumes Vegetarian diet
ORAL HABITS: Pt. brushes teeth with soft
toothbrush and non medicated toothpaste in
a horizontal fashion once in a day and tongue
cleaning regularly.
6. ON EXAMINATION:
EXTRA ORAL:
• Facial symmetry:
Bilaterally symmetrical
• Lymph nodes :Non
tender and non
palpable
• TMJ : on inspection
normal mouth
opening, no abnormal
jaw movements or
deviation seen
• On palpation no
tenderness or clicking
or crepitus felt
INTRA ORAL
• Lips- Competent, No
abnormality detected
• Mucosa- No
abnormality detected
• Palate- No
abnormality detected
• Floor of mouth- No
abnormality detected
• Tongue- No
abnormality detected
• Tonsils- No
abnormality detected
• Any other- No
abnormality detected
12. HARD TISSUE EXAMINATION:
Number of teeth present : 28
Number of teeth missing: Decayed tooth: -
Restored tooth: -
Type of occlusion: Angle’s Class I malocclusion with
unilateral crossbite
18. PHASE I THERAPY ( NON SURGICAL
PHASE)
Scaling and root planning
Diet control
Occlusal therapy
Correction of restorative and prosthetic factors
Excavation of caries and restoration (temporary)
Antimicrobial therapy
Provisional splinting and prosthesis
Minor orthodontic treatment
19. TOOTH BRUSHING:
To use a Soft
toothbrush with a
minimally abrasive
dentifrice twice a day
Modified Stillman
technique to be
taught
INTER-DENTAL AID
•Inter dental floss and
interproximal brush to
be prescribed
A 30 yr old female patient name manishaben Solanki residing in chandkheda came here with the chief complaint of yellowish discolation of tteth since 3 month.
