1. TREATMENT PLANNING
M IDLINE
Treat to:
Upper Midline Lower Midline Facial Midline/Special Inst:________________
_________________________
Achieve Midline by:
Global Simulation Dental Movements Combination
__Class II Left __Space Management/Closure
__Class II Right __Asymmetrical IPR (max amount if any)
__Class III Left __Severe Angulation Correction
__Class III Right __Cant Correction w/Severe Angulation
__Translation for Functional Shift __Correction of Major Arch Asymmetry
A RCHFORM
Reference Arch:
Upper Arch Lower Arch Independent Arch
Archform Type: Natural Other ______________________
Archform Coordination:
Expansion Constriction Maintain 6’s
__Upper __Upper
__Lower __Lower Specify (max) amount of expansion/constriction
__Left Side __Left Side if >1mm to achieve proper overjet and eliminate
__Right Side __Right Side crossbite _____________
Specify Archform Reference Teeth:
Anterior Protraction __Upper __Lower Maintain Anterior A/P
Anterior Retraction __Upper __Lower __Specify (max) distance amount _____________
C LASS
Molar Class: Canine Class:
Class I Class II Class III Class I Class II Class III
Achieve Class by:
Global Simulation Dental Movements Combination
__IPR (maximum amount)
__Allowed to distalize/mesialize
__Make angulation and/or rotational changes

2. R EFERENCE TEETH
Specify Axial (Angulation) Reference Teeth
O CCLUSAL PLANE
Treat to:
Upper Occlusal Plane Lower Occlusal Plane Independent Occlusal Planes
Curve of Spee: Cant Correction: Yes No
Level Maintain Upper Anterior
Lower Posterior
Left Right Both
Specify Occlusal Plane (Vertical) Reference Teeth (EOP/POP/FOP):
Leveling Occlusal Plane:
Specify Intrusion/Extrusion for Cant: OVERJET:
Intrusion Extrusion
Anterior Incisal Contact:
__Upper __Upper
Yes No (Gap)/Estimated value
__Left Side __Left Side
_________ mm
__Right Side __Right Side
_____
OVERBITE:
__Lower __Lower
__Left Side __Left Side
__Right Side __Right Side <1mm 1 – 2 mm >2 mm
S PECIAL INSTRUCTIONS
Surgical: Prosthetics: Fixed Teeth:
Maxilla Kind _____________________
Mandible Limited Alignment:
Type ___________________ Explain ____________________________________________
Space Management – Upper Arch: Space Management – Lower Arch:
__Mesial __Distal __Reciprocal __Mesial __Distal __Reciprocal
Special Instructions: Special Instructions:
____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________