Retakes: Photos: eo eos eop sm rio fio lio mx Md



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Tx Plan:

Name_________________________________ Class _________ Phase I II C Lmt No. mos. _________

Retakes: Photos: EO EOS EOP Sm RIO FIO LIO Mx Md

PA’s: 21 12 2-2 VBWS FMS PANO and have Dr.check_____________

P
NOTE:

<2/2

Long/Short TB

CS

ADD on


Elastics

HG

Lingual buttons


erio exam: Ceph Ceph measures

Models: Check bite/Retrim Relabel Do Bolton

Brackets to use: MBT Gold Orthos Self-Ligat Clear

imp for BB BB depth/OJ ________ Place seps ______________


Imps for: Mays Hyrax Hyrax Quad Helix CBJ________________

PHA LLA Pendex E-arch Other: _________________

Resep ________________ Ext _____________ When?______________________

Mx Md

Reassess


Detail

DB/FR/Rets

DB/RTS/RCL

_____________________________________________________________

Tx Plan:

Name_________________________________ Class _________ Phase I II C Lmt No. mos. _________

Retakes: Photos: EO EOS EOP Sm RIO FIO LIO Mx Md

PA’s: 21 12 2-2 VBWS FMS PANO and have RP check_____________

P
NOTE:

<2/2

Long/Short TB

CS

ADD on


Elastics

HG

Lingual buttons


erio exam: Ceph Ceph measures

Models: Check bite/Retrim Relabel Do Bolton

Brackets to use: MBT Gold Orthos Self-Ligat Clear

imp for BB BB depth/OJ ________ Place seps ______________


Imps for: Mays Hyrax Hyrax Quad Helix CBJ________________

PHA LLA Pendex E-arch Other: _________________

Resep ________________ Ext _____________ When?______________________

Mx Md

Reassess


Detail

DB/FR/Rets

DB/RTS/RCL

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 $_________________.




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.

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 $_________________.



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.




Name:

Exam Date:

M/D

Age:

Dentist:

Records:

Age:

CC:

Attitude:

Time/Moving Pbs:

Med Hx:

Growth:

Dent Hx:




Teeth: Primary, mixed, permanent, missing


Pan date:

Resorp:

Root shape:

Leew:

Fullerupt:

TMJ: OK


7’s

year




8

8







Other:




8

8







DX: Class Dental:


Skeletal:

Other:




TREATMENT OBJECTIVES

1. Skeletal Class

Dental Class

OJ Ideal 2-2

2. Level to ideal OB 2-2

3. Align

4. Transverse: Widen   MLs on

5.

TREATMENT ALTERNATIVES

Advantages

Disadvantages

1.







2.







3.







4.










Consult Date:




Init

Present: M D P




Init

Time Req:

X




Fluoride Rx/Peridex







Ext. of Teeth










8

8

Soon

Later








Retention:Hawleys   Clear   Bonded  

X










8

8

Sulcus Slice







Dental Care

X




Frenectomy  La  La Li







Oral Hygiene

X




Gingivoplasty







Diet & Appl. Care

X




Surgery







Coop: HG, EXP, CBJ, EL

X




Bolton







Vacations

X




Perio: Gingivitis Recession Bulk

X




Retainers

X




Resorption

X




Appointments

X




Decalcification Present







Broken Appointments

X




Restorative







Emergency Number

X




TMJ

X







Results/Limits/Concerns: To achieve: 1 = great 2 = good 3 = limited




Facial / Skeletal Result




Optimal Perio Health




Growth Dependent




Stability




Dental and Smile Result




Shortest Treatment time




Optimal Occlusal Result




Minimal Discomfort




Optimal TMJ and Myofacial Result




Noncompliance Biomechanics




Optimal Dental Health




Cooperation Dependent




Foster Overall Positive Self-image







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______________________________________________________________________

__________________________________________________________________________________________


____ 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






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