Orthodontic Comprehensive Evaluation & Treatment Plan

Date: [Date of evaluation and/or records review]

Patient Name: [Full name]

DOB: [DOB]

Provider: [Orthodontist name, credentials]

Encounter Type: [in-person evaluation / records review / both]

Chief Concern

[Patient-stated goals and concerns; referral reason if applicable; transfer or re-treatment context] (Use patient's own words when available; mark as patient-reported.)

Records Reviewed

(List only records actually reviewed with date and quality notes. Omit record types not obtained unless clinically relevant, in which case note as not available with reason.)

• Clinical photographs (extraoral/intraoral): [date; diagnostic quality; limitations]
• Digital scans / study models: [date; type; quality]
• Panoramic radiograph: [date; quality]
• Lateral cephalogram: [date; quality]
• CBCT: [date; indication; field of view; quality]
• Prior orthodontic records: [source; date range; relevance]
• Periodontal/dental records from referring provider: [source; date; pertinent findings]
• Clinically relevant records not available: [record type and reason not obtained]

Relevant History

Medical: [Orthodontic-relevant conditions; medications affecting bone metabolism or bleeding; allergies (latex/nickel); growth status; significant comorbidities] (Include only orthodontic-relevant items.)

Dental/Orthodontic: [Prior orthodontic treatment (type, duration, retainers, relapse); extractions; trauma; endodontics; missing teeth with etiology; current oral hygiene and caries risk; periodontal history]

Functional: [TMD symptoms (pain/clicking/locking); oral habits (digit sucking, tongue thrust, bruxism, mouth breathing); speech or swallow concerns] (Include only if relevant.)

Examination Findings

Extraoral

• Facial symmetry: [symmetric / asymmetric with description]
• Profile: [straight / convex / concave]
• Vertical pattern: [dolichofacial / mesofacial / brachyfacial]
• Smile analysis: [incisor display at rest and full smile in mm; gingival display in mm]
• Lip competence: [competent / incompetent; strain present / absent]
• TMJ exam: [tenderness, joint sounds, range of motion, deviations] (Include only if performed.)

Intraoral

• Soft tissue: [findings]
• Oral hygiene: [status]
• Caries/demineralization: [present with locations / absent]
• Periodontal: [recession, inflammation, tissue biotype if assessed]

Dentition

• Dentition stage: [primary / mixed / permanent]; [dental age relative to chronological age]
• Missing teeth: [tooth numbers with etiology: congenital / extracted]
• Erupting teeth: [teeth and sequence anomalies if present]
• Impactions: [tooth numbers and suspected positions]
• Retained primary teeth: [tooth numbers]

Occlusal Measurements

(Enter measured values with units; omit items not applicable.)

• Molar classification: Right [Class I / II / III]; Left [Class I / II / III]
• Canine classification: Right [Class I / II / III]; Left [Class I / II / III]
• Overjet: [__] mm
• Overbite: [__] mm ([__]%) [with / without] impingement
• Anterior open bite: [__] mm
• Crowding: Maxillary [__] mm; Mandibular [__] mm
• Spacing: Maxillary [__] mm; Mandibular [__] mm
• Crossbite: [teeth involved]; [unilateral / bilateral]; [dental / skeletal / functional]; functional shift [present: __ mm / absent]
• Midlines: Maxillary to facial [coincident / __ mm R / __ mm L]; Mandibular to facial [coincident / __ mm R / __ mm L]; Maxillary to mandibular [coincident / __ mm R / __ mm L]
• Curve of Spee: [__ mm depth]
• Significant rotations: [teeth and degree]
• Bolton discrepancy: [overall / anterior]; [__ mm excess maxillary / mandibular]

Record Interpretation

(Include only modalities reviewed. Summarize key diagnostic findings from each.)

• Photographs: [Key facial and intraoral observations]
• Models/Scans: [Arch form; crowding/spacing quantification; transverse coordination; occlusal contacts; CR/CO discrepancy if suspected]
• Panoramic: [Tooth presence and eruption paths; impactions; root morphology; bone levels; third molar status; restorations/endodontics affecting mechanics]
• Cephalometric: [Skeletal AP classification with key values; vertical pattern with MPA; incisor inclination; soft tissue profile; growth status estimate with method]
• CBCT: [Indication-specific findings; incidental findings requiring follow-up]

Assessment

Diagnostic Summary

[Overall malocclusion classification with skeletal, dental, and soft tissue components; key drivers of malocclusion; treatment readiness constraints; prognosis considerations] (One to two paragraphs; use uncertainty language where appropriate.)

Problem List

(Prioritize by clinical significance. Include only applicable categories.)

• Eruption/impactions: [findings]
• Transverse: [findings]
• Sagittal: [findings]
• Vertical: [findings]
• Alignment/arch length: [findings]
• Midlines: [findings]
• Periodontal/caries risks: [findings]
• Functional/habits: [findings]

Treatment Plan

Objectives

(Measurable goals tied to problem list. Quantify in mm or degrees where feasible.)

• [Objective]
• [Objective]
• [Objective]

Alternatives Discussed

(Document each alternative actually discussed with benefits and limitations. Always include observation/no treatment when clinically appropriate.)

• [Alternative]: [benefits; limitations]
• [Alternative]: [benefits; limitations]

Recommended Plan

[Overview paragraph explaining chosen strategy and rationale linked to diagnostic findings and patient goals]

Pre-Orthodontic: (Include only if needed.)

• [Oral hygiene/caries control requirements]
• [Periodontal clearance or therapy]
• [Extractions: tooth numbers and rationale]
• [Referrals: specialty and purpose]

Active Treatment:

• Appliance: [type and prescription]
• Anchorage: [plan and locations if applicable]
• Alignment sequence: [overview]
• Space management: [IPR sites/amounts and/or extraction pattern with rationale]
• Transverse correction: [method if applicable]
• Sagittal correction: [method if applicable]
• Vertical control: [method if applicable]
• Impaction management: [exposure method, traction mechanics, sequencing if applicable]

Retention:

• Retainer type: Maxillary [type]; Mandibular [type]
• Wear schedule: [initial wear; long-term wear]
• Follow-up: [cadence]
• Relapse expectations: [counseling provided]

Timeline

[Estimated active treatment duration as range; key variables affecting duration (growth, eruption, compliance); appointment cadence; decision points for reassessment] (Express as ranges; avoid guarantees.)

Risks

General risks discussed: [decalcification/caries; gingivitis; root resorption; pain/irritation; appliance breakage; incomplete correction; treatment extension; relapse] (Include risks actually discussed.)

Patient-specific risks: [Individualized risks supported by clinical findings]

Monitoring plan: [Radiographic intervals if indicated; oral hygiene checkpoints; criteria for pausing treatment; timing for reassessment of eruption/impaction progress]

Consent

[Documentation that patient/guardian was informed of diagnosis, proposed treatment, material risks, and alternatives including no treatment; opportunity for questions provided]

• Interpreter: [yes with language / no] (Include only if applicable.)
• Decision: [accepted recommended plan / chose alternative / deferred]
• If accepted: [written consent obtained; retention expectations reviewed]
• If deferred: [reason; follow-up plan]

Referrals and Coordination

(Include only if applicable.)

• Referrals placed: [specialty; purpose]
• Communication sent: [recipient; content summary]