MYOFUNCTIONAL ORTHODONTIC EVALUATION

Current date : Parents/Patient major co

Patient name :
D.O.B Age
Referred by Previous Orthodontic re
Evaluation performed by

DENTAL ALIGNMENT ARCH FORM OCCLUSION FACIAL DEVELOPOMENT

UPPER LOWER 0 Correct bite relationship 0 Good facial development
0 Good dental alignment 0 Normal 0 Normal 0 Overbite 0 Deficiency in mid-face
0 Crowding in upper jaw 0 Narrow 0 Narrow 0 Overjet 0 Deficiency in lower-face
0 Crowding in lower jaw 0 Flattened 0 Flattened 0 Open bite 0 Increased lower facial height
0 Midline correct 0 Cross bite
0 Midline discrepancy 0 anterior
0 posterior
Notes Notes Notes Notes

BREATHING & POSTURE TONGUE SWALLOW

0 Light nasal breathing 0 Correct tongue rest posture 0 Correct swallowing pattern
0 heavy nasal breathing 0 Incorrect tongue rest posture 0 Incorrect swallowing pattern
0 Mouth breathing 0 low tongue posture 0 tongue thrust
0 while awake 0 resting on or in between teeth 0 mentalis activity
0 while sleeping lingual frenum attachment 0 buccinator activity
0 Good posture 0 suffucient range of movement
0 Poor posture 0 tight attachment
0 forward head
0 forward shoulders
Notes Notes Notes

HABITS TMJ DISFUNCTION TREATMENT NOTES

0 No history of habits
0 thumb/finger sucking 0 temporalis
0 pacifier 0 lat. Pterygoid
0 bottle 0 masseter
0 other 0 posterior cervical
0 trapezius
0 TMJ click
0 TMJ pain
duration TMJ consult required (Y/N)
ATION

Parents/Patient major concerns

Previous Orthodontic recommendations:

acial development
ncy in mid-face
ncy in lower-face
ed lower facial height

LIPS & CHEEKS

0 Correct lips rest posture
0 Incorrect lips rest posture
0 apart at rest
0 orofacial muscle strain at rest
when lips are together
0 incompetent lips

Notes