ORTHODONTIC CHART

DIAGNOSTIC & TREATMENT PLAN CHART

PATIENT INFORMATION RECORD

Chart #: _____ Name: _____________________________________________________________ Gender (M/F): _____
Nickname: ___________ Birth Date (mm/dd/yyyy): _______________ Age: _______ Date of Exam: ________________
Home Address: _______________________________________________________________ Home #: ____________
Occupation: ________________ Office #: ____________ Email Add: _____________________Mobile #: ____________
For minors:
Parent/Guardian’s Name: _____________________________ Occupation: ________________ Office #: ____________

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

PANORAMIC X-RAY ANALYSIS ​(Indicate the tooth number: FDI)

A. Present Teeth: ______ Erupting Teeth: ______ Missing Teeth: ______ Impacted Teeth: ______
Retained Deciduous: ______ Root Fragments: ______ Root Resorption: ______
Open Apex: ______ Root Canal Treated: ______ Bone Loss: ______ *Supernumerary: ______
CAST ANALYSIS
A. Classification
a. Canine Relationship R: ____________________ L: _________________
b. Molar Relationship R: ____________________ L: _________________
B. Overbite: __________ mm ( ) Normal ( ) Deep Bite ( ) Open Bite
C. Overjet: __________ mm ( ) Normal ( ) Edge to Edge ( ) Negative Open Bite
D. Presence of Crossbite: ( ) Anterior: ____________ ( ) Posterior: ____________
E. Rotated tooth/teeth: _________
F. Curve of Spee: __________ mm
G. Presence of Anomalies: ( ) Peg-shaped: ________ ( ) Supernumerary: ________ ( ) Anodontia: ________

SPACE ANALYSIS

Space Required (SR)

Upper Right / Q1 Upper Left / Q2 Lower Left / Q3 Lower Right / Q4

(mm) (mm) (mm) (mm)

Central

Lateral

Canine

Total SR

1st Premolar

2nd Premolar

Total SR

Space Available (SA)

Upper Right / Q1 Upper Left / Q2 Lower Left / Q3 Lower Right / Q4

(mm) (mm) (mm) (mm)

Anterior Portion
1 + 2 + 3 = SA

Mid Portion
4 + 5 = SA

Computation

Formula: Upper Right / Q1 Upper Left / Q2 Lower Left / Q3 Lower Right / Q4

SA - SR = Value (mm) (mm) (mm) (mm)

Legend: Anterior
( - ) Lacks Space
( + ) Spacing Mid
CEPHALOMETRIC ANALYSIS

Steiner’s Analysis

Angle Normal Values Patient’s Value Interpretation

Skeletal ANB 2.5​° (​ 0° - 5°)

Pattern Class I = 2° - 5°
Class II = above 5°
Class III = below 0°
Class III tendency = 0.5° - 1.5°

Jaw at Fault SNA 81​° ​(77​°​ - 85​°​)

Retruded Maxilla = below 77​°
Protruded Maxilla = above 85°

SNB 78​° ​(75° - 81°)

Retruded Mandible = below 75​°
Protruded Mandible = above 81°

Occ-SN 31.3​°
Growth Low GrowthPattern = below 31.3​°
Pattern High GrowthPattern = above 31.3°

SN-MP (GoGn) 13.5​°

Forward Horizontal = below 13.5​°
Downward Vertical = above 13.5°

IMPA 90​° (85° - 95°)

Protruded L1 = below 85​°
Tweed Retruded L1 = above 95°
Analysis
FMIA 65​° (60° - 70°)
Proclined L1 = below 60​°
Reclined L1 = above 70°

FMA 25​° (22° - 28°)

Flat MP = below 22​°
Steep MP​ = above 28°

Dental U1-L1 130​° (123° - 137°)

Pattern Acute / Labioverted = below 123°
Obtuse / Linguoverted = above 137°

Tooth at U1-NA 22​°

Fault Linguoverted = below 25°
Labioverted = above 25°

L1-NB 2​5°
Linguoverted = below 25°
Labioverted = above 25°

Chin Pog-NB 4mm

Position Deficient Chin = below 4
Prominent Chin = above 4

ELLP E-line 0mm

(Esthetic Lip Tip of Nose to Tip Concave = below 0
Line Plane) of Chin
Convex = above 0

