It is important to undertake clinical assessment in a logical sequence, so that nothing is missed. Use the Orthodontic Assessment sheet and include them into teh patinets notes. Assessement is undertaken in 4 stages, then followed by a summary, development of a problem list, the treatment aims and finally treatment plan:
- Extra oral
- Intra Oral
- Radiographic findings/Investigations
- Problem list
- Aims of treatment
- Treatment plan
a. REASON FOR ATTENDANCE: Referred for treatment, or opinion only? Patient's complaint.
b. MEDICAL HISTORY:Remember extractions, gingival health in presence of appliances, etc.
c. DENTAL HISTORY: Previous extractions, dental treatment, etc..
d. ATTITUDE TO TREATMENT: Of patient and parents. Likely level of cooperation: dentistry generally, ortho appliances, monthly adjustment visits (time off school, traveling) etc.
2. Extra-Oral Examination
a. GENERAL: Height, developmental stage.
b. SKELETAL PATTERN:T
b(i). Transverse: Facial asymmetry. Mandibular/maxillary widths.
b(ii). Antero-posterior: Clinical assessment. Skeletal I, II or III.- Mild, moderate, severe Use the fingers to palpate A and B point.
b(iii). Vertical: Steepness of mandibular plane, Normal, High, Low
b(iv). Face heights. Clinical assessment. Normal, reduced, increased
c. SOFT TISSUES:
c(i). Lips: Competent or incompetent. Height of lower lip line. Hyperactive? Hypertonic or hypotonic?
c(ii). Tongue: Size. Position. Behavior, especially in swallowing (tongue thrust, etc.).
c(iii). Rest position: Habitual posturing of the mandible.
c(iv). Habits: Thumb, finger or lip sucking, etc..
c(v). TMJ : Clicks, deviations, pain, limitation of opening.
3. Intra-Oral Examination
a. DENTITION: Teeth present in the mouth. Oral hygiene. Caries Restorations. Injured teeth, etc..
b. LOWER LABIAL SEGMENT: Crowding, spacing, displaced teeth, rotations. Angulation of lower incisors to mandibular base.
c. UPPER LABIAL SEGMENT: Crowding, spacing, displaced teeth, rotations. Angulation of upper incisors to maxillary base.
d. INCISOR RELATIONSHIP
d(i)Classification: Class I, II div1 II div 2, III. Incisor angulation (retroclined -average - proclined)
d(ii). Overjet (mm).
d(iii). Overbite (mm): complete or incomplete.
d(iv). Incisor Centerlines - coincident? Correct relationship is central and within face?
e. LOWER BUCCAL SEGMENTS: Crowding, spacing. Site of crowding. Rotations, displaced teeth.
f. UPPER BUCCAL SEGMENTS: Crowding, spacing. Site of crowding. Rotations, displaced teeth.
g. POSTERIOR OCCLUSION: Molars and canines - Class I, II, or III.
h. CROSSBITES/DIPLACEMENTS:Posterior crossbites - local, unilateral, bilateral. Check for mandibular displacement.
4. Radiographic findings:
Unerupted teeth. Absent teeth, extra teeth. Pathology. Skeletal assessment (cephalometric analysis).
(Index of Orthodontic Treatment Need)
Summarize the main points of the case history and your findings.
7. Problem List
List in priority the problems/features of the malocclusion
8. Aims of treatment
What are are your treatment outcomes eg ideal (to Class I skeletal, incisor and buccal realtionship?)
9. Treatment Plan
What active treatment is required to achive your treatment aims. see treatment planning