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Orthodontic Chart: Patient Information Record
Orthodontic Chart: Patient Information Record
CHIEF COMPLAINT
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ORTHODONTIC HISTORY
Past Orthodontic Treatment: Yes / No Date Removed: ____________
CLINICAL EXAMINATION
A. Presence of Habits ( ) Thumb / Finger Sucking ( ) Lip Sucking ( ) Tongue Thrusting
( ) Night Grinding / Clenching ( ) Mouth breathing ( ) Nail Biting
( ) Others: __________
B. Temporomandibular Joint ( ) Clicking / Popping Sound ( ) Pain
( ) Locked Jaw: Opening / Closing
C. Periodontal Condition ( ) Normal ( ) Gingivitis/( ) Periodontitis ( ) Mobility: _____ Degree: _____
PHOTOGRAPHS
A. EXTRAORAL PHOTOS
a. Profile ( ) Straight ( ) Convex ( ) Concave
b. Lip Posture ( ) Competent / Normal ( ) Everted ( ) Incompetent / Short lips
c. Facial Type ( ) Mesofacial / Mesoprosopic / Average
( ) Dolicofacial / Leptoprosopic / Narrow
( ) Brachyfacial / Europrosopic / Broad
d. Facial Symmetry ( ) Symmetric ( ) Asymmetric: R / L
B. INTRAORAL PHOTOS
a. Gingival Display ( ) Normal ( ) Minimal ( ) Excessive
b. Smile Line ( ) Average ( ) Low ( ) High
c. Midline Upper: ( ) Correct / ( ) Incorrect: ___ mm off mid to the R / L
Lower: ( ) Correct / ( ) Incorrect: ___ mm off mid to the R / L
d. Adenoids / Tonsils ( ) Present ( ) Inflamed ( ) Removed
SPACE ANALYSIS
Central
Lateral
Canine
Total SR
1st Premolar
2nd Premolar
Total SR
Anterior Portion
1 + 2 + 3 = SA
Mid Portion
4 + 5 = SA
Computation
Legend: Anterior
( - ) Lacks Space
( + ) Spacing Mid
CEPHALOMETRIC ANALYSIS
Steiner’s Analysis
Occ-SN 31.3°
Growth Low GrowthPattern = below 31.3°
Pattern High GrowthPattern = above 31.3°
L1-NB 25°
Linguoverted = below 25°
Labioverted = above 25°
Wits Analysis
45.0 34.7
● If the overall ratio exceeds 77.2, the discrepancy is in excessive mandibular arch length:
● If the overall ratio exceeds 91.3, the discrepancy is in excessive mandibular arch length:
R 6 5 4 3 2 1 1 2 3 4 5 6 L
FINAL DIAGNOSIS
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PROPOSED TREATMENT
Objectives/Plan:
( ) Non-extraction ( ) Extraction: Tooth # ____________
( ) Appliance: Type ____________
( ) Fixed Braces: Type _____________ ( ) Removable: Aligners
( ) Retainer: Type______________
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PATIENT’S REMARKS:
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Patient’s Name and Signature Date
CI 4 mm 4 mm BR Bracket Removal
2nd PM 4 mm 4 mm RC Recementation
SS Stainless Steel
AW Archwire
IL Individual Ligaties
EC E-chain
CR Canine Retraction
L/A Level/Alignment
Patient’s Name: ______________________________________________________________ Date Started: __________
Technique: __________________________________ Slot: _____________ Bracket Type:
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Dentist: ________________ Total Fee: ______________ Monthly Adjustment Due: _____________ for _______ months
Remarks
Remarks
Remarks
Remarks
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U
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