M E M B E R S H I P I N O R T H O D O N T I C S : C A S E H I S T O R Y T E M P L A T E

THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH

MEMBERSHIP IN ORTHODONTICS

CASE HISTORY TEMPLATE

DATE OF EXAMINATION: [month, year of examination]

CANDIDATE NUMBER: [N]

CASE NUMBER: [N]

PATIENT’S INITIALS: [I.I]

COLOUR CODE:

[attach colour sticker here]

CASE SUMMARY

[A brief description of the case, maximum 150 words, Arial font, 11pt]

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SECTION 1. PRE-TREATMENT ASSESSMENT

PATIENT DETAILS

Initials

Sex

Age at start of treatment

Date of start of treatment

Duration of treatment.

Patient Complaint

Medical History

Other relevant information

EXTRA-ORAL ASSESSMENT

Skeletal Antero-Posterior

Skeletal Vertical

Skeletal Transverse

Soft Tissue Assessment

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INTRA-ORAL ASSESSMENT

Mandibular Arch crowding/spacing

Maxillary Arch crowding/spacing

Incisor relationship

Overjet (mm)

Overbite

Centrelines

Left Buccal Segment relationship (molars)

Left Buccal Segment relationship (canines)

Right Buccal Segment relationship (molars)

Right Buccal Segment relationship (canines)

Crossbite (Displacement)

Other occlusal features

Bolton Analysis (3-3)

Bolton Analysis (6-6)

General Dental Condition

GENERAL RADIOGRAPHIC EXAMINATION

Absent teeth

Teeth of poor prognosis

Other relevant radiographic findings

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PRE-TREATMENT PHOTOGRAPHS: EXTRA-ORAL

[Insert frontal and profile photographs here]

PRE-TREATMENT PHOTOGRAPHS: INTRA-ORAL

[Insert anterior, lateral and occlusal photographs here]

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PRE-TREATMENT STUDY MODELS

[Insert 3-D images or photographic views of cast models on this page]

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PRE-TREATMENT RADIOGRAPHS

[Insert radiographs here]

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PRE-TREATMENT CEPHALOMETRIC TRACING:

[Insert cephalometric tracing here]

PRE-TREATMENT CEPHALOMETRIC ANALYSIS:

Variable Norms T0
SNA

SNB

ANB

MMPA

Face height ratio

SN to maxillary plane

Upper incisor to maxillary plane

Lower incisor to mandibular plane

Interincisal angle

Wits appraisal

Lower incisor to APo line

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DIAGNOSTIC SUMMARY:

[Maximum 100 words, Arial font 11pt]

PROBLEM LIST [max 10 bullet points appropriate to the case]

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

TREATMENT PLAN

Appliances

Extractions

Special Anchorage

Additional dental treatment

Retention

TREATMENT PROGRESS

Age at start of active treatment

Total active treatment

End of retention

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SECTION 2. TREATMENT
IMAGES OF KEY STAGES / MECHANICS IN TREATMENT

[Insert images here – 20 Images Max]

Comment Box: (each max 30 words – comment boxes may be used throughout this section as a
legend for one or a series of images – see example case)

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MID/ NEAR-END/END of TREATMENT RADIOGRAPHS

[Insert radiographs here]

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MID-TREATMENT CEPH ANALYSIS (max two cephalometric analyses)

[Insert analysis here – sample templates below]

Variable T0 T1

SNA

SNB

ANB

MMPA

Face height ratio

SN to maxillary plane

Upper incisor to maxillary plane

Lower incisor to mandibular plane

Interincisal angle

Wits appraisal

Lower incisor to APo line

Variable T0 T1 T2
SNA

SNB

ANB

MMPA

Face height ratio

SN to maxillary plane

Upper incisor to maxillary plane

Lower incisor to mandibular plane

Interincisal angle

Wits appraisal

Lower incisor to APo line

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CEPHALOMETRIC SUPERIMPOSITION

Pre-treatment: Black
Post-functional (T1): Blue
End of Treatment (T2): Red

[Insert images and titles here as required – example titles given below]

A) Overall superimposition, registered on Bjork’s stable structures

B) Maxillary superimposition, registered on Bjork’s stable maxillary structures
C) Mandibular superimposition, registered on Bjork’s stable mandibular structures

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SECTION 3. POST-TREATMENT ASSESSMENT

END OF TREATMENT STUDY MODELS

[Insert 3-D images or photographic views of cast models on this page]

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POST - TREATMENT PHOTOGRAPHS: (Extra-Oral and Intra-Oral - Max 8 images)

[Insert photographs on this page]

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POST - TREATMENT PHOTOGRAPHS: (Retainers) (Max 3 images)

[Insert photographs on this page]

SECTION 4. CRITICAL APPRAISAL

(Max 250 words – Arial font, 11pt)

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