Digital Case Documentation Format for Case Presentation TMD Candidate s Name: CLAYTON A. CHAN, D.D.S. Case No.: 1 Our Disciplines ORTHOPEDIC Patient s Initials: CL (EXAMPLE CASE) RESTORATIVE OCCLUSION CONNECTIONS
Dear Candidate, Please gather your images and pictures of four (4) phase I orthotic cases documenting evidence, validation of clinical proficiency and treatment effectiveness. This power point template will help act as a guide for you to systematically insert the required images for each case. Each case should involve one or more of the following: 1) cervical dysfunction, 2) TMD primary, 3) Class II Div. 2 and or 4) anterior open bite tendency problems related to restorative, implants, prosthetics and or natural dentition that you have diagnosed and treated within the past 24-36 months. This case documentation format will serve as a means for the candidate to show proficiency in diagnosis, overall treatment planning and validation of the treatment effectiveness in phase I stabilization process in assessing the following areas: 1) masticatory muscles stability, 2) occlusal stability, 3) TM joint stability, 4) central nervous system (CNS) stability and 5) other orofacial areas of stability that supports phase I treatment effectiveness. Each case should demonstrate the phase I orthotic management and stabilization process. It is important you FOLLOW the Case Documentation Requirements as per pages 2-8 of the OC Awards Application OCCLUSION CONNECTIONS
INSTRUCTIONS BEFORE YOU PROCEED TO INSERT DATA Please make a duplicate ORIGINAL COPY of this complete power point (ppt) file template for your records before proceeding. You will need to create another copy of this ppt file for each of the 4 individual documented cases that you will then enter and insert the required patient case photos and images for each case. Do not hesitate to comment with a special note by texting next to image(s). This will help clarify particular aspects of your case that the reviewer would not have known about the case. You can add additional slides as you need to insert more photos for additional documentation to help further tell the story about the key features about each case (challenges you had and how you over came the problem and what you learned by doing the case).
Case Documentation FORM 1. Please insert image of the completed Case Documentation Form for each case with the boxes checked to confirm that you have completed of each requirement forms of documentation.
PHASE I ORTHOTIC CASE DEMONSTRATING STABILIZATION EFFECTIVENESS Case No. 1 2 3 4 Patient s ID# or Initials Age of Patient Cervical Dysfunction TMJ Primary Class II Div. 2 Anterior Open Bite (tendency) Date Case Started Date Case Completed Stabilization Orthotic Lab Used Future Phase II Treatment Method 1 CL 32 ---- YES YES ---- 8-6-12 3-13-13 SELF LAB ORTHO/ ORTHOPEDICS 2 3 4 * Indicate which type of NM challenge was present with your case by noting the category with a YES
CHIEF COMPLAINT: Please list what are the main concerns and reasons for phase I orthotic treatment. 1. Ringing in the ears 2. Tiredness all the days. 3. Pressure all around the head. 4. Clogged ear right side. 5. Patient has seen numerous TMD experts and presents with both night time and day time appliances that have been ineffective after numerous visits and attempts at stabilizing his condition with has been going on for over 10 years.
MEDICAL HISTORY Are there any significant medical conditions that would affect records gathering, patient treatment or long term prognosis. Insert Image of Med Hx Form (s)
DENTAL HISTORY Are there any significant medical conditions that would affect records gathering, patient treatment or long term prognosis. Insert Image of Dental Hx Form(s)
PATIENT HISTORY (Clinical Examination) Insert Relevant Images of Periodontal form Insert Relevant Prosthetic considerations if any No prosthetics concerns at this time. Patient presents with all his teeth present. No teeth missing. Patient has had previous maxillary and mandibular orthognathic surgery. See radiographic images.
PATIENT HISTORY (Clinical Examination) List the TMJ Problems (Chief Concerns) Craniomandibular Visual Index Form 1. Ringing in the ears 2. Tiredness all the days 3. Pressure all around my head 4. Clogged ear right side
PATIENT HISTORY (Clinical Examination) (Insert Musculoskeletal Occlusal Signs & Symptoms Sheet) Brief History: Patient having problems for 10 years (1999). All his life he has had this problem. With 3 years of orthodontic treatment. After orthodontic treatment he had bi maxillary Oral Surgery, closing anterior open bite. No symptoms for 10 years, but symptoms started around February 2011 with Neck and Back pain. Got worse in September 2011 with severe neck and back pain with ringing of the ears bilaterally in Sept 2011. Patient was taking Klonozapan he took 6 months to wean himself off this medication which was causing his severe problems not allowing him to sleep sometimes 3 days at a time.
