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THE CASE REPORT

Download Case Requirement PDF

The recommended case report format and the sequence are described below. For your convenience, the entire format is available as a template. You may fill in the patient particulars and take a print out. Each page must be placed in a transparent protective cover. Each case report must include:

1. TITLE PAGE
2. SUMMARY OF TREATMENT
3. HISTORY AND ETIOLOGY
4. CEPHALOMETRIC SUMMARY
5. DIAGNOSIS

include a brief description of the nature and extent of the anomalies for skeletal and dental and/or facial problems.

6. TREATMENT PLAN

include your diagnostic analysis and reason for choosing a particular treatment plan, extraction or nonextraction, appliances used, anchorage considerations, type of retention, supplemental therapy, and prognosis.

7. SPECIFIC OBJECTIVES OF TREATMENT FOR:
  • Maxilla
  • Mandible
  • Maxillary dentition
  • Mandibular dentition
  • Facial Esthetics
8. TREATMENT PROGRESS

include a description of the actual treatment, response to treatment, and any complications. Do not record what was done at each appointment from your treatment chart.

9. RESULTS ACHIEVED

refer to the objectives stated for the maxilla, mandible, maxillary dentition, etc., and confirm that the objectives were reached or explain why an objective was not realized.

10. RETENTION

describe appliances and supplementary procedures.

11.CRITICAL EVALUATION

include all pertinent observations and prognosis for stability. Describe posttreatment changes. State what you learned about your specific diagnosis and treatment.

THE RECORDS

The objective of making quality records for the purpose of establishing a sound diagnosis is very important. One set of pre-treatment records and one set of post-treatment records are required for each case report. The following records are required to be presented in the Candidate for the Case Report Examination

IDENTIFICATION OF RECORDS

Each item in the case report must be clearly marked with ALL of the following:

  • Candidate number,
  • Case report number,
  • Date of record,
  • Patient age
  • Stage of treatment identified by colored dot: (see example below)
  • BLACK dot (Pretreatment records),
  • BLUE dot (Interim or progress records if indicated), arid
  • RED dot (Posttreatment records).

Adhesive labels, not embossed tape, must be used to identify records.

PRETREATMENT RECORDS

  • Dental casts
  • Full mouth set of periapical radiographs or panoramic radiograph (If a panoramic radiograph is submitted, maxillary and mandibular incisor periapical radiographs and any other pertinent radiographs are recommended, but not mandatory.)
  • Lateral Cephalogram in all cases, frontal cephalogram in required cases
  • Cephalometric tracings
  • Facial color photographs
  • Intraoral color photographs
  • Summary of cephalometric measurements

INTERIM RECORDS

Interim Records are required only for two-stage malocclusion correction and for surgical cases.

  • Dental casts
  • Full mouth set of periapical radiographs or panoramic radiograph (If a panoramic radiograph is submitted, maxillary and mandibular incisor periapical radiographs and any other pertinent radiographs are recommended, but not mandatory.)
  • Lateral Cephalogram in all cases, frontal cephalogram in required cases
  • Cephalometric tracing and serial composite tracings
  • Facial color photographs
  • Intraoral color photographs
  • Summary of cephalometric measurements

POST-TREATMENT RECORDS

  • 1. Dental casts
  • 2. Full mouth set of periapical radiographs or panoramic radiograph (If a panoramic radiograph is submitted, maxillary and mandibular incisor periapical radiographs and any other pertinent radiographs are recommended, but not mandatory.)
  • 3. Lateral Cephalogram in all cases, frontal cephalogram in required cases
  • 4. Cephalometric tracing and serial composite tracings
  • 5. Facial color photographs
  • 6. Intraoral color photographs
  • 7. Summary of cephalometric measurements

Post treatment records must be made at the time of appliance removal or within one (1) year of that date. At the time the post treatment dental casts are made, the patient's malocclusion correction, including the successful management of second molars, must be completed. Radiographs' made within three (3) months before completion of treatment may be substituted for the final radiographs, provided all the treatment objectives are seen to be achieved on those radiographs

RECORDS DESIGNATION

  • Pretreatment Records are designated by BLACK.
  • Interim Records are designated by BLUE.
  • Post treatment Records are designated by RED.

DENTAL CASTS – Guide lines

Impressions should extend far enough into the sulcus to allow accurate reproduction of all soft tissue anatomy in the dental casts. The casts should be trimmed in maximum intercuspation or in the intercuspal position. Second molars should be fully erupted and in their final position at the time the posttreatment casts are made.

Trimming or carving on the anatomical portion of the dental casts should be limited to the removal of bubbles and defects. Alteration of tooth anatomy is considered records falsification. A lower lingual retainer, either bonded or banded, may be in place when post treatment casts are made. After the casts are prepared, they should be smoothed and polished in such a manner that tooth and soft tissue detail is not destroyed.

All models shall be made in good quality white orthodontic stone plaster only and suitably polished. Models made in color plaster or with plastic bases are unacceptable.

Gnathologically mounted models are acceptable in select cases, provided suitable mounting articulators are also provided by the candidate.

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PERIAPICAL OR PANORAMIC RADIOGRAPHS

Periapical and panoramic radiographs must be of diagnostic quality. The films must be oriented correctly with right and left sides clearly marked. Only the name of the doctor should be covered with tape. The patient's name and date should be visible. The radiographs should be placed in a transparent protective cover.

Digital radiography: If computer generated images are used they must have high resolution of color and clarity, and they must accurately represent both soft and hard tissues. The candidate is reminded that all records are legal documents and must not be altered.

CEPHALOGRAMS

Cephalograms must show as much anatomy as possible, especially in vital landmark areas. They should be properly standardized, oriented, and processed. The soft tissue profile must be visible. Only the name of the doctor should be covered with tape. The patient's name and date should be visible. The radiographs should be placed in a transparent protective cover.

Digital radiography: If computer generated images are used, they must have high resolution of color and clarity, and they must accurately represent both soft and hard tissues. The candidate is reminded that all records are legal documents and must not be altered.

CEPHALOMETRIC TRACINGS

  • Pretreatment tracings must be BLACK.
  • Post treatment tracings must be RED.
  • Interim tracings must be BLUE.

Cephalograms must be manually and accurately traced by the candidate using a small diameter tracing pencil or pen on an acetate sheet. Computer generated tracings are not acceptable. Templates may be used to trace the tooth outlines. Anatomical structures should be identified accurately in preparation for the marking of landmarks and the drawing of reference lines. All measurements must be recorded on the cephalometric summary sheet and on the tracing. The soft tissue outline of the facial profile is required for each tracing. Tracings should be enclosed in transparent plastic protectors, without backing, for superimposition by the examiners.

Candidates may use whatever landmarks, lines and measurements they wish, provided valid standards are available. The areas of study listed on the Cephalometric Summary sheet must be evident on the cephalometric tracing and their respective values must be recorded. The candidate must be thoroughly familiar with all aspects of the cephalometric radiographs, tracings, and measurements, including the meaning as applicable to each specific case.

COMPOSITE TRACINGS

A minimum of three (3) composite tracings are required:

  • Craniofacial,
  • Maxillary, and
  • Mandibular.

The three composites should be manually traced by the candidate with a small diameter pencil or pen.

The following procedure for composite tracings is required:

1. Craniofacial Composite - register on sella with the best fit on the anterior cranial base bony structures (Planum Sphenoidum, Cribriform Plate, Greater Wing of the Sphenoid) to assess overall growth and treatment changes. (Superimposed on Sella-Nasion line registered at Sella)

2. Maxillary Composite - register on the lingual curvature of the palate and the best fit on the maxillary bony structures to assess maxillary tooth movement.

3. Mandibular Composite - register on the internal cortical outline of the symphysis with the best fit On the mandibular canal to assess mandibular tooth movement and incremental growth of the mandible.

Candidates must use the same colors for the composite tracings that are used for the cephalometric tracings. Tracings must be enclosed in transparent plastic protectors.

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FACIAL PHOTOGRAPHS

The facial photograph requirement for each case report is one (1) profile photograph, one (1) frontal at rest photograph, and one (1) frontal smiling photograph. The Board prefers that photographs be taken with relaxed lips; however, views with lips lightly touching are also acceptable. Supplemental photographs may be included and are encouraged. Glamour photos are not necessary. They should be oriented to Frankfort Horizontal.

If computer generated images are used, they must have high resolution of color and clarity, and they must accurately represent both soft and hard tissues. The candidate is reminded that all records are legal documents and must not be altered.

FACIAL PHOTOGRAPH REQUIREMENTS:

1. Quality standardized facial photographic color prints of post card size, with the face positioned as a vertical frame.

2. Patient’s head oriented accurately in all three planes of space and on Frankfort Horizontal.

3. Two (2) or more anterior views – one (1) frontal at rest, and one (1) frontal smiling photograph

4. One (1) or more lateral views, facing to the right OR left.

5. White background free of distractions. (Color background is not accepted)

6. Quality lighting revealing facial contours.

7. Ears exposed for purpose of orientation.

8. Eyes open and looking straight ahead. Glasses removed.

INTRA ORAL PHOTOGRAPH REQUIREMENTS:

The minimum intraoral photographic requirement for each case report is: one (1) Frontal / anterior view, one (1) right lateral view, and one (1) left lateral view with the teeth in maximum intercuspation, one (1)each of mandibular and maxillary occlusal views in color. They should be oriented to the occlusal plane. If mirror images are used, print them in reverse and mount them as you are looking at the patient.(Eliminate the mirror effect) Slides are not permitted.

If computer generated images are used, they must have high resolution of color and clarity, and they must accurately represent both soft and hard tissues. The candidate is reminded that all records are legal documents and must not be altered.

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INTRAORAL PHOTOGRAPH REQUIREMENTS:

1. Quality standardized post card sized intra oral prints in color.

2. Patient’s occlusal plane parallel with the top and bottom of the color.

3. One (1) frontal view in maximum intercuspation.

4. Two (2) lateral views (right and left).

5. Two (2) occlusal views (maxillary and mandibular).

6. Free of distractions (i.e., labels and fingers).

7. Lighting should reveal anatomical contours with minimal shadows.

8. Use two (2) cheek retractors. (Preferably transparent cheek retractors)

9. Free of saliva and/or bubbles.

10. Clean dentition.

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