CASE HISTORY PROFORMA

NAME:
AGE:
SEX:
ADDRESS:

O. P. NO:
DATE:

1) CHIEF COMPLAINT :

2) HISTORY OF PRESENT ILLNESS:

3) PRE-NATAL HISTORY:
a. Informer

: Patient/ Father/ Mother/ others

b. Condition of mother
during pregnancy

Drug / Trauma / Disease etc.

c. Delivery

Full term / Premature

d. Type

Normal / Forceps / Caesarian

4) MEDICAL HISTORY:

Anaemia
Bleeding tendency
Cardio Respiratory disease
Drugs use, allergies and abuse
Endocrine disorders
Fits and faints
Gastrointestinal disorders
Hospital admissions and
attendances

Infections
Jaundice
Kidney disease
Likelihood of pregnancy
Malignant disease
Neurological and Psychiatric
problems
Other relevant conditions
Prosthesis and transplant
patients

5) DENTAL HISTORY:

6) FAMILY HISTORY:

7) HABITS:
a. Finger or Thumb sucking:
b. Tongue thrusting

c. Nail / Lip Biting

d. Bruxism

e. Mouth Breathing

8) SYSTEMIC EXAMINATION:

o VITAL SIGNS

Pulse rate -

Respiratory rate

Blood pressure o CVS

o RS

o CNS

o GIT

o EXTREMITIES

:
2

Temperature

9) LOCAL EXAMINATION:
A) FRONTAL ANALYSIS:
I.

General facial characteristics:

o symmetry:
o balance:
o length:

upper third:middle third :lower third:-

o morphology:II.

Upper third face:

Shape and symmetry of the:
o calvarium:
o temporal areas:
o frontal areas:
o eye brows:

III.

Middle third face:

Eyes and orbits:
o intercanthal distance (32 +/- 4mm):_________________
o interpupillary distance (65 +/- 4mm):________________
o inner and outercanthal symmetry:__________________
o upper and lower eyelid symmetry:__________________
3

o other(muscles, sclera):__________________________
Nose:
Form and symmetry of
o glabella: _____________________
o dorsum: _____________________
o tip: _________________________
o alar base: ____________________

Cheeks:
Symmetry and projection of
o malar eminences: _______________
o infraorbital rims: ________________
o paranasal areas: _________________
Ears:
o symmetry: ____________________
o level: ________________________
o projection: _____________________
o deformities: ____________________

IV.

Lower third face:

Lips:
Teeth:
o exposure of upper teeth at rest _______ Smiling________
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o symmetry _____
o exposure of lower teeth at rest_____ Smiling _______
o symmetry______
o dental Symmetry___________
o dental midline _________
Chin
o symmetry: Left________mm Right________mm
o shape:__________
Mandibular angles:
o symmetry____________
o deficient________
o

hyperplastic___________

B) PROFILE ANALYSIS
Upper third:
Fore head: Frontal bossing
Supraorbital hypoplasia
Supraorbital rim projection (5 to 10mm)
Middle third:
Nose
o glabellar angle: excessive/absent
o bridge projection(5 to 8mm)______________
o dorsum prominence: Convex /Concave
o supratip beak: Present / Absent
o nasal tip: Upturned / Downturned
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o nasolabial angle (90 to 110 degree) ________

o columella:

Angle Upward / Downward

Lower third:
Lips
o upper lip - Normal/ Protrusive/ Retrusive
(Relative to subnasale)
o lower lip - Normal/ Protrusive/ Retrusive
(Relative to upper lip)
o labiomental fold: Normal/Deficient/Excess
o chin projection: Normal/ Retrusive/ Protrusive
o neck-chin angle (1350): Normal/Deficient/Excessive

C) TEMPOROMANDIBULAR JOINT EVALUATION

Mandibular movements:
o maximal interincisal distance; (50mm)_______mm
Deviation: Left____mm
Right____mm
o protusive(6mm):____________mm
Deviation: Left_____mm
Right____mm
o excursive(6mm each)
Left____mm
Right____mm

D) OCCLUSAL EVALUATION
Functional evaluation:
o centric occlusion centric relation:
o compatible / incompatible:
o tooth attrition:
Static Evaluation
o midline to face: upper R/L ____________mm
o arch form: Upper_________ Lower ________
o arch Symmetry: Upper_______ Lower ______
o missing teeth______________
o overerupted teeth___________
o unerupted teeth____________
o occlusal plane______________
o curve of Spee: Excessive / Reverse
o crowding: Upper________ Lower________

Inter arch relation

o molar

Right I

II

III

Left

II

o canine Right I

II

III

Left

II

o overjet _________mm
o overbite___________mm
o openbite__________mm
o upper to lower midline_________________
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o crossbite ____________

10. SPEECH ASSESSMENT:

11. OBJECTIVE ANALYSIS:

o Photography (standard orthodontic views)
o Cephalometric analysis
o Model analysis

12. DIAGNOSIS:

13. TREATMENT PLANNING:

14. SURGICAL PROFILE:

15. PRE ANAESTHETIC EVALUATION:

16. SURGERY:
o Approach Extraoral/ Intraoral
o Osteotomy cut
o Distraction vector
o Osteodistractor placement
Submucosal
Transcutaneous
17. POSTOPERATIVE COURSE:
o Latency period
o Rate of distraction
o Rhythm of distraction
o Duration of distraction
o Consolidation period
o Device removal
18. FOLLOW UP:
o Radiographs ( 5th,12th postop days, on completion, 2nd, 6th month postop )
o Photographs ( 5th,12th postop days, on completion, 2nd, 6th month postop )
o Postsurgical orthodontics

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