PATIENT HISTORY (Clinical Examination) (Insert image of the Musculoskeletal Screening Questionnaire)
PATIENT HISTORY (Clinical Examination) Skeletal Classification: Class I Class II Class III Dental Classification: Class I Class II division 1 Class II division 2 Class III Facial Profile Classification: Maxillary Average Prognathic Retrognathic Mandibular Average Prognathic Retrognathic
Diagnostic Classification for Craniomandibular Disorders Provide the diagnostic classification you have determined for this case and submit image of Classification for Craniomandibular Disorders Form here. Use the Classification for Craniomandibular Disorders Form and insert an image of the completed form here. www.occlusionconnections.com
Patient Subjective Summery REPORT Provide proof for each (dated) intermittent follow up visit during the course of treatment and scored (0-5) of the various musculoskeletal occlusal signs and symptoms showing phase I orthotic therapy effectiveness for each case. Use the Patient Subjective Summary Form and insert an image of the completed form here. www.occlusionconnections.com
RADIOGRAPHS BEFORE TREATMENT: Lateral Cephalogram (CO)
RADIOGRAPHS BEFORE TREATMENT: Panoramic
RADIOGRAPHS BEFORE TREATMENT: Full mouth Series
RADIOGRAPHS BEFORE TREATMENT: Tomograms CO/MIP: Right TM Joint Tomograms CO/MIP: Left TM Joint
RADIOGRAPHS BEFORE TREATMENT: Tomograms Habitual Rest: Right TM Joint Tomograms Habitual Rest: Left TM Joint www.occlusionconnections.com
RADIOGRAPHS BEFORE TREATMENT: Tomograms Maximum Open: Right TM Joint Tomograms Maximum Open: Left TM Joint If case presents with Limited Maximum Opening that is also acceptable. **Just indicate it as such and show follow up Tomograms indicating improvement after Orthotic treatment
BEFORE TREATMENT: Retracted: Overjet/ Overbite - Unposed Retracted Frontal View (Lateral view optional) www.occlusionconnections.com
BEFORE TREATMENT: Intra Oral View in CO Before Treatment: Frontal, Left Lateral and Right Lateral Views www.occlusionconnections.com
BEFORE TREATMENT: Intra Oral View Occlusal Before Treatment: Upper and Lower Arch Views
BEFORE TREATMENT: Close Up 1:2 Magnification Full smile (Frontal, Left Lateral and Right Lateral) Views www.occlusionconnections.com
BEFORE TREATMENT: Extra Oral Facial Frontal, Lateral Right Profile Views Smile Relaxed Profile (Lightly closed on back teeth)
BEFORE TREATMENT: Postural Frontal, Lateral Right Profile Views
BEFORE TREATMENT: Diagnostic Models in CO: Frontal, Left Lateral and Right Lateral www.occlusionconnections.com
BEFORE TREATMENT: Occlusal Arch Upper and Lower arch views www.occlusionconnections.com
BEFORE TREATMENT: Diagnostic Models with Optimized Bite: Frontal, Left Lateral and Right Lateral www.occlusionconnections.com
MID PROGRESS TREATMENT: Additional CLINICAL Photos Showing Progress of Phase I Orthotic Stabilization
MID PROGRESS TREATMENT: Photos documenting Orthotic resurfacing/management (Optional) Decided to add a little more definitive anterior contact to help improve AP proprioception of this severe Class II retrognathic and restricted left condylar/disc case.
AFTER TREATMENT with ORTHOTIC: Intra Oral Smile After Treatment - Frontal, Left Lateral and Right Lateral Views Photos should be retracted views
AFTER TREATMENT with ORTHOTIC: Extra Oral Facial Frontal, Lateral Right Profile Views Smile Relaxed Profile (Lightly closed on optimized bite)
AFTER TREATMENT with ORTHOTIC: Postural Frontal, Lateral Right Profile Views
AFTER TREATMENT with ORTHOTIC: Occlusal Views Showing Orthotic Occlusal Marks Centric Marks Lateral Excursion Marks
RADIOGRAPHS AFTER TREATMENT: Tomograms Right and Left TM Joint After Stabilization with Phase I GNM Orthotic Follow up showing improved ROM (Optional) Insert Images here **Follow up Tomograms demonstrating improvement in condylar positioning after GNM Orthotic treatment.
Concluding Summary: Please summarize your insights, perspectives and lessons learned from this case regarding the following: 1. Masticatory muscle stability. 2. Occlusal stability. 3. TM Joint stability. 4. Central nervous system (CNS) stability 5. Other orofacial areas that you found unique when having to stabilize this case. 6. What is your proposed recommended phase 2 finishing treatment plan Ortho, Restorative, combination and or will patient stay in orthotic as a crutch appliance? 7. Rank the difficulty of this case: Easy, moderate or difficult to treat? - Moderate 8. Patient subjective summary score started at 26 total and ended at a score total of 1. Patient happy and is back playing tennis. 9. Long term treatment plan: Corrective ortho/orthopedics Maxillary and mandibular arch expansion will be required to level and align the arches with supportive transitioning of the VDO via sequential segmenting of the lower removable orthotic while at the same time verticalization mechanics to re-establish the occlusion on an optimized myo-trajectory.