Wits Analysis

Skeletal AO - BO Class I = 0 - 3mm

Pattern Class II = 0 & below
 Class III = 3 & above
ANTERIOR RATIO
Sum of Mandibular 6 mm X 100 = Anterior Ratio
Sum of Maxillary 6 mm

Max 6 Mand 6 Max 6 Mand 6 Max 6 Mand 6

40.0 30.9 45.5 35.1 50.5 39.0

40.5 31.3 46.0 35.5 51.0 39.4

41.0 31.7 46.5 35.9 51.5 39.8

41.5 32.0 47.0 36.3 52.0 40.1

42.0 32.4 47.5 36.7 52.5 40.5

42.5 32.8 48.0 37.1 53.0 40.9

43.0 33.2 48.5 37.4 53.5 41.3

43.5 33.6 49.0 37.8 54.0 41.7

44.0 34.0 49.5 38.2 54.5 42.1

44.5 34.4 50.0 38.6 55.0 42.5

45.0 34.7

● If the overall ratio ​exceeds 77.2​, the discrepancy is in excessive mandibular arch length:

___________________________ - ___________________________ = ________________________

Actual Mandibular 6 Correct Mandibular 6 Excess Mandibular 6

● If the overall ratio ​less than 77.2​:

___________________________ - ___________________________ = ________________________

Actual Maxillary 6 Correct Maxillary 6 Excess Maxillary 6

BOLTON’S TOOTH SIZE ANALYSIS

Max 12 Mand 12 Max 12 Mand 12 Max 12 Mand 12

85 77.6 94 85.8 103 94.0

86 78.5 95 86.7 104 95.0

87 79.4 96 87.6 105 95.9

88 80.3 97 88.6 106 96.8

89 81.3 98 89.5 107 97.8

90 82.1 99 90.4 108 98.6

91 83.1 100 91.3 109 99.5

92 84.0 101 92.2 110 100.4

93 84.9 102 93.1

● If the overall ratio ​exceeds 91.3​, the discrepancy is in excessive mandibular arch length:

___________________________ - ___________________________ = ________________________

Actual Mandibular 12 Correct Mandibular 12 Excess Mandibular 12

● If the overall ratio is ​less than 91.3​:

 ___________________________ - ___________________________ = ________________________
Actual Maxillary 12 Correct Maxillary 12 Excess Maxillary 12
MESIO-DISTAL WIDTH OF TEETH

Sum of Maxillary 12 = _______ mm

Sum of Max. Ant. 6 = _____ mm

R 6 5 4 3 2 1 1 2 3 4 5 6 L

Sum of Mand. Ant. 6 = ____ mm

Sum of Mandibular 12 = _______ mm

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 INFORMED ORTHO TREATMENT PLAN CONSENT

 I, ___________________, am fully aware of the orthodontic treatment plan explained to me by the Urban Smiles
Dental Team. I am giving my consent to proceed with the treatment plan.

______________________________________ ____________________
Patient’s Name and Signature Date

BRACKET HEIGHT LEGEND

Tooth Upper Lower BP Bracket Placement

CI 4 mm 4 mm BR Bracket Removal

LI 3.5 mm 4 mm OA Ortho Adjustment

C 4.5 mm 4.5 mm NW New Wire

1st PM 4 mm 4 mm MP Maintain Position

2nd PM 4 mm 4 mm RC Recementation

1st M 3.5 mm 3.5 mm RP Replacement

2nd M 4 mm 4 mm NITI Nickel Titanium

RCS Reverse Curve of Spee

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:
________________________
Dentist: ________________ Total Fee: ______________ Monthly Adjustment Due: _____________ for _______ months

Date Dentist Arch Wire Procedure Next Procedure Amount

Paid

Remarks

Remarks

Remarks

Remarks

Remarks

U
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Remarks