Orthodontic Claim Attachment

Patient Oscar Needsortho
Date of birth April 24, 1986 Sex Male
Contact info Primary Home:
555 Home Street
Fairfax, VA 22031, US
Tel: +1(555)555-0001
Patient IDs 111223333 2.16.840.1.113883.4.1
Document Id 6dfca1a2-4cdc-4e62-804d-61f3a6d90090
Document Created: August 1, 2018, 13:00, PST
Healthcare service Comprehensive orthodontic treatment of the adult dentition from August 15, 2017 to July 25, 2018
Performer (primary care physician) Olga Orthodontist, DMD of Fairfax Orthodontic Care
Author Olga Orthodontist, DMD
Contact info Work Place:
12345 Main Street
Fairfax, VA 22031, US
Tel: +1(555)555-0002

Table of Contents


Orthodontic Observations

Observation Value
Orthodontic Narrative 32 year old male with history of bicycle accident at age 6. Skeletal class I
Orthodontic Habits Tongue thrust
Traumatic Deviations (previous trauma) Right side Ramus notably longer than left side causing significant chin point deviation and lower
Asymmetry of Lower Face Chin point deviates 10mm to the left of midsagittal plane.
Condylar Abnormality Left side condyle displays evidence of previous (healed) fracture / short compared to right side
Craniofacial Anomalies N/A
Orthognathic Surgery Possibility Possible to improve lower face midline correction.
Airway Problems N/A
Treatment Precondition Temporomandibular Dysfunction
Diagnostic Feature Posterior crossbite limited to right side
Craniofacial Anomaly N/A
Dental Abnormality Tooth #4 - Absent
Dental Abnormality Tooth #17 - Absent
Dental Abnormality Tooth #32 - Absent
Dental Abnormality Tooth #A - Ankylosed
Dental Abnormality Tooth #1s - Supernumerary
Benefits Requested Comprehensive Treatment
Dentition Stage Permanent
Overjet 3mm
Overbite 2mm
Openbite 4mm
Arch Crowding Anterior Maxilla - 4mm
Arch Crowding Anterior Mandible - 7mm
Labiolingual Deviation 3mm

PROBLEMS

  1. Patient on statin for cholesterol

Salzmann Malocclusion Severity Assessment

Observation Value
Salzmann Index 26
Posterior Inter-Arch Deviation Tooth 6 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 6 - Openbite
Posterior Inter-Arch Deviation Tooth 5 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 11 - Anterior Deviation
Posterior Inter-Arch Deviation Tooth 12 - Anterior Deviation
Posterior Inter-Arch Deviation Tooth 13 - Anterior Deviation
Posterior Inter-Arch Deviation Tooth 14 - Anterior Deviation
Overjet Teeth Count 2
Crossbite Teeth Count 2
Openbite Teeth Count 2
Missing Teeth Count Posterior Maxilla - 1
Crowded Teeth Count Anterior Mandible - 4
Rotated Teeth Count Anterior Maxilla - 2
Rotated Teeth Count Anterior Mandible - 4



Document maintained by Fairfax Orthodontic Care
Contact info Work Place:
12345 Main Street
Fairfax, VA 22031, US
Tel: +1(555)555-0002
Assigned entity Tommy Toothman
Contact info Work Place:
12345 Main Street
Fairfax, VA 22031, US
Tel: +1(555)555-0002
Legal authenticator Olga Orthodontist, DMD signed at July 25, 2018, 13:00, PST
Contact info Work Place:
12345 Main Street
Fairfax, VA 22031, US
Tel: +1(555)555-0002