Form 40 Orthodontic_Examination_Record

Orthodontic Examination Record

Oral Health Centre of Western Australia

Main Complaint11

Main Complaint

Medical History

(Please complete the medical history questionnaire)

Item	Options / Findings
General Health	Good / Poor

Dental History

Item	Options / Findings
Trauma	N / Y (# ___)
Premature Tooth Loss	N / Y (# ___)
Regularity of Dental Checks	6/12 / 12/12 / Irregular
Oral Habits	N / Y (specify)
Past Dental Experience

Social History

Item	Options / Findings
School
Year
Behaviour	Good / Well adjusted / Introverted / Restless / Difficult / Uncooperative
Parental Support	Supportive / Indifferent / Difficult
Other Comments

Growth

Item	Options / Findings
Body Type	Ecto / Meso / Endo
Height	___ cm
Weight	___ kg
Parent’s Height	___ cm
Menarche	N / Y
At age	___
Developmental Status	Prepubertal / Pubertal / Postpubertal / Adult

Patient History and Main Complaint

TMJ / Occlusal Examination

Range of Movement

Measurement	Finding / Reference
Max. Inter-incisal Opening	40–50 mm
Lateral Excursion — Right	___ mm
Lateral Excursion — Left	___ mm
Lateral Excursion reference	8–12 mm
Protrusion	6–10 mm
Retrusion	1–2 mm
Deviation on Opening	N / Y (right / left)
CR–CO Shift	N / Y (specify)

Signs and Symptoms

Item	Options / Findings
Clicks / Crepitus	N / Y (right / left)
TMJ Pain	N / Y
Masticatory Muscles Tender	N / Y

Facial Examination

Frontal

Feature	Options / Findings
Shape	Ovoid / Taper / Square
Type	Dolicho / Meso / Brachy
Symmetry	N / Y (specify)
Lower Facial Height (LFH)	Long / Equal / Short
Lips	Competent / Incompetent / Potentially competent
Incisal Display — at rest	1–2 mm
Incisal Display — at smile	100% (over 8 mm)
Gingival Display	1 mm for female / 0 mm for male
Cant of Occlusal Plane	N / Y (specify)

Profile

Feature	Options / Findings
Profile	Straight / Convex / Concave

Nose

Feature	Options / Findings
Nose	Normal / Small / Prominent
Nasolabial Angle	Normal / Obtuse >120° / Acute <90°
Normal Nasolabial Angle Range	90–120°
Mode of Breathing	Nasal / Oral / Both
Nasal Passages	Clear / Blocked

Upper Lip

Feature	Options / Findings
Length	22 mm / Normal / Short / Long
Curvature	Straight / Concave / Convex
Inclination	Straight / Proclined / Retroclined
Attachment	40%

Chin

Feature	Options / Findings
Mental Sulcus	Normal / Flat / Deep
Chin Button	Normal / Flat / Prominent

Lower Lip

Feature	Options / Findings
Position	Balanced / Everted / Procumbent
Mentalis	Normal / Hypotonic / Hypertonic

Intra-Oral Examination

Soft Tissue22

Item	Options / Findings
Oral Mucosa	Pink and healthy / Pathology (specify)
Tonsils	Normal / Enlarged
Upper Frenum	Normal / High
Lower Frenum	Normal / High

Periodontal Health

Item	Options / Findings
Oral Hygiene	Good / Fair / Poor
Gingiva	Healthy / Inflamed / Generalised / Localised to: ___
Bleeding on Probing (BOP)	None / Slight / Profuse
Attached Gingiva	Adequate / Inadequate <3 mm (specify)
Pocketing	Absent / Present (specify)

Hard Tissue

Item	Options / Findings
Teeth Present
Condition of Existing Restorations	Caries-free / Good / Acceptable / Poor
Caries Risk	Low / High

Occlusion

Measurement	Recorded Value	Classification
Overjet (OJ)	2–3 mm	Normal / Increased / Reduced
Overbite (OB)	30–40%	Minimal / Normal / Deep / Impinging

Occlusal Relationship	Right	Left
Molar Occlusion	Class I / II / III	Class I / II / III
Canine Occlusion	Class I / II / III	Class I / II / III

Feature	Options / Findings
Open Bite	Absent / Present (specify)
Crossbite	Absent / Present (specify)

Dental Midlines

Relationship	Options / Findings
Upper to Facial	Correct / Deviated to Right / Left
Lower to Facial	Correct / Deviated to Right / Left
Upper and Lower Dental Midline Coincident	Y / N (specify)

Signatures and Verification

Field	Details
Patient Signature	Parent or guardian if under 18 years
Date
Clinician Signature
Clinician ID
Supervisor Signature	If student clinician
Supervisor ID

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1. Original PDF page 1: Form 40 Orthodontic Examination Record, p.1↩︎

2. Original PDF page 2: Form 40 Orthodontic Examination Record, p.2↩︎