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COMPREHENSIVE TREATMENT Patient: ________________________ Age: ____ years ____ months Date:_____________ The doctor has completed an analysis of the orthodontic records and has found the following areas of concern: ___Overbite ___Underbite ___Jaw relationship problem: ___lower jaw underdeveloped ___upper jaw underdeveloped ___lower jaw overdeveloped ___Expected jaw growth limited or unfavorable direction ___Crossbite ___Arch constriction or narrow arch form ___Back teeth not lined up ___Midline shift ___Asymmetry ___Excessive gum showing with smiling ___Openbite ___Tongue thrust habit ___Excessively deep bite ___Wear of teeth ___Crowding of the teeth ___Spacing of the teeth ___Rotations of the teeth or malalignment ___Missing teeth ___High root resorption potential ___Oral hygiene ___Gum concerns: ___frenum ___recession ___bulk ___TMJ signs or symptoms or history of problems ___Other_______________________________________________________________________ ________________________________________________________________________ The doctor’s treatment recommendations are: ___Comprehensive-Full Orthodontic Treatment with ___Full braces ___Headgear: Type:___________________ Hours:_________________ ___CBJ Growth Appliance ___Expansion_________________________________________________ ___Palatal holding arch ___Lower lingual arch ___Habit appliance:_______________________ ___Bite buttons ___Extraction of teeth:__________________________________________ ___Frenectomy, gingivoplasty, gingival graft, or other periodontal therapy ___Elastics ___Other:____________________________________________________ ___One set of retainers and supervision of retention for two years Anticipated limitations of treatment are:_______________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ The anticipated length of this treatment is _______ months and the treatment fee is $___________________ which can be paid: 1. With a downpayment of $__________________ and a contract for ______ months for $____________ per month. 2. With a 6% reduction of the fee for payment in full at the beginning of treatment by either cash or check. Fee reduction is $_________________ for a total of $________________. 3. With a 3% reduction of the fee for payment in full at the beginning of treatment by credit card. Fee reduction is $________________ for a total of $_________________. Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com PHASE I TREATMENT Patient: _______________________ Age: ___ years ___ months Date: _____________ The doctor has completed an analysis of the orthodontic records and has found the following areas of concern: ___Overbite ___Underbite ___Jaw relationship problem: ___lower jaw underdeveloped ___upper jaw underdeveloped ___lower jaw overdeveloped ___Expected jaw growth limited or unfavorable direction ___Crossbite ___Arch constriction or narrow arch form ___Back teeth not lined up ___Midline shift ___Asymmetry ___Excessive gum showing with smiling ___Openbite ___Tongue thrust habit ___Excessively deep bite ___Wear of the teeth ___Crowding of the teeth ___Spacing of the teeth ___Rotations of the teeth or malalignment ___Missing teeth ___High root resorption potential ___Oral hygiene ___Gum concerns: ___frenum ___recession ___bulk ___TMJ signs or symptoms or history of problems ___Other___________________________________________________ The doctor’s treatment recommendations are: ___Phase I-Early Orthodontic Treatment which will consist of: ___Limited braces ___Headgear: Type_____________________Hours:_______ ___CBJ Growth Appliance ___Expansion_____________________________________________ ___Palatal holding arch ___Lower lingual arch ___Habit appliance:_________ ___Bite buttons ___Extraction of teeth:__________________________________ ___Frenectomy, gingivoplasty, gingival graft, or other periodontal therapy ___Other_________________________________________________ ___Temporary retainer(s) ___Supervision until full eruption of the teeth ___Phase II (full orthodontic treatment) may be needed in the future Anticipated limitations of treatment are:______________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The anticipated length of this treatment is________ months and the treatment fee is $___________________, which is paid with a downpayment of $__________ and a contract for _______ months for $_________ per month. The fee can also be paid in full at the beginning of treatment, or with an alternative payment plan. Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com PHASE II TREATMENT Patient: ________________________ Age: ____ years ____ months Date:_____________ The doctor has completed an analysis of the orthodontic records and has found the following areas of concern: ___Overbite ___Underbite ___Jaw relationship problem: ___lower jaw underdeveloped ___upper jaw underdeveloped ___lower jaw overdeveloped ___Expected jaw growth limited or unfavorable direction ___Crossbite ___Arch constriction or narrow arch form ___Back teeth not lined up ___Midline shift ___Asymmetry ___Excessive gum showing with smiling ___Openbite ___Tongue thrust habit ___Excessively deep bite ___Wear of teeth ___Crowding of the teeth ___Spacing of the teeth ___Rotations of the teeth or malalignment ___Missing teeth ___High root resorption potential ___Oral hygiene ___Gum concerns:___frenum ___recession ___bulk ___TMJ signs or symptoms or history of problems ___Other_______________________________________________________________________ ________________________________________________________________________ The doctor’s treatment recommendations are: ___Phase II-Full Orthodontic Treatment with ___Full braces ___Headgear: Type:___________________ Hours:_________________ ___CBJ Growth Appliance ___Expansion_________________________________________________ ___Palatal holding arch ___Lower lingual arch ___Habit appliance:_______________________ ___Bite buttons ___Extraction of teeth:__________________________________________ ___Frenectomy, gingivoplasty, gingival graft, or other periodontal therapy ___Other:____________________________________________________ ___One set of retainers and supervision of retention for two years Anticipated limitations of treatment are:_______________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ The anticipated length of this treatment is _______ months and the treatment fee is $___________________ which can be paid: 1. With a downpayment of $__________________ and a contract for ______ months for $____________ per month. 2. With a 6% reduction of the fee for payment in full at the beginning of treatment by either cash or check. Fee reduction is $_________________ for a total of $________________. 3. With a 3% reduction of the fee for payment in full at the beginning of treatment by credit card. Fee reduction is $________________ for a total of $_________________. Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com TREATMENT RECOMMENDATIONS AFTER A PROGRESS EVALUATION Patient: ___________________________ Age: ___years ___months Date: _____________ The doctor has completed a review of progress to date and has found the following areas of continued concern: ___Overbite ___Underbite ___Jaw relationship problem: ___lower jaw underdeveloped ___upper jaw underdeveloped ___lower jaw overdeveloped ___Expected jaw growth limited or unfavorable direction ___Back teeth not lined up ___Crossbite ___Arch constriction or narrow arch form ___Midline shift ___Asymmetry ___Excessive gum showing with smiling ___Openbite ___Excessively deep bite ___Crowding of the teeth ___Spacing of the teeth ___Rotations of the teeth or malalignment ___Missing teeth ___High root resorption potential ___Oral hygiene ___Gum concerns:___frenum ___recession ___bulk ___TMJ signs or symptoms or history of problems ___Other_______________________________________________________________ The doctor's treatment recommendations are: ___Deband, temporary retention, and recall until full eruption ___Extention of Phase I-Limited treatment ___Phase II-Full Orthodontic Treatment This treatment would include: ___Full braces ___Herbst ___Headgear ___Bionator ___Expansion_____________________________________________ ___Palatal holding arch ___Lower lingual arch ___Habit appliance:__________________ ___Bite buttons ___Extraction of teeth:_______________________________________ ___Frenectomy, gingivoplasty, gingival graft, CFR, or other periodontal therapy________________________________________________ ___Other:_________________________________________________ ___Orthognathic surgery_____________________________________ ___One set of retainers, with supervision of retention for two years. Anticipated limitations and considerations of treatment are:_______________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The anticipated length of this treatment is ________ months and the treatment fee is $______________, which can be paid with a downpayment of $_______________ and a contract for ______ months for $____________ per month. Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com Name: Exam Date: Dentist: Records: CC: Med Hx: Attitude: Growth: M/D Age: Age: Time/Moving Pbs: Dent Hx: Teeth: Primary, mixed, permanent, missing Pan date: Resorp: Root shape: TMJ: OK 8 Leew: Fullerupt: 7’s year Other: 8 8 8 DX: Class Dental: Skeletal: Other: Skeletal Class Level to ideal OB Align Transverse: Widen Dental Class OJ Ideal TREATMENT ALTERNATIVES 1. 2. 3. 4. Advantages TREATMENT OBJECTIVES 1. 2. 3. 4. 5. Consult Date: Time Req: Ext. of Teeth Dental Care Oral Hygiene Diet & Appl. Care Coop: HG, EXP, CBJ, Vacations Retainers Appointments Broken Appointments Emergency Number MLs on Init X 8 8 Soon Later 8 8 EL 2-2 2-2 X X X X X X X X X Results/Limits/Concerns: To achieve: 1 = great Facial / Skeletal Result Growth Dependent Dental and Smile Result Optimal Occlusal Result Optimal TMJ and Myofacial Result Disadvantages Present: M D P Fluoride Rx/Peridex Retention:Hawleys Clear Bonded Sulcus Slice Frenectomy La La Li Gingivoplasty Surgery Bolton Perio: Gingivitis Recession Bulk Resorption Decalcification Present Restorative TMJ 2 = good Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com 3 = limited Optimal Perio Health Stability Shortest Treatment time Minimal Discomfort Noncompliance Biomechanics Init X X X X Optimal Dental Health Foster Overall Positive Self-image Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com Cooperation Dependent Name of Patient: ____________________________________________________________________________________________ LIST OF POSSIBLE RISKS RESULTING FROM ORTHODONTIC TREATMENT AND LIMITATIONS OF TREATMENT ____ Fracture of a tooth due to large fillings ____ Fracture of tooth due to eating hard foods or trauma ____ Desired skeletal correction not achieved due to: ____ Lack of patient cooperation ____ Lack of growth ____ Lack of growth in proper direction ____ Other:______________________________________________________________________________________ ____ Desired bite not achieved due to: ____ Ankylosis of teeth fused to the bone ____ Lack of patient cooperation ____ Tooth-size problems ____ Primary molars present without permanent teeth to replace them ____ Small lateral incisors, need to enlarge/widen teeth ____ Large lateral incisors ____ Other tooth size problems ____ Other:______________________________________________________________________________ ___________________________________________________________________________________ ____ Decalcification and decay due to: ____ Poor oral hygiene ____ Eating foods/drinks high in sugar ____ Lack of dental cleanings at 3-6 month intervals with wires removed ____ Root canal therapy flare ups ____ Tooth nerve death with darkening of the tooth from unknown cause requiring root canal therapy ____ Gingivitis/Periodontitis with irreversible bone loss due to ____ Poor oral health ____ Other:_____________________________________________________________________________________ ____ Gum “bunching” due to fibrous gum tissue ____ Gum recession ____ Root resorption, or excessive root shortening, which decreases the support of the teeth from ____ Canines ____ Trauma _____ Unknown cause ____ Increased need for restorative treatment ____ Enlarge upper laterals ____ Other:______________________________________________________________________________________ ____ Sinus preventing movement of upper back teeth ____ TMJ concerns and problems ____ Hormonal changes ____ Stress ____ Bruxism/clenching ____ Other or unknown cause______________________________________________________________________ Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com __________________________________________________________________________________________ ____ Lack of stability of position of teeth (relapse) after the braces are removed ____ Unexpected impaction of teeth ____ Slow eruption of the teeth ____ Longer than anticipated treatment time due to______________________________________________________________ ____ Need for orthognathic surgery due to _____________________________________________________________________ ____ Other:______________________________________________________________________________________________ These risks have been discussed with me by Dr. ________________ or one of the staff. I am willing to undergo orthodontic treatment understanding these risks or limitations of treatment. ________________________________________________________ _______________________________________ Signature of patient/parent Date Diagnosis and Treatment Planning - International Training Institute © 2009 www.ITICourses.com
