Orthodontic Claim Attachment

Patient Octavia Needsortho
Date of birth June 1, 2007 Sex Female
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 45b48227-e792-4c98-a92d-b03ffac4d3ae
Document Created: August 1, 2018, 13:00, PST
Healthcare service Comprehensive orthodontic treatment of the adolescent dentition from January 1, 2018 to August 1, 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 11 year old female with skeletal and dental class II malocclusion
Orthodontic Habits Reported thumb sucking habit until 3 years ago
Traumatic Deviations N/A
Asymmetry of Lower Face Symmetric, but displays a long lower face height
Condylar Abnormality N/A
Craniofacial Anomalies N/A
Orthognathic Surgery Possibility Possible, but after growth cessation
Airway Problems N/A
Treatment Precondition N/A
Diagnostic Feature Deep Impinging Overbite with destruction of soft tissue
Diagnostic Feature Lip incompetence due to horizontal overbite
Diagnostic Feature Bimaxillary protrusion
Craniofacial Anomaly N/A
Dental Abnormality N/A
Benefits Requested Comprehensive Treatment
Dentition Stage Mixed (transitional)
Overjet 10mm
Overbite 10mm
Arch Crowding Anterior Maxilla - 4mm
Arch Crowding Anterior Mandible - 5mm
Labiolingual Deviation 6mm

PROBLEMS

  1. Reported seasonal allergies to pollen

Salzmann Malocclusion Severity Assessment

Observation Value
Salzmann Index 32
Posterior Inter-Arch Deviation Tooth 6 - Anterior Deviation
Posterior Inter-Arch Deviation Tooth 5 - Anterior Deviation
Posterior Inter-Arch Deviation Tooth 4 - Anterior Deviation
Posterior Inter-Arch Deviation Tooth 3 - Anterior 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
Overbite Teeth Count 4
Overjet Teeth Count 4
Rotated Teeth Count Anterior Maxilla - 2
Rotated Teeth Count Anterior Mandible - 4
Crowded Teeth Count Anterior Maxilla - 2
Crowded 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 August 1, 2018, 13:00, PST
Contact info Work Place:
12345 Main Street
Fairfax, VA 22031, US
Tel: +1(555)555-0002