Chief Complaint

1. Chief Complaint

2. Identifying Data • Age: • Sex: • Race: • Occupation:

3. Contributory Medical or Dental History (Ignore if normal) • Medical diagnosis and history • Medications • Previous orthodontics, splints, surgery, etc.

4. Temporomandibular Disorder (Ignore if normal)

5. Clinical Diagnostic Exam • Dental: • Periodontal: • Neurologic, Muscular, Orthopedic,Neurovascular: • Occlusal Analysis:

6. Pre-treatment Facial slides Frontal Frontal/Smiling

7. Pre-treatment Facial slides Right 45゜ Right Profile

8. Pre-treatment X-RaysCephalometric Film Frontal Lateral

9. Pre-treatment X-RaysPanoramic Film or Full Mouth X-Rays

10. Pre-treatment X-RaysWrist Film (Growing Patients)

11. Pre-treatment X-RaysSMV

12. Pre-treatment TMJ X-RaysAxis Oriented Tomograms or CBCT

13. Pre-treatment Intraoral Slides Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal

14. Pre-treatment Mounted Models Right Buccal Frontal Left Buccal Right Overjet CPI Left Overjet

15. Pre-treatment CPI or MPI

16. Pre-treatment Axiograph or Axi-path

17. CO-CR Conversion • Tracing CO in Black • Tracing CR in Purple

18. Pre-treatment Ricketts CR

19. Pre-treatment Roth-Jarabak CR

20. Reason of splint therapy

21. Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Left Buccal Overjet

22. Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Left Buccal Overjet

23. Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Left Buccal Overjet

24. Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Left Buccal Overjet

25. CPI Data Sheet Summary

26. Changes in CPI data during splint therapy Left Right Initial 00 weeks 00 weeks L R 00 weeks 00 weeks 00 weeks 00 weeks 00 weeks

27. Post Splint Facial slides Frontal Frontal/Smiling

28. Post Splint Facial slides Right 45゜ Right Profile

29. Post Splint X-RaysCephalometric Film Frontal Lateral

30. Post Splint TMJ X-RaysAxis Oriented Tomograms or CBCT

31. Post Splint Intraoral Slides Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal

32. Post Splint Mounted Models Right Buccal Frontal Left Buccal Right Overjet Left Overjet

33. Post Splint Split Cast Check

34. Post Splint Ricketts CR

35. Post Splint Roth-Jarabak CR

36. Pre Splint VS Post Splint Full Superimposition • Tracing Pre Splint in Black • Tracing Post Splint in Green

37. Pre Splint VS Post Splint 5 Point Superimposition • Tracing Pre Splint in Black • Tracing Post Splint in Green

38. Post Splint Axiograph or Axi-path

39. Post Splint Mounted Models3-D Check Right Buccal Frontal Left Buccal Right Overjet Left Overjet

40. Problem List After Splint Therapy

41. Treatment Plan

42. Mechanics

43. Post Splint VS VTO Full Superimposition • Tracing Post Splint in Green • Tracing VTO in Red

44. Post Splint VS VTO 5 Point Superimposition • Tracing Post Splint in Green • Tracing VTO in Red

45. Post Splint VS VTO Image

46. Treatment Progress Intraoral SlidesWire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later

47. Treatment Progress Intraoral SlidesWire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later

48. Treatment Progress Intraoral SlidesWire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later

49. Treatment Progress Intraoral SlidesWire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later

50. Treatment Progress Intraoral SlidesWire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later