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Chief Complaint
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Identifying Data Age: Sex: Race: Occupation:
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Contributory Medical or Dental History (Ignore if normal)
Medical diagnosis and history Medications Previous orthodontics, splints, surgery, etc.
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Temporomandibular Disorder (Ignore if normal)
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Clinical Diagnostic Exam
Dental: Periodontal: Neurologic, Muscular, Orthopedic, Neurovascular: Occlusal Analysis:
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Pre-treatment Facial slides
Frontal Frontal/Smiling
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Pre-treatment Facial slides
Right 45゜ Right Profile
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Pre-treatment X-Rays Cephalometric Film
Frontal Lateral
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Pre-treatment X-Rays Panoramic Film or Full Mouth X-Rays
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Pre-treatment X-Rays Wrist Film (Growing Patients)
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Pre-treatment X-Rays SMV
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Pre-treatment TMJ X-Rays Axis Oriented Tomograms or CBCT
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Pre-treatment Intraoral Slides
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal
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Pre-treatment Mounted Models
Right Buccal Frontal Left Buccal Right Overjet CPI Left Overjet
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Pre-treatment CPI or MPI
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Pre-treatment Axiograph or Axi-path
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CO-CR Conversion Tracing CO in Black Tracing CR in Purple
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Pre-treatment Ricketts CR
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Pre-treatment Roth-Jarabak CR
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Reason of splint therapy
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Splint Therapy Progress Slides
00 Weeks Later Right Buccal Frontal Left Buccal Overjet
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Splint Therapy Progress Slides
00 Weeks Later Right Buccal Frontal Left Buccal Overjet
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Splint Therapy Progress Slides
00 Weeks Later Right Buccal Frontal Left Buccal Overjet
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Splint Therapy Progress Slides
00 Weeks Later Right Buccal Frontal Left Buccal Overjet
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CPI Data Sheet Summary
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Changes in CPI data during splint therapy
Right Left Initial 00 weeks 00 weeks 00 weeks L R 00 weeks 00 weeks 00 weeks 00 weeks
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Post Splint Facial slides
Frontal Frontal/Smiling
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Post Splint Facial slides
Right 45゜ Right Profile
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Post Splint X-Rays Cephalometric Film
Frontal Lateral
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Post Splint TMJ X-Rays Axis Oriented Tomograms or CBCT
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Post Splint Intraoral Slides
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal
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Post Splint Mounted Models
Right Buccal Frontal Left Buccal Right Overjet Left Overjet
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Post Splint Split Cast Check
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Post Splint Ricketts CR
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Post Splint Roth-Jarabak CR
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Pre Splint VS Post Splint
Full Superimposition Tracing Pre Splint in Black Tracing Post Splint in Green
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Pre Splint VS Post Splint
5 Point Superimposition Tracing Pre Splint in Black Tracing Post Splint in Green
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Post Splint Axiograph or Axi-path
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Post Splint Mounted Models 3-D Check
Right Buccal Frontal Left Buccal Right Overjet Left Overjet
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Problem List After Splint Therapy
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Treatment Plan
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Mechanics
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Post Splint VS VTO Tracing Post Splint in Green Tracing VTO in Red
Full Superimposition Tracing Post Splint in Green Tracing VTO in Red
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5 Point Superimposition
Post Splint VS VTO 5 Point Superimposition Tracing Post Splint in Green Tracing VTO in Red
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Post Splint VS VTO Image
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Treatment Progress Intraoral Slides Wire sequence
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later
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Treatment Progress Intraoral Slides Wire sequence
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later
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Treatment Progress Intraoral Slides Wire sequence
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later
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Treatment Progress Intraoral Slides Wire sequence
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later
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Treatment Progress Intraoral Slides Wire sequence
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later
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Treatment Progress Intraoral Slides Wire sequence
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later
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End of fixed type appliance therapy Mounted Models
Right Buccal Frontal Left Buccal Right Overjet CPI Left Overjet
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End of fixed type appliance therapy Axi-path or Axiograph
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Gnathological Positioner Set-up
Right Buccal Frontal Left Buccal Right Overjet Left Overjet
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Post-treatment Intraoral Slides
Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal
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Post-treatment Mounted Models
Right Buccal Frontal Left Buccal Right Overjet CPI Left Overjet
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Post-treatment CPI or MPI
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Post-treatment Facial slides
Frontal Frontal/Smiling
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Post-treatment Facial slides
Right 45゜ Right Profile
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Post-treatment X-Rays Cephalometric Film
Frontal Lateral
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Post-treatment X-Rays Panoramic Film or Full Mouth X-Rays
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Post-treatment TMJ X-Rays Axis Oriented Tomograms or CBCT
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Post-treatment Ricketts
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Post-treatment Roth-Jarabak
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Post Splint VS Post Tx Tracing Post Splint in Green
Full Superimposition Tracing Post Splint in Green Tracing Post Ontho. in Blue
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5 Point Superimposition
Post Splint VS Post Tx 5 Point Superimposition Tracing Post Splint in Green Tracing Post Ontho. in Blue
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VTO VS Post Tx Tracing VTO in Red Tracing Post Ortho. in Blue
Full Superimposition Tracing VTO in Red Tracing Post Ortho. in Blue
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5 Point Superimposition
VTO VS Post Tx 5 Point Superimposition Tracing VTO in Red Tracing Post Ortho. in Blue
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