OMFS Orthognathic Consult
CC: referred for jaw surgery consultation
HPI: *** is a *** year old *** who presents to our clinic to review treatment planning to address a skeletal malocclusion that exists from a dentofacial deformity. The patient has been referred by Dr. *** who feels as though the skeletal discrepancy may benefit from a combined orthodontic and surgical treatment approach. The patient states that chewing is extremely difficult for them because of the deformity. They note jaw fatigue and sore muscles from the large amount of chewing that they need to do. When eating tougher foods, the jaw will get so sore that they attempt to swallow larger bites than normal, which leads to difficulty swallowing. This only occurs as a result of jaw fatigue after a long meal. Furthermore, they notice a difficulty in pronouncing certain words because of the position of their tongue relative to their teeth, which is due to the jaw discrepancy. Furthermore, ***.
PMH: denies
PSH: denies
Meds: denies
Allergies: NKDA
SH: denies tobacco, EtOH, RDU; here with family today: ***; any extra-curricular activities or hobbies that will affect jaw surgery: ***
Skeletal Maturity: very little growth has been noted recently and serial cephalometric analysis has been stable
ROS: denies chest pain, shortness of breath, coughing, wheezing, palpitations; reports good exercise tolerance
Exam:
Gen: NAD, AAOx3
Head: NC AT
Eyes: sclera white, EOMI b
Ears: EAC clear bilaterally
Nose: see below
Throat: uvula midline, normal oropharyngeal tone and structure
Face, Jaws and Mouth:
Mandibular AP Position: ***
Maxillary AP Position: ***
Transverse position: ***
Vertical position: ***
Labiomental fold: ***
Nasolabial angle: ***
Cervicomental angle: ***
Mentalis: ***
Maxillary midline relative to facial midline: *** mm
Mandibular midline relative to maxillary midline: *** mm
Chin position relative to mandibular midline: *** mm
Maxillary cant: *** mm
Incisal display at rest: *** mm
Incisal display with animation: *** mm
overjet: *** mm
overbite or open bite: ***
Canine class: class ***
Molar class: class ***
Crowding: ***
MIO: ***mm
Protrusion: ***mm
Left lateral: ***mm
Right lateral: ***mm
Pain in muscles of mastication: ***
Preauricular tenderness: ***
Joint click or pop: ***
Joint crepitus: ***
CR-CO discrepancy: ***
Nasal Exam:
no nasal deviation
nasal tip deviation to ***
C-shape nasal deformity
S-shape nasal deformity
Imaging:
Panorex:
Mandibular condyles: ***
Wisdom teeth: ***
Periodontal disease: ***
Caries: ***
Missing teeth: ***
Lateral Ceph:
skeletal deformities as noted above
mandibular plane angle: ***
skeletal diagnosis: ***
vertebral body skeletal maturity: CVM 5-6***
PA Ceph:
Mandibular deviation: ***
Canting: ***
CBCT:
multidimensional nature of the deformity (AP, vertical, and transverse) appreciated
Airway analysis: ***
Assessment: *** is a *** year old *** with the following diagnoses related to the dentofacial deformity.
Maxillary hypoplasia M26.02
Maxillary transverse deficiency M26.09
Maxillary posterior vertical excess M26.01
Maxillary vertical excess M26.01
Maxillary asymmetry M26.11
Maxillary occlusal plane canted M26.11
Apertognathia
Mandibular hypoplasia M26.04
Mandibular hyperplasia M26.03
Mandibular asymmetry M26.12
Hemimandibular hyperplasia M26.12
Congenital facial asymmetry Q67.0
Microgenia M26.05
Macrogenia M26.06
Malocclusion M26.4
Class II malocclusion M26.212
Class II deepbite malocclusion M26.212
Class II openbite malocclusion M26.212
Class II asymmetric malocclusion M26.212
Compensated Class II malocclusion M26.216
Class III malocclusion M26.213
Class III deepbite malocclusion M26.213
Class III openbite malocclusion M26.213
Class III asymmetric malocclusion M26.213
Compensated Class III malocclusion M26.213
Anterior openbite malocclusion M26.220
Posterior openbite malocclusion M26.221
Deepbite malocclusion M26.23
Abnormal jaw closure M26.51
Crowding M26.31
Excessive spacing of teeth M26.32
Anomalies of tooth positioning M26.39
Masticatory dysfunction R13.11
Anterior soft tissue impingement M26.81
Posterior soft tissue impingement (cheek biting) M26.82
Dysphagia / difficulty swallowing R13.10
Speech and articulation concerns
Obstructive sleep apnea (OSA) G47.33
Cleft lip Z87.790
Cleft palate Z87.790
Cleft lip and palate Z87.790
Osteoarthritis / degenerative joint disease M19.91
TMJ sounds on opening / closing jaw M26.69
Internal derangement of temporomandibular joint M26.633
TMJ articular disc disorder / dislocation M26.633
Arthralgia (joint pain) M26.623
Temporomandibular joint adhesions / ankylosis M26.613
Rheumatoid arthritis M06.9
Temporomandibular joint capsulitis M77.8
Myalgia (muscle pain) M79.1
Muscle dystonia M62.838
Muscle spasm M62.838
Temporalis tendinitis M77.8
Bruxism F45.8
Headache / facial pain G44.209
Deviated nasal septum J34.2
Hypertrophy of nasal turbinates J34.3
Nasal deformity M95
Impacted wisdom teeth (complete bony)
Impacted wisdom teeth (partial bony)
Impacted wisdom teeth (soft tissue)
Nonfunctional wisdom teeth
Plan:
extractions required:
type of surgery:
estimated timing:
phase of care:
will communicate with orthodontist:
insurance plan: