D O N E B Y : D R . J A M A L B I N H A F I Z

S U P E R V I S E D B Y : D R . A H M A D A L T A R A W N E H

D R . J U M A N A T B A I S H A T

D R . B A S H A R A L M O M A N I

D R . A N W A R A L R A H A M N E H

Orthodontic Case Presentation

Patient Information

Name: R.K

Age: 14yrs

Occupation: Student

Marital status: Single

Residence: Amman

Nationality: Jordanian

Medical and Dental History

Medical History: Denied any medical problems

Dental History: Trauma 4 years ago on Upper Central and lateral incisors with incisal filling on the Left central and lateral incisors.

Habits: No Habits

Chief Complaint

“ طالعة فوق بعض وأسناني العلوية

.لبرا ”

“ My upper teeth are overlapped and protruded.”

Extra Oral Photos

Skeletal Assessment

Anteroposterior:

Class II Skeletal Pattern

Skeletal Assessment

Vertical Assessment:

Average lower facial height

Skeletal Assessment

Transverse: P-A X-ray Symmetrical face

TMJ

Signs of TMD (No clicking, crepitus, but find tenderness and pain to palpation).

Normal mouth opening.

Displacement. *

No Limitation in lateral movement.

Soft Tissue Assessment

Convex facial profile

Soft Tissue Assessment

Transverse: composite photographs Facial Asymmetry

Soft Tissue Assessment

Lip tonicity and competence:

•Thick upper and lower lips•Incompetent lips

Frontonasal angle: 135⁰

(Normal 115⁰-135⁰)

Nasolabial angle: 85⁰

(Normal 90⁰-110⁰)

Labiomental angle: 95⁰

(Normal 114⁰-140)

Smile Aesthetics Assessment

Mini- estathetic• 80% crown show when smiling

• No gingival show of the upper gingiva.• Smile extends to mesial surface of first premolar on the right side, and to distal surface of canine on left side.

Smile Analysis

• Buccal corridors: narrow

• The smile arc: Incisal edges of upper anterior teeth are not parallel to the upper border of the lower lip

• Flat smile arc.• Less attractive smile.

Tooth Proportions

Micro – esthetic:Golden proportion for maxillary

anterior teeth is 55%

Height:width1:9 90%

Gingival Height, Connectors

Gingival level: Low gingival level of canines.

Normal connectors

Intra Oral Examination

Intra Oral Examination

• Fair oral hygiene with mild gingivitis and dental plaque. •Composite filling on upper left 1,2 and upper Rt. 4•White spot lesion on upper Rt. 5.• Thin attached gingiva in lower ant. segment.• Teeth Present in oral cavity (permanent dentition)

7 6 5 4 3 2 1 1 2 3 4 5 6 7

7 6 5 4 3 2 1 1 2 3 4 5 6 7

Lower Arch

U-shaped lower arch

Anterior segment:

Will alignment anterior segment

Labially inclined

Buccal segment:

Lingually inclined lower left 4,5

Rotated lower right 5

Upper Arch

U-shaped arch.

Anterior segment:

Rotated upper incisors with mild crowding .

Upper left canine palatallytilted.

Normal Buccal segment

Anterior Segment Relationship

Class II div. I incisor relationship

Midlines discrepancy; lower shifted 3mm to Rt. Andupper shifted 1mm to Lt.

• Overjet = 6.5 mm

Overbite = 40% Complete on teeth

Buccal Segment Relationship

Molar relationship: R: Class II L: Class I

Canine relationship: R: Class II L: Class I

Scissor bite in Lt.4&5

Functional Asymmetry (dental displacement)

C.R

C.O

Study Model Analysis

Study Model Analysis

Anteroposterior:

Canine: Class IIMolar: Class II

Canine : Class IMolar: Class I

Study Model Analysis

Transverse

Midlines discrepancy.

Study Model Analysis

Vertical

O.B= 40% deep bite complete on the teeth.

Study Model Analysis

Right side: 1 mm Left side: 3mm

Curve of Spee:

Study Model Analysis

Study Model Analysis

Lower arch

U shaped arch form

Slight Dental Asymmetry

Intermolar width: 42mm

(Noraml 41.1 mm)

Intercanine width: 25 mm

(Normal 24.4mm )

Study Model Analysis

upper arch

U shaped arch form

Slight Dental Asymmetry

Intermolar width 44mm

(normal 44.3)

Intercanine width 32 mm

(Normal 31.3)

Space Analysis

1177889.59.57877.511U

654321123456

1077.5765.55.5677.5710L

Upper Arch:

Space available 75 mm

Space required 78.5 mm

-3.5 mm (mild crowding)

Lower Arch:

Space available 67 mm

Space required 66 mm

1 mm (spacing)

Bolton Analysis

1177889.59.57877.511U

654321123456

1077.5765.55.5677.5710L

Anterior Bolton ratio= 37/50= 74%

(normal value: 77.2± 1.65%)

Overall Bolton ratio= 86/100.5= 85.5%(normal value: 91.3± 1.91%)

Royal London Analysis

Upper ArchLower Arch

-3.5 mm+1 mmCrowding/Spacing

00Angulation change

0-1Leveling curve of Spee

0-2Inclination change

-80Incisors A/P change

00Arch Width

-11.52-Total

Visualized Treatment Objectives

Midline-Molar relationship

R LMolarCl II

MolarCl I

Midline

Visualized Treatment Objectives

Lower arch discrepancy

0

0

0

0

-1 -1

0 -1

-3 +3

-4

-4

+1

+1

Crowding 3*3

6*6

Protrusion

Curve of SpeeMidline

Total 3*3

6*6

R L

Visualized Treatment Objectives

Anticipated treatment change

Midline MolarMolar CuspidCuspid

Pre-Treatment IOTNDental