Orthodontic records: what a complete set contains
Key points
- Orthodontic records are the information collected about a patient at one point in time: history and examination notes, photographs, study models and, when justified, radiographs.
- Each type of record shows something the others do not. A later set, laid next to an earlier one, shows what has changed.
- Radiographs are part of the records only when they are justified for the individual patient.
- Every item carries the patient, the date and the stage, and is taken the same way each time, so that sets from different times can be compared.
- In the Studio, Simplified Practice holds the patient file and its record sets. Cast, Ceph, CBCT and Face open the models, cephalograms, scans and facial photographs.
What orthodontic records are
Proffit and colleagues describe records as part of the diagnostic process in orthodontics, and group them into a few general types: the history and clinical examination, photographs, study models and radiographs [1]. A complete set gathers these for one patient at one point in time.
Records do two jobs. They document the patient as they were on the day the set was taken. And they make comparison possible: a set taken later is laid next to the first, and the differences can be seen and measured. Both jobs depend on records that are complete, clear and labelled.
This article describes what each type of record contains and how sets are kept. It does not say which records a particular patient needs, or how records are used to decide on treatment.
History and clinical examination notes
The written part of the record comes first. It usually holds:
- the patient’s details, and the reason they came, in their own words;
- the medical and dental history, including medicines and allergies;
- the findings of the examination: the face from the front and in profile, the teeth, gums and arches and how they meet, and the movement of the jaws;
- the date, and who took the history and examined the patient.
Notes are most useful when they follow the same order every time. A finding that was never written down cannot be compared later, and a note written in a different order each time is hard to compare with the last.
In the Studio, the patient file in Simplified Practice holds “Details, medical alerts, treatment stage, tags and a timeline from the start of treatment to the next appointment.” Its Diagnosis and plan tab is described as “A tab for your own notes”, including examination findings, “written by you”. Practice stores what you write; in the words of its landing page, “It does not make clinical decisions.”
Photographs
Sandler and Murray describe photographs as an essential part of the clinical record in orthodontics [2]. A standard set has two groups:
- Extraoral views: the face from the front at rest, from the front smiling, in profile and from three-quarter.
- Intraoral views: the teeth from the front, the right and left buccal segments, the upper and lower occlusal surfaces, and a view of the overjet.
Taken the same way at each visit, photographs show changes that are hard to put into words. The views, the equipment and the common errors are covered in Clinical photography in orthodontics.
In the Studio, Simplified Practice keeps photographs in record sets “with frames for extraoral and intraoral photos”. Simplified Face measures frontal, smile and profile photographs: you calibrate the photo, place the landmarks, and read each value next to its published reference value.
Study models
Study models record the teeth and arches in three dimensions. They can be:
- Plaster models, cast from impressions of the upper and lower arches, kept with a record of how the teeth meet.
- Digital models: 3D files made with an intraoral scanner, or by scanning plaster models, often saved as STL, PLY or OBJ files.
A model can be measured long after the patient has left the chair: tooth widths, arch widths, and the space in each arch. Plaster models take room to store and can break. Digital models need a file format that will still open years later, and a backup.
In the Studio, Simplified Cast opens “3D scans of the upper and lower study models” as STL, PLY or OBJ files; you mark the teeth and landmarks, and it works out the space and tooth-size analyses. For plaster models there is no scan to open, but you can “type caliper widths instead”. On the Plus and Pro plans, Simplified Practice keeps STL scans: “Upper and lower arch scans in the patient file, with a 3D view.”
Radiographs
Radiographs are part of the records when they are justified for the individual patient, and guidelines ask for each exposure to be justified [3], [4]. This article does not say which radiographs a patient should have, or when.
When radiographs are part of a set, they are kept with the rest of it and labelled the same way: the patient, the date and the type of image. A radiograph that cannot be matched to its date and its set is of little use for comparison.
In the Studio:
- Simplified Ceph traces a lateral cephalogram opened as an image (JPG, PNG, BMP or WebP); a DICOM file is exported as an image first.
- Simplified CBCT opens a CBCT scan exported as DICOM. Its landing page says the scan “is opened and viewed in your browser, and it is not uploaded”. See How to read a dental CBCT scan.
- Simplified Practice keeps “a lateral cephalogram, a panoramic radiograph and documents” in each record set.
Labelling, dating and storing records
Records are compared across time, often over years. That works only if each item can be traced, and each set was taken the same way. In practice:
- Label every item with the patient’s name or file number, the date it was taken, and the stage it belongs to: the first set, a progress set, or the final set.
- Keep each set together. A photograph from one date next to a model from another can mislead.
- Take the same records the same way each time: the same photographic views, the same way of making models, the same image settings where they apply.
- Keep the originals. Edits for a report or a talk are made on copies, so the original record stays as it was taken.
- Back up digital records, and check from time to time that old files still open.
In the Studio, Simplified Practice keeps record sets and says: “Add a new set at each stage.” Its backup saves “everything as one file, with or without images”, to restore or merge on another computer. Where the records are kept, in the words of the Practice landing page: “In this browser on this device. If you sign in, a copy is also kept in your private Studio cloud, so your records open on your other devices. When you are signed in, a short list of the next 14 days of appointments is also sent to our server for reminders. If you use patient messages, they are kept on the Studio server.” The privacy policy adds: “Without an account, everything you enter stays on your device and nothing clinical reaches us.”
The record types and the Studio tools
| Record | What it records | In the Studio |
|---|---|---|
| History and examination notes | The patient’s history and the examination findings, in writing | Practice: the patient file and your own notes |
| Extraoral photographs | The face from the front at rest and smiling, in profile and from three-quarter | Practice: record sets. Face: measures frontal, smile and profile photos |
| Intraoral photographs | The teeth and arches from the front, the sides and above | Practice: record sets |
| Study models | The teeth and arches in three dimensions | Cast: STL, PLY or OBJ models, or typed caliper widths. Practice (Plus and Pro): arch scans |
| Radiographs, when justified | Structures that cannot be seen on the face or in the mouth | Ceph: lateral cephalograms. CBCT: CBCT scans. Practice: cephalogram and panoramic frames |
Consent
Consent and record-keeping rules depend on the country and the clinic, and this article does not cover legal requirements. Using a patient’s photographs outside their record, for teaching, publication or marketing, needs the patient’s written consent.
Limits
- A general description. Record sets differ between clinics and countries. The list here is the usual set of record types, not a standard.
- Not a list of requirements. This article does not say which records any patient needs at any stage, or how records are used to decide on treatment.
- Tools record and measure. The Studio stores and measures what you enter or open. It does not decide which records to take.
Keep records in Simplified Practice
Simplified Practice keeps your patient files in one place: every visit with the wire and procedures for each arch, photos, X-rays and scans. Record sets have frames for extraoral and intraoral photos, a lateral cephalogram, a panoramic radiograph and documents, and you add a new set at each stage. The Free plan holds up to 10 patient files, with the treatment card, photos and X-rays, and backups. Plus has no patient limit and adds the schedule, follow-up lists, fees, printing and STL scans.
Educational content for clinicians and students. This page describes the types of orthodontic record and how they are kept. It does not say which records a patient needs, does not cover treatment or legal requirements, and does not replace clinical judgement.
References
- Proffit WR, Fields HW, Larson BE, Sarver DM. Contemporary Orthodontics. 6th ed. Philadelphia: Elsevier; 2019. ISBN 978-0-323-54387-3.
- Sandler J, Murray A. Clinical photography in orthodontics. J Clin Orthod. 1997;31(11):729-739.
- American Academy of Oral and Maxillofacial Radiology. Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(2):238-257.
- Kapila SD, Nervina JM. CBCT in orthodontics: assessment of treatment outcomes and indications for its use. Dentomaxillofac Radiol. 2015;44(1):20140282. doi: 10.1259/dmfr.20140282. PMID: 25358833