😁 Orthodontic Assessment

Orthodontic (Invisalign) Assessment Template (Heidi-Compatible) --- Patient Info & Chief Complaint **Dentist:** Dr. Emily Carter **Nurse:** Sarah Jones **MH Checked and Updated:** No **RFA (Reason for Attendance):** - Orthodontic assessment / Invisalign consultation **Chief Concerns:** - Patient’s description: "I'm unhappy with how crooked my front teeth are." - Clinical goals: Patient wants straighter teeth and a more confident smile. **Previous Orthodontic Treatment:** No --- Extraoral Exam **TMJ:** - Clicking / Crepitus / Popping / Grating / Deviation: None noted - TMJ Pain: No - TMJ Manipulation: Easy - Range of Opening: 45 mm **MoM / Lymph Nodes:** Within normal limits **Skeletal Assessment:** - AP Relationship (Skeletal base): Class I - Vertical (FMPA): Average - Facial Thirds Even: Yes - Transverse: Symmetrical **Smile Aesthetics:** - Incisal show at rest: 2 mm - Incisal show on smiling: 10 mm - Smile arc parallelism: Parallel - Buccal Corridors: Narrow - Midline coincident with facial midline: Yes - Upper & Lower Midlines coincident: Yes - Lip form: Thin - Lip Competency: Competent - Lip Catch: No - Nasolabial Angle: Normal --- Intraoral Exam **Oral Hygiene:** Fair **Biotype:** Thin **BPE:** 2, 2, 2, 2, 2, 2 **Soft Tissues:** Healthy **Tooth Quality / Caries / Perio / Restorations / Wear / Trauma:** No caries, healthy periodontium, no restorations, no wear, no trauma **Upper Arch:** - Crowding: Moderate - Spacing: Mild - Rotations / Malalignment: Upper incisors rotated - Labial Segment Inclination: Proclined - Arch Shape: Symmetrical **Lower Arch:** - Crowding: Mild - Spacing: None - Rotations / Malalignment: Lower incisors slightly rotated - Labial Segment Inclination: Upright - Arch Shape: Symmetrical --- Occlusal Scheme **Incisal Relationship:** Class I **Molar Relationship:** - RHS: I - LHS: I **Canine Relationship:** - RHS: I - LHS: I **Overjet:** 2 mm **Overbite:** 30 % - Complete **Crossbites:** None **Teeth Involved:** None **Lateral Excursions:** - Right: Canine guidance - Left: Canine guidance **Protrusive Excursion:** Anterior guidance --- Radiographic & Photo Records **Radiographs:** OPG - Date: 1 November 2024 - Justification: Routine orthodontic assessment - Grade: A - Radiographic Findings: No significant findings **Photos Taken:** EO, IO --- Diagnoses & Problem List **Diagnosis:** Mild to moderate crowding and malalignment of upper and lower anterior teeth. **Problem List (with plan to correct / accept / improve):** 1. Crowding of upper incisors. 2. Rotation of upper incisors. 3. Mild crowding of lower incisors. 4. Proclined upper incisors. **Treatment Goals:** - Aesthetic (face, smile, soft tissue): Improve smile aesthetics and alignment. - Occlusion (static and functional): Achieve ideal overjet and overbite. - Structure (dentition and restorations): Align teeth and maintain healthy dentition. - Biology (periodontium, roots, bone): Maintain healthy periodontium. --- Discussion & Treatment Plan **Options Discussed:** 1. Referral to Orthodontic Specialist – comprehensive treatment, possible skeletal/facial changes 2. GDP-led cosmetic alignment (3-3 focus): a. Invisalign – Clear removable aligners (24/7 wear), IPR and attachments may be used b. Fixed Appliances – Clear brackets, faster movements, discreet **Patient Decision / Preferred Option:** Invisalign **Discussion Summary:** Discussed Invisalign treatment, expectations, risks, timelines (12-18 months), costs, and the potential need for IPR and attachments. **Treatment Plan:** - Records Appointment: Yes - Consent / Photos / Scans completed: Impressions and photos taken. - Referral Made: N/A **4STP Notes:** 1. Presenting Complaint: Patient is unhappy with the appearance of their crooked teeth. 2. Upper Anterior Reference Point: Incisal edge of central incisors. 3. Upper Expansion Point: N/A 4. Final Overjet & Overbite Goals: 2mm overjet, 30% overbite. **Next Steps / Follow-Up:** Schedule records appointment for impressions, photos, and scans. Discuss Invisalign treatment plan in detail. --- (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)