Orthodontic treatment is based on appropriate diagnosis and treatment planning. Typical orthodontic records must include a medical history, oral exam, facial and intraoral photographs, study casts, a panoramic and a lateral cephalogram head film supplemented by intraoral views as needed.
Medical History
The patient's past and present may contain relevant information bearing on their health past, present, and future. Typically there are only a few conditions that would prevent a person from receiving orthodontic treatment such as cardiovascular disease due to need for SBE coverage, nonsteroidals , diabetes. Lastly, any allergies should be noted. The most common allergies that may complicate treatment are to nickel, since it is found in most wires, and latex, which is found in some elastic material. As with any condition, it should be followed up with the patient's physician.
Dental History and examination
Orthodontic diagnosis begins with the clarification of the patient chief complaint and it is important to ask if he was receiving any previous orthodontic care. Then, one should inquire if his parents received orthodontic treatment, and if so, what the nature of their problem was. A question should be asked about whether the patient ever had any traumatic injury involving the teeth or jaws. The examination must include clinical exam and radiographic exam.
The clinical exam is the study of the facial proportions, muscular states and intraoral inspection.