Clinical Assessment:

It is important to undertake clinical assessment in a logical sequence, so that nothing is missed. Use the Orthodontic Assessment sheet and include them into teh patinets notes. Assessement is undertaken in 4 stages, then followed by a summary, development of a problem list, the treatment aims and finally treatment plan:

1) History
2) Extra oral
3) Intra Oral
4) Radiographic findings/Investigations
5) Summary
6) IOTN
7) Problem list
8) Aims of treatment
9) Treatment plan

History

REASON FOR ATTENDANCE: Referred for treatment, or opinion only? Patient's complaint.
MEDICAL HISTORY: Remember extractions, gingival health in presence of appliances, etc.
DENTAL HISTORY: Previous extractions, dental treatment, etc..
ATTITUDE TO TREATMENT: Of patient and parents. Likely level of cooperation: dentistry generally, ortho appliances, monthly adjustment visits (time off school, traveling) etc.

Extra-Oral Examination

GENERAL: Height, developmental stage.

SKELETAL PATTERN:T
Transverse: Facial asymmetry. Mandibular/maxillary widths.

Antero-posterior: Clinical assessment. Skeletal I, II or III.- Mild, moderate, severe
Use the fingers to palpate A and B point.

Vertical: Steepness of mandibular plane, Normal, High, Low

Face heights. Clinical assessment. Normal, reduced, increased

SOFT TISSUES:
Lips: Competent or incompetent. Height of lower lip line. Hyperactive? Hypertonic or hypotonic?

Tongue: Size. Position. Behavior, especially in swallowing (tongue thrust, etc.).
Rest position: Habitual posturing of the mandible.
Habits: Thumb, finger or lip sucking, etc..
TMJ : Clicks, deviations, pain, limitation of opening.

Intra-Oral Examination

DENTITION: Teeth present in the mouth.
Oral hygiene. Caries Restorations. Injured teeth, etc..

LOWER LABIAL SEGMENT:
Crowding, spacing, displaced teeth, rotations. Angulation of lower incisors to mandibular base.
UPPER LABIAL SEGMENT:
Crowding, spacing, displaced teeth, rotations. Angulation of upper incisors to maxillary base.

INCISOR RELATIONSHIP:
Classification: Class I, II div1 II div 2, III.
Incisor angulation (retroclined -average - proclined)

Overjet (mm).
Overbite (mm): complete or incomplete.

Incisor Centerlines - coincident? Correct relationship is central and within face?

LOWER BUCCAL SEGMENTS: Crowding, spacing. Site of crowding. Rotations, displaced teeth.
UPPER BUCCAL SEGMENTS: Crowding, spacing. Site of crowding. Rotations, displaced teeth.

POSTERIOR OCCLUSION: Molars and canines - Class I, II, or III.

CROSSBITES/ DIPLACEMENTS:
Posterior crossbites - local, unilateral, bilateral.
Check for mandibular displacement.

Radiographic findings:
Unerupted teeth. Absent teeth, extra teeth. Pathology. Skeletal assessment (cephalometric analysis).

IOTN (Index of Orthodontic Treatment Need):

Summary:
Summarize the main points of the case history and your findings.

Problem list:
List in priority the problems / features of the malocclusion

Aims of treatment:
What are are your treatment outcomes eg ideal (to Class I skeletal, incisor and buccal realtionship?)

Treatment Plan:
What active treatment is required to achive your treatment aims.
see treatment planning