College of Dentistry, KSU

Naif Bindayel, BDS, MS

OrthodonticAssessmentForm(Sample)
Residents Name: _________________________ Assessment Date.: ____________

Patients Name: _____k. T.______________________ File No.: _____12345_____

Gender: _Male__, Date of Birth: _1/4/1999_
A. HISTORY:
Chief Complaint: anterior bite is off ! "
Medical History: ______2005: Asthma, on Ventlolin______
__________________________________________________________________
Dental History: Regular dental check up, brushing once a day,
_______________ And not flossing___________________
Habits: None_______________________________________________
B. Skeletal Assessment:
1. Anteroposterior : Skeletal Class I pattern, straight profile
_______
2. Vertical:__Slightly decreased FMPA and lower facial height
________________________________________________________
3. Transverse: ___No asymmetry with acceptable facial
esthetics

1|Page

Instructors Initials
________

College of Dentistry, KSU

Naif Bindayel, BDS, MS

TMJ findings: No signs of TMJ dysfunction and good range

of motion

C. Soft Tissue Assessment:

1. Lip tonicity and competence: Competent lips with the lower lip
resting in front of the upper incisors level_____________
2. Smile esthetics:_Acceptable smile esthetics, normal smile line
______________________________________________________________
3. Tongue function: Normal tongue size, shape and function
______________________________________________________________
D. Intra-oral Assessment:
1. Teeth Present:
Developmental Stage:_Mixed Dental Stage__
7 5 4 3
3 4 5
7
6 E D C 2 1
1 2 C D E 6_________
6 E D C 2 1
1 2 C D E 6
7 5 4 3
3 4 5
7
Oral Hygiene: ___Fair______ Periodontal Condition:____Fair____
Caries: _#16, occlusal_______ Teeth of Poor Prognosis:___None______
2. Lower arch alignment: ___Mild crowding of lower anterior teeth
3. Upper arch alignment: __Upper anteriors are displaced palatally
4. Teeth in Occlusion:
-

Incisor Classification: Class III

Buccal Segment, Right Side:

Canine: Class I_ , Molar: Class I

Buccal Segment, Left Side:

Canine: Class II_, Molar: Class I

Centerlines:
_________________2 mm____

2|Page

Overjet: -1.5_ mm, Overbite: _1_mm

Crossbites:
_______2 1_____1

2________

Instructors Initials
________

College of Dentistry, KSU

Naif Bindayel, BDS, MS

E. Cephalometric Analysis (please skip, if a cephalometric was not indicated)

Cephalometric
Measure
SNA
SNB
ANB
SN to MxPl
MMPA
Facial Proportion
Mx Incisor to MxPl
Mn Inciosr to MnPl
Mn Inc. to APog
Inter-incisal angle
Upper Lip to E-Line
Lower Lip to E-Line
NLA (Nasolabial)

Caucasian
Norm
81 3
78 3
3 2
8 3
27 4
55% 2%
109 6
93 6
+1 mm 2 mm
135 10
- 2 mm 2 mm
0 mm 2 mm
90 - 100

Measur
-ement

Interpretation

mm

mm
mm

F. Diagnostic Summery:
K. is 10 yr-old boy, presented with a chief complaint of
my anterior bite is off. He was diagnosed with Asthma
4 years ago and on Ventolin medication. K. presents with
skeletal Class I pattern, Class I molar relationships,
Class I right canine, and unit Class II left canine.
Negative overjet of -1 mm, with anterior cross bite.
and mild upper and lower anterior crowding. Upper dental
midline is shifted to the right by 2 mm.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

3|Page

Instructors Initials
________

College of Dentistry, KSU

Naif Bindayel, BDS, MS

G. Treatment Objectives:
Limited orthodontic early treatment for:
1. Correction of the anterior cross bite
2. Achieve and maintain a positive overjet
_________________________________________________________________
__________________________________________________________________
__________________________________________________________________
H. Treatment Plan:
Anterior cross bite will be corrected using a removable
upper appliance with jack-screw for correction in the
anteroposterior direction. Bilateral posterior bite planes
will be incorporated in the appliance to disengage the bite
and allow correction.
Parents will be asked to active the screw twice a week,
and scheduled for a follow up until correction is
achieved

Prepared by: Dr. ______________________________ Date: ____________________

Approved by: Dr. ______________________________ Date: ____________________

4|Page

Instructors Initials
________