History

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The history is obtained by interviewing the patient and is, therefore, the subjective component of the evaluation. It has multiple parts, including:

  • Chief complaint(s)
  • History of the present illness
  • Past medical history
  • Review of systems

The chief complaint describes the patient’s symptoms or problems. It should not be a statement of treatment (e.g., “I need surgery”). Examples of suitable chief complaints are: “I have difficulty chewing,” “my bite is off,” and/or “my face is crooked.”

The history of the present illness should comprehend the following:

  • When did the deformity first become apparent and how did it evolve?
  • Does the patient have chewing problems? In trying to ascertain this, one should be specific when questioning patients. Many tend to answer “no” to the general question: Do you have chewing problems?  Yet they may answer in the positive when asked a more explicit question like:  Can you cut food with your front teeth (i.e., incising)?
  • Does the patient have breathing problems (e.g., mouth-breathing, snoring, or witnessed apnea)?
  • Does the patient have speech problems?
  • Does the patient have social or emotional problems related to the deformity?
  • Does the patient have other comorbid conditions? One should ask about TMJ symptoms (e.g., joint pain, joint noises, limited or abnormal motion), soft-tissue impingements, and/or other diseases that may affect the jaws. 

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