Diagnostic photographs are required, including three facial photographs (profile, frontal, and smiling), and five intraoral photographs (frontal, right lateral, left lateral, and maxillary and mandibular occlusal).
A properly completed and scored Salzmann Malocclusion Severity Assessment form
A panoramic and/or cephalometric radiograph
Additional documentation from referring general dentists, pediatric behavioral health or mental health providers, or a statement that no other documentation was presented
A narrative description of any severe deviation(s) affecting the mouth and/or underlying structures that would not be evident from the diagnostic materials provided
In lieu of photographs, properly trimmed study models, bite registration (will not be returned)
Cases submitted for review without the documentation listed above will be returned to the submitting office.
The following references correspond to the sample Salzmann Scoring Sheet which follows this section.
SECTION A. Intra Arch Deviation
Only the four maxillary incisors should be included in this category. Additionally, the maximum score for this line cannot exceed eight (8) points, and no tooth may be scored twice, such as counting a tooth as both crowded and rotated.
Only the four mandibular incisors should be included in this category. Additionally the maximum score for this line cannot exceed four (4) points, and no tooth may be scored twice, such as counting a tooth as both crowded and rotated.
Rotation in the posterior area only refers to tooth irregularities that interrupt the continuity of the dental arch and involve all or part of the lingual or buccal surfaces such that rotated posterior teeth have buccal or lingual surface(s) wholly or partially facing the proximal surface of adjacent teeth.
Mesio-distal deviation only refers to the mandibular teeth that have their buccal cusps (mesio buccal cusp of the first permanent molar) occluding entirely mesial or distal to the accepted normal relation to the maxillary teeth.
Posterior crossbite only refers to the maxillary posterior teeth that are buccally or lingually displaced out of the entire occlusal contact with the opposing arch.
Closed Spacing means space insufficient for the complete eruption of a tooth. Only permanent teeth may be counted when completing the malocclusion assessment record for the determination of medical necessity. By definition, interceptive therapy is not a covered service unless it is needed to prevent a skeletal abnormal developmental condition.
Member Name: _________________
DELTA DENTAL OF NEW JERSEY
SALTZMANN HANDICAPPING MALOCCLUSION ASSESSMENT RECORD
Ant = anterior teeth (4 incisors). Post = posterior teeth (including canine, premolars, and first molar). No. = number of teeth affected.
B. INTER-ARCH OEVIATION
1. Anterior Segment
OVERBITE (MAX 4 TEETH)
SCORE MAXILLARY TEETH
AFFECTED ONLY EXCEPT
7 8 9 10
7 8 9 10 23 24 25 26
7 8 9 10
7 8 9 10
'Score maxillary or mandibular Incisors. No. = number of teeth affected.
2. Posterior Segments
RELATE MANDIBULAR TO
SCORE AFFECTED MAXILLARY
G. OTHER DEVIATIONS (use additional sheet if necessary)
If the total score is less than twenty-four (26) points Delta Dental shall consider additional information of a substantial nature about the presence of other severe deviations affecting the mouth and underlying structures. Other deviations shall be considered severe if, left untreated; they would cause irreversible damage to the teeth and underlying structures.
Is there presence of other severe deviations affecting the mouth and underlying structures? (If any, comment below). Y/N