Case history
OPD/ file no.:
Date:
Name:
Age / sex:
Address:
Occupation:
Chief complaint:
Medical History
Dental History:
Patient’s personal details
Prenatal history:
At birth:
Post natal history:
Family history:
Clinical evaluation
General examination
Height and weight:
Gait:
Posture:
Body built:
Extra oral examination
Shape of head:
Facial form:
Facial asymmetry:
Facial profile:
Facial divergence:
Facial height:
Assessment of skeletal pattern:
Vertical plane:
Lip:
Tonicity of lips:
Amount of incisor and gingival display:
Nose:
Nasolabial angle:
Chin:
Mento labial sulcus:
Intra oral examination
Oral hygiene status:
Examination of gingiva:
Examination of frenal attachment:
Upper labial frenum:
Lower labial frenum:
Lower lingual frenum:
Examination of tongue:
Examination of palate:
Examination of tonsils and adenoids:
Assessment of Dentition
Number of teeth present in the oral cavity:
Teeth missing:
Teeth unerupted:
Other:
Overjet:
Overbite:
Transverse relationship:
Individual tooth irregularities:
 Crowding
 Spacing
 Rotation/s
 Other:
Curve of spee:
Midline:
Angle’s classification: Molar relation:
Canine relation:
Incisor relation:
Functional Examination
Postural rest position/ intraocclusal space:
Evaluation of path of closure:
Evaluation of breathing pattern:
Examination of TMJ:
Maximum mouth opening:
Evaluation of swallowing Deglutition
Examination of speech
Study Model
Model analysis & inference:
Carey’s arch perimeter analysis:
Bolton’s analysis:
Ashley Howe’s analysis:
Other:
Facial Photographs
Frontal view
Profile view
Oblique view
Intra oral photographs:
Left and right lateral view:
Intra oral photographs
Frontal view:
Maxillary occlusal view:
Mandibular occlusal view:
Left occlusal view:
Right occlusal view:
Radiographs
Peri apical radiographs
Bitewing radio graph
Panoramic radiograph/ orthopantomograph:
Lateral cephalogram:
Variable
Inference:
Normal value
Measured value
Index of Orthodontic Treatment Need (IOTN)
The IOTN combines aesthetic components and dental health components:
Aesthetic components (AC)
Dental health components (DHC)
Aesthetic components (AC)
Using a series of 10 color photos the degree of 'dental attractiveness' is assessed.
The patient should be involved in the subjective assessment.
Grade 1 = aesthetically optimal dentition
Grade 10 = aesthetically worst imaginable dentition
Grade 1-4 = no or slight need
Grade 5-7 = moderate or borderline need
Grade 8-10 = Definite need
Dental health components (DHC)
Grade 1: no treatment need
Grade 2: mild. Little need
Grade 3: moderate / borderline need
Grade 4: severe/ need treatment
Grade 5: extreme/ need treatment
Diagnosis
Problem list:
Pathological
Treatment plan:
Developmental