ORTHODONTIC EXAMINATION FORM

(Student Form)

Treating Doctor
Aseel Rosi
Patient Data
Patient Name
Rafa Alsultan File Number

Date of Birth
2 / 7 /2000 Ethnic Background Middleeastern Gender
Female
Referral Source

Motivation Internal External Occupation student Marital Status

single
Phone Number 0535038551 Date of Examination 2 /
2 /
2023

Chief Complaint checkup

History
Past Medical History
None
Medical Alert None
Allergies Pollen
Present Medication wave
Past Dental History Perio orthe
Restorations

Previous Orthodontic Tx Yes2019forbmouthssatisfied

Familial Malocclusion No
Previous Trauma
No
Mouth breathing Digit sucking Pacifier sucking Others
Habits
Tongue Thrust Clenching/bruxism Lip biting nail
Previous
biting

Functional Analysis
Pain Yes No Frequency & Duration:
Clicking/Crepitus Yes No Rt. / Lt. / Both:Both
TMJ
Tenderness to Palpation Yes No
Open/Close Movement Straight Deviation Restriction
Respiration Oral Nasal Oro-nasal
Speech Normal Other
 Clinical Extra-Oral Examination
Frontal

I
Facial Form Mesocephalic Dolichocephalic Brachycephalic
Symmetry (Facial Midline) Symmetrical Chin to right Chin to left

Dental midlines to facial midline 2pm

Imm
Smile Arc Normal Flat Reverse
Occlusal Cant Normal To the right To the left
Upper Incisor tooth show
Lip Competence
3
At rest (mm) _________________
Competent
Smiling (%) _________________
100
Incompetent
2
Gingiva (mm) ________________

Upper Normal Full Thin

Lip Form
Lower Normal Full Thin
Profile
Skeletal Pattern CI CII CIII
Lower Facial Height Proportion Normal Increased Decreased

I
Frankfort Mandibular Plane Angle Normal Increased Decreased
Nasio-labial angle Normal Acute Obtuse
Upper On line Behind line In front of line
Lips to E-Line

É
Lower On line Behind line In front of line
Chin Projection Weak Normal Strong
Nose Prominent/Large Average Small
Soft Tissue Profile Straight Convex Concave

Clinical Intra-Oral Examination

Dentition Stage Primary Early Mixed Late Mixed Permanent

I
Oral Hygiene Good Fair Poor
Caries Activity Low Medium High
Gingiva* Healthy Inflamed
Gingival Recession
Frenal Attachment
Palate Vault
I Yes
Normal
Normal
14 No
High
Deep
Low
Flat

*Other periodontal Problem: ………………………………….

Caries (C), Restoration (R), Extracted (X), Absent (O),

Supernumerary (S), Impacted (I), Ectopic (E), Decalcified/White Spot (D),
Atypical form (A), Broken (B), Discolored (DC), Non-vital (NV)

R R R R
8 7 6 5/E 4/D 3/C 2/B 1/A 1/A 2/B 3/C 4/D 5/E 6 7 8
8 7 6 5/E 4/D 3/C 2/B 1/A 1/A 2/B 3/C 4/D 5/E 6 7 8

C R R
*Other dental abnormalities: ……………………………………
 Lower Arch
Arch Form Tapered Square Ovoid
Crowding Crowding Crowding Crowding
No Crowding
(Mild) (Moderate) (Severe)
No spacing Diastema Generalized spacing
Spacing

Upper Arch
Arch Form Tapered Square Ovoid
Crowding Crowding Crowding Crowding
No Crowding
(Mild) (Moderate) (Severe)
No spacing Diastema Generalized spacing
Spacing

In Occlusion
Incisor Relationship (British Standards Institute 1983) CI I CII/1 CII/2 CIII

Molar Relationship
Right

I II iIII
Left

I II III

Canine Relationship
Right

I II III i
Left

I II III

Overbite Normal 30 Increased Decreased

Overjet
a mm Anterior Open Bite

I
Curve of Spee Normal Flat Deep Reverse
Angle‘s Classification CI I CII/1 CII/2 CIII

Posterior Cross-bite
Dental Midlines Anterior Cross-bite (Buccal/Lingual)
Displacement
R L Ant.

fixed retier Present in upper arch

 Records

Type of Records Taken Date

Orthopantomograph Examination
Un-erupted Teeth Congenitally Absent Tooth of Poor Root
Teeth Prognosis Resorption

Other Features/Pathology
(Condyles, Rami, Maxillary Sinuses, Bone Anomalies, 3rd Molars, Root Curvature, Ankylosis, Impactions, Caries……)

Summary

IOTN
Dental Health Component Aesthetic Component

Problem List

A
Supervisor Signature: ……………………………………………………………….. Date: ……………………………………………………