case presentation

CASE PRESENTATION

RHEA THOMASPG STUDENT

SAVEETHA UNIVERSITY.

CHIEF COMPLAINT A 23 year old male patient by name

KUMAR reported to the department with a chief complaint of crowding in the lower anteriors

History• PRENATAL HISTORY: NRH

• POSTNATAL HISTORY: NRH

• CHILDHOOD DISEASES: NRH

• HABITS: NIL

• ANY INJURIES SUFFERED: NIL

• FAMILIAL MALOCCLUSION : NIL

General History• Reasons for orthodontic treatment : Esthetics .

• Attitude : positive.

Clinical ExaminationPHYSICAL STATUS:

Build : ModerateBody type : Mesomorphic

EXTRA ORAL EXAMINATION:

• Shape of head : mesocephalic • Facial form : mesoprosopic • Interlabial gap : nil

EXTRA ORAL EXAMINATION:

• Mild Convex profile• Mild posterior

divergence• Normal Nasolabial angle• average FMA • Chin: not prominent• competent lips

Functional examination

• Incisor Exposure – at rest : not vissible

– during smile : 4mm

Functional examination• Respiration : Nasal • path of closure : NAD• TMJ : NAD• Mastication and speech : NAD• Deglutition :NAD• Perioral muscle activity: Normal

Intra oral examination

• Oral Hygiene : Fair• Gingiva : normal• Frenal Attachment : Normal• Tongue ( size , shape and movements ) :

Normal• Oral Mucosa : Normal• Palatal Contour : high vault

Hard tissue examination

87654321 12345678 87654321 12345678 present .

Maximum mouth opening ; 45mmFreeway space ; 4mmCurve of spee ; 3mmMidline : lower midline shift

Inter Arch Relationship

Maxillary arch

• V shaped • asymmetrical • Crowding in relation to

upper anteriors

Mandibular arch

• u shaped• Asymmetrical• Crowding in relation

to lower anteriors

Vertical relation ship• Overbite; 5mm

• Overjet; 8 mm

horizontal relation ship

Antero posterior relationship

• Molar relation:

right side - Class 1

left side – Class 1

• Canine relation:

right side – Class 2

left side – Class 2

Model photographs

Model analysis

Carey’s Analysis Tooth material excess by 5mm in lower arch,

indicates need for extraction of 1st premolars.

Arch perimeter analysis Tooth material excess by 9 mm in upper arch,

indicates need for extraction of 1st premolars .

Model analysis

Ashley howe’s analysis PMBAW % - 50% indicates non extraction

Pont’s analysis measured pre molar and molar values less than calculated pre

molar and molar values, indicate need for extraction

Bolton’s analysis 0verall ratio of 91.66% and anterior ratio of 83.33%

• Indicating over all mandibular tooth material excess by 9.6mm and anterior mandibular excess by 3.9mm

LATERALCEPH

OPG

CEPHALOMETRIC EVALUATION

Measurements Mean Actual

SKELETAL

SNASNBGo-Gn to SNANBSNDSLSE

820 800 320 20 760 51 mm22 mm

84822720 800 58 mm18 mm

Orthognathic Maxilla orthognathic mandibleHorizontal growth patternClass I skeletal pattern

Steiner’s Analysis

FH – SN =

DENTAL

1 to NA (mm)

1 to NA __ 1 to NB (mm)__ 1 to NB __1 to 1

Occl to SN

PP to SN

4 mm

220

4 mm

250

1310

140

80

14 mm

480

6mm

300

1050

160

100

Severely proclined upper incisors

Severely proclined lower incisors

Reduced interincisal angle

Wits Analysis :

AO is coincident with BO indicating a SK CL.I

Mc Namara’s AnalysisMeasurements Mean ActualN perpendicular to Point AN perpendicular to PogonionFacial AxisMandibular Plane angle Eff. Max lengthEff. Mand lengthMaxillomandibular differentialLower Anterior Face Height

0 + 2 mm0 to – 4 mm

900

26 + 482 - 83 mm

58 - 59 mm

+2mm+1mm

960

250

89mm110 mm21mm65 mm

Orthognathic maxilla

Orthognathic mandible

average growth pattern

Mildly Increased lower ant height

Measurements Mean Actual1 to point AL1 to A Po line Nasolabial Angle

4 mm1 – 2 mm90 - 1100

7 mm5mm1040

Proclined upper and lower incisors

Acute nasolabial angle

Measurements Mean ActualSaddle angle Articular Angle Gonial AngleU/ Gonial AngleL/ Gonial Angle Sum of Posterior Angle

123 + 50

143 + 60

128 + 70

52 – 550

72 -750

396+ 60

1020

1400

1210

520

690

3630 Horizontal growth pattern

Rakosi Jarabak’s Analysis

Schwartz Analysis

Measurements Mean Actual

Extent of Anterior Cranial Base

Extent of Ascending Ramus

Extent of Maxillary length Extent of Mandibular base

52 mm 48.5mm

67mm

66mm

47 mm

53 mm

72mm

Mildly reduced ascending ramus height

C Axis

S – Mpt : 440 [ 42-440 ]

67mm [age + 48.51]

G Axis

S – G pt : 690 (66-670+_ 4)

BETA angle : 25 degrees [27 -35]

indicating

Holdaway’s Soft Tissue Analysis

Measurements Mean Actual

Upper Lip CurvatureH line angle Nose tip to H line Upper Sulcus DepthUpper lip thicknessUpper lip strainLower lip to H lineSoft tissue chin thicknessLower sulcus depth

907 – 15 0 mm5 mm15 mm2 mm0 mm10 – 12 mm5mm

85mm 23mm -7mm10mm15 mm5 mm5 mm10 mm4mm

\

Imbalance in between lips.

A case of skeletal class I with orthognathic maxilla,orthognathic mandible with horizontal growth pattern and mildly increased lower anterior facial height with proclined upper and lower incisors, acute nasolabial angle .

SYNTHESIS OF CEPHALOMETRIC EVALUATION

Antero posteriorSKELETAL

Skeletal CL.I

ANB: 2(2) SteinersConvexity of pt A; +3 mm rickettsAO coincident BO WIT”S Appraisal

SNA :84(82) N- Pt A: 2mmEff max length : 89 mm(82-83mm)

Convexity at Pt A : +3 mm

Antero posterior

ORTHOGNATHIC MAXILLA

Steiner’s

Mc Namara

Ricketts

SKELETAL

ORTHOOGNATHIC MANDIBLE

SNB : 82 ( 80 )N Pog; 1mm (0-4mm)Effective mandibular length-110mm(115-118mm)

Steiner’sMc Namara

Horizontal Relation Horizontal growth pattern

FMA : 21(25 )Lower Gonial angle: 69( 72 – 75)Jaraba2k ratio :%Basal plane angle :(25)

Dental AXIAL Inclination

upper incisor proclined

1 to NA (mm) : 14 mm (4 mm) 1 to NA : 48 ( 22) 1 to SN : 115( 102 + 2) 1 to Palatal plane : 60 (70 + 5)

Dental AXIAL Inclination

lower incisor proclined L 1 to NB - 6mm L 1 to NB - 80 L 1 to APog - mm L 1 to APog -

Space analysisSpace required; maxilla mandible

Correction of crowding 0mm 0mm

Levelling curve of spee 0mm 0mm

Correction of proclination 22mm 15mm

Correction of molar relation 0mm 0mm

correction of rotation Ant 0mm 2mm

Total space required 22mm 17mm

Space available;Space present between teeth 7mm 2mm

Space obtained from proclination 0mm 0mm

Space obtained by derotation 1mm 0mm

Total space available 8mm 2mm

Discrepancy 14mm 15mm

A case of skeletal class I attributable to anteinclined orthognathic maxilla and orthognathic mandible with mildly increased lower anterior facial height with vertical growth pattern with Angles class I malocclusion with increased overjet, with proclined anteriors with spacing in anteriors and convex profile, acute nasolabial angle and incompetent lips .

Diagnosis

Problem ListSkeletal; horizontal growth pattern. mildly increased lower ant face height.

dental; mildly proclined upper and severly proclined lower anteriors spacing in upper and lower anteriors

Soft tissue; convex profile imbalance in between lips acute nasolabial angle

TREATMENT OBJECTIVES

• maintain class I molar and canine relation on both sides

• Correction of proclination in upper and lower anteriors

• Space closure in upper an lower anteriors

• Improving facial balance and lip competency.

FACTORS TAKEN IN TO CONSIDERATION

• Skeletal class I• orthognathic maxilla• orthognathic mandible• Vertical growth pattern• Mildly Increased lower anterior facial height• Class I Molar and canine relation• Increased overjet • Normal upper and lower dental heights• Acute nasolabial angle• Incompetent lips• Convex profile

TREATMENT PLAN

camouflage method;- Extraction of 14,24,34 and 44.- Strap up with PEA .022 M.B.T. prescription.- To use transpalatal arch and second molar banding to aid in

anchorage- To give nance palatal button before starting with retraction for

aiding in retraction- To start levelling and aligning with 016 NiTi and to step up till

019x025 s.s.- To use friction mechanics for retraction- Anchorage; maxilla-maximum. mandible-maximum-Retention plan- upper- hawleys retainer. lower- lower lingual bonded retainer.