my residents – Dr. Mohammadamin Narimani

Dr. M. Narimani

Registered as a General Dentist in Ontario

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RESIDENTS INTAKE / ORTHODONTIC EVALUATION FORM

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2. Case History

3. Functional Analysis

TMJ sound (click):

Yes

Max mouth opening:

Jaw movement:

Airway:

Speech:

Swallowing:

Muscles:

4. Clinical exam, Macroesthetic, Frontal view analysis

Symmetry:

Nose:

Chin:

Facial Thirds:

Facial Height:

Facial Index:

Facial Form:

Lips:

Smile Arc:

Buccal Corridors:

Occlusal cant:

Upper midline to face midline:

Upper midline to lower midline:

5. Clinical Exam, Macro esthetic, profile view analysis

Profile:

LAFH:

Chin projection:

Lip protrusion (E-line):

Incisors position:

Nasolabial Angle:

Mentolabial Angle:

Chin-Throat Angle:

Chin-Throat Distance:

6. Intra oral exam

Mucosal condition:

Gingival condition:

Periodontal condition:

Tongue:

Tonsils :

Arch-symmetry :

Arch form:

Midline:

Tooth anomaly, missing, supernumerary, malformed:

Bolton Discrepancy:

Ectopic or out of arch:

Curve of Spee:

Functional shift:

Inter-arch Midline:

Transverse:

verjet / Scissor bite:

Sagittal canines:

Molars:

Vertical:

7. Diagnostic Records

Pathologic lesion:

Condyles:

Dental development:

Root morphology:

Caries:

Periodontal condition on Pan:

Growth potential CVM:

A-P skeletal condition:

Maxilla:

Mandible:

Vertical skeletal:

Upper incisors:

Lower incisors:

8. Data Gathering

Additional information needed during initial examination:

Chief complaint history

Medical history

Dental history

History of trauma

Habits

Presence of dental home

Family history of mandibular growth

Maturation characteristics

Other"

Other initial information:

Additional record or information needed prior to orthodontic treatment:

Hand wrist

CBCT

PSG

Myofunctional evaluation

Electromyographic evaluation

Serial ceph

TEC99 scan

TMJ and associated musculature health

Mounted models

Additional Radiographs

Perio charting

Other

Other records needed:

9. Diagnosis, problem list - Soft Tissue

Profile

Soft tissue pogonion

LAFH

Asymmetries

Nasolabial angle

Mentolabial angle

Vermilion display

Maxillary incisor and gingival display

Lip competence

Smile Arc

Smile Cant

Buccal corridors

Chin-throat angle / distance

Other

Other soft tissue diagnosis:

10. Growth assessment:

CS1

CS2

CS3

CS4

CS5 or more

11. Skeletal Diagnosis

Maxilla transverse:

Maxilla sagittal:

Mand sagittal:

Skeletal class:

Vertical pattern:

12. Dental Diagnosis

Transverse findings:

Anterior/Posterior cross bite

Rolled in dentition

Midline deviation (Yaw)

Molar Angle classification:

Canine Angle classification:

Over Jet:

Incisors:

Over bite:

Space Analysis:

Developmental problem:

Missing/supernumerary

Ectopic eruption/Transposition

Impaction

Other

Other developmental problem:

Gingival / perio consideration:

Recession

Attached gingiva

Perio consult

13. Etiology of this patient

Skeletal

Dental

Parafunctional / Habit

Soft tissue (Tongue, frenum, tonsils & muscles)

Breathing

Genetic

Trauma

Pathology

Other

Other etiology:

14. Treatment objective

Asymmetry:

Lip:

Incisor/gingival display:

Smile Arc:

Buccal corridors:

Maxilla Transverse:

Maxilla Sagittal:

Maxilla Vertical:

Mand Sagittal:

Mand Vertical (redirect):

Maxillary incisors Transverse:

Maxillary incisors Sagittal:

Maxillary incisors Vertical:

Molars Transverse:

Molars Sagittal:

Molars Vertical:

COS:

Extract:

If extraction, which tooth:

Anchorage:

Mandibular dental treatment objective notes:

15. Treatment plan

Non ext

Ext

Surg Orthosurgery

Camouflage

TAD

Other

Other treatment plan:

16. Treatment Implementation and Management

Recommend treatment method:

Treatment sequence:

Phase I

Functional

Braces

Invisalign

Problems anticipated:

Anchorage considerations:

17. Prognosis:

18. Treatment Duration:

19. Retention

Retention duration:

Retention type:

20. Other consideration

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