ORTHO EVAL FORM Pediatric Dentistry Ph.609-200-5437 Ph.732-737-7336 littleteethprinceton@gmail.com Child's Name* First Last Date Of Birth* Date Format: MM slash DD slash YYYY Gender*FEMALEMALEChief ComplaintLast Dental Visit Date Format: MM slash DD slash YYYY LipsCompetentIn-CompetentIncisor Display At Rest 0mm 1mm 2mm 3mm 4mm 5mm 6mm Other Incisor Display At Rest (Other)Incisor show on Smile 100% 90% 80% 70% 60% 50% Other Incisor Shown on Smile (Other)Gingival Display On Smile None Mild Moderate Severe Maxillary Midline On Right Left Maxillary Midline (mm)Mandibular Midline On Right Left Mandibular Midline (mm)Angles Classification Class I Class II Div I Class II Div I Sub Div R Class II Div I Sub Div L Class II Div II Class II Div II Sub Div R Class II Div II Sub Div L Class III Class III Sub Div R Class III Sub Div L CrossBiteNoneAnteriorAnterior and PosteriorPosterior LeftPosterior RightPosterior BilateralTendencyOverBite None 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% OpenBite None Anterior Posterior Anterior and Posterior Tendency Maxillary Arch Length Adequate Mild Crowding Moderate Crowding Severe Crowding Mild Spacing Moderate Spacing Severe Spacing Mandibular Arch Length Adequate Mild Crowding Moderate Crowding Severe Crowding Mild Spacing Moderate Spacing Severe Spacing Palate Normal High Constricted High and Constricted DENTITIONDentition MissingABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132ImpactedABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132SupernumeraryABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132TransposedABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132EctopicABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132FracturedABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132DiscoloredABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132WornABCDEFGHIJKLMNOPQRST1234567891011121314151617181920212223242526272829303132Habits None Thumb Finger Nail Biting Clenching Grinding Tongue Thrust Mouth Breathing Probable Tx Plan Phase I U and L Phase I Upper Phase I Lower Phase II Comprehensive Fixed Invisalign Orthognathic Combination Upper Arch Only Lower Arch Only Recall Tx Time 6 Months 6-12 Months 12 Months 12-18 Months 18 Months 18-24 Months 24 Months Tx Comment Narrative (Patient)Tx Comment Narrative (Doc)Ph 1 to monitor till permanent teeth errupt Yes No OrthodontistDr.MoDr.Shah
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