Patient Evaluation and Records Collection

Patient evaluation and records collection is the first stage of an orthodontic work-up, in which the clinician takes a history, performs a clinical and functional examination, and assembles a standardized set of diagnostic records. These records typically include facial and intraoral photographs, study casts or digital models of the dentition, and the radiographs used for analysis, together forming the evidence base from which a diagnosis is built.

Definition

Patient evaluation and records collection is the history-taking, clinical and functional examination, and assembly of standardized orthodontic records (photographs, study models, and radiographs) that together document a case for diagnosis and planning.

Scope

The entry covers the elements of the orthodontic examination and the standard records that document a case, and why standardisation and completeness of records matter for diagnosis and for following change. It treats the records collection process at a descriptive level; it does not prescribe which records to take for an individual or substitute for clinical assessment.

Core questions

• What does an orthodontic clinical and functional examination assess?
• Which standardized records document an orthodontic case?
• Why does standardisation of records support diagnosis and follow-up?
• How do the records together inform the diagnostic problem list?

Key concepts

• History and chief concern
• Clinical and functional examination
• Facial and intraoral photographs
• Study casts and digital models
• Diagnostic radiographs
• Standardisation of records
• Baseline for follow-up

Mechanisms

Each record captures a different facet of the case. The history records the patient's chief concern and relevant medical and dental background; the clinical examination assesses the dentition, occlusion, function, and facial soft tissues; photographs document the face and the intraoral situation; study casts or digital models reproduce the dental arches and occlusal relationships for measurement; and radiographs provide bony and skeletal information. Standardising how each is obtained makes them comparable between patients and over time, so that the same records taken later can document change. Andrews' description of the features of normal occlusion illustrates the kind of detailed observation that study models and clinical examination are meant to capture.

Clinical relevance

Complete, standardised records are the foundation on which an orthodontic diagnosis and any later assessment of progress rest, and understanding them aids interpretation of case documentation. This entry describes records collection in general terms and is not a basis for deciding which records or examinations an individual patient should undergo.

Evidence & guidelines

Professional practice treats a standardised record set as the basis for diagnosis and for documenting change, and selection of radiographic records in particular follows need-based justification rather than routine acquisition.

History

The composition of the orthodontic record set was consolidated through the twentieth century as photography, dental casting, and standardised radiography became routine. The lateral cephalogram joined photographs and study models as a standard record after the 1930s, and analyses such as Steiner's and descriptions of occlusal norms such as Andrews' gave clinicians explicit reasons to obtain and measure each record. Digital photography and intraoral scanning have since changed how the same records are captured and stored.

Key figures

• Lawrence F. Andrews
• Cecil C. Steiner
• William R. Proffit

Seminal works

• andrews-1972
• steiner-1960

Frequently asked questions

What records make up a standard orthodontic work-up?

Typically a history and clinical examination together with facial and intraoral photographs, study casts or digital models of the dentition, and the radiographs used for analysis, such as a panoramic film and a lateral cephalogram.

Why are study models or digital scans taken?

They reproduce the dental arches and occlusion outside the mouth so that tooth positions and arch relationships can be measured and compared, including before and after treatment.