Orthodontic Claim Attachment

Patient Olivia Needsortho
Date of birth November 14, 2008 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 8ebd8c7d-97d6-4a78-8a23-945b62420531
Document Created: August 1, 2018, 13:00, PST
Healthcare service Comprehensive orthodontic treatment of the adolescent dentition from February 15, 2017 to June 4, 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 10 year old female presents with maxillary transverse and anteroposterior deficiency. Class III dental relationship with anterior and posterior crossbite.
Orthodontic Habits Tongue thrust.
Traumatic Deviations N/A
Asymmetry of Lower Face N/A
Condylar Abnormality N/A
Craniofacial Anomalies Cleidocranial dysplasia: retention of multiple non-resorbed primary teeth and multiple supernumerary teeth in maxilla and mandible. Midface hypoplasia induced class III skeletal relationship
Orthognathic Surgery Possibility Possible to align maxilla and mandible post growth cessation.
Airway Problems N/A
Treatment Precondition N/A
Diagnostic Feature Articulatory defect secondary to dental defect
Craniofacial Anomaly Cleidocranial dysostosis
Dental Abnormality Tooth #4s - Supernumerary
Dental Abnormality Tooth #11s - Supernumerary
Dental Abnormality Tooth #12s - Supernumerary
Dental Abnormality Tooth #20s - Supernumerary
Dental Abnormality Tooth #28s - Supernumerary
Dental Abnormality Tooth #29s - Supernumerary
Benefits Requested Comprehensive Treatment
Dentition Stage Mixed (transitional)
Overjet -4mm
Openbite 7mm
Arch Crowding Anterior Maxilla - 7mm
Arch Crowding Anterior Mandible - 8mm
Labiolingual Deviation 5mm

PROBLEMS

  1. Minor hearing loss, Ear infection, and Orthopedic complications.

Salzmann Malocclusion Severity Assessment

Observation Value
Salzmann Index 63
Posterior Inter-Arch Deviation Tooth 6 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 5 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 4 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 3 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 11 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 12 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 13 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 14 - Posterior Deviation
Posterior Inter-Arch Deviation Tooth 6 - Crossbite
Posterior Inter-Arch Deviation Tooth 5 - Crossbite
Posterior Inter-Arch Deviation Tooth 4 - Crossbite
Posterior Inter-Arch Deviation Tooth 3 - Crossbite
Posterior Inter-Arch Deviation Tooth 11 - Crossbite
Posterior Inter-Arch Deviation Tooth 12 - Crossbite
Posterior Inter-Arch Deviation Tooth 13 - Crossbite
Posterior Inter-Arch Deviation Tooth 14 - Crossbite
Posterior Inter-Arch Deviation Tooth 6 - Openbite
Posterior Inter-Arch Deviation Tooth 11 - Openbite
Overjet Teeth Count 4
Crossbite Teeth Count 10
Openbite Teeth Count 6
Crowded Teeth Count Anterior Maxilla - 4
Crowded Teeth Count Anterior Mandible - 4
Rotated Teeth Count Anterior Maxilla - 3
Closed Space Teeth Count Anterior Maxilla - 1
Closed Space Teeth Count Posterior Maxilla - 2
Closed Space Teeth Count Posterior Mandible - 3



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 June 4, 2018, 13:00, PST
Contact info Work Place:
12345 Main Street
Fairfax, VA 22031, US
Tel: +1(555)555-0002