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Reason for Consultation: The patient presents for a consultation for combined ortho-surgical treatment.
Referring Professional: Dr.
Length of Orthodontic Treatment: 1 year
Habits: non-smoker, occasional alcohol, no illicit drug use.
Head and Neck: No cervical or facial swelling or masses
Intra-Oral: The oral mucosa is intact with no ulcers, masses, leukoplakia or erythroplakia.
Right Molar: II
Left Canine: II
Left Molar: II
Facial type: Mesocephalic
Maxillary cant: No
Mandibular angle symmetry: Symmetric
Orbital dystopia: No
Scleral show: No
Alar base width: Normal
Malar Projection: Adequate
Nasal tip: Normal
Nasolabial angle: Normal
Labiomental angle: Normal
Chin: Well proportioned
Mentalis Strain: No
Midlines(relative to midfacial)
Nose: 0 mm
UDML: 0 mm
LDML: 0 mm
Chin: 0 mm
Upper Incisor Show at Rest: mm
Upper Incisor Show on Smile: mm
Gingival Show on Smile: mm
Facial Thirds: equal
Opening path: No deviation or deflection
No clicking or crepitation
Based on clinical and radiographic history and examination, all maxillary and mandibular growth has been completed.
Maximal incisal opening MIO: >40 mm
Thyromental distance: Greater than 3 fingers
Neck range of motion: Within normal limits
Mallampati: Class II
Forrest Gump is an ASA I patient, with a Class II skeletal and dental malocclusion. The deformity is secondary to . Given the nature of the deformity, they would benefit from combined ortho-surgical treatment.
I have discussed with the patient the basic nature of combined orthodontic-surgical intervention for the correction of dentofacial deformities. Dolphin Aquarium software was utilized to demonstrate the orthognathic surgical techniques. I have discussed the perioperative course, recovery period and risks associated with surgery including but not exclusively neurosensory changes, infection, hardware removal, need for revision surgery, and relapse.
Thank you for allowing us to participate in the care of your patient. I would be happy to discuss the case further should you have any questions or concerns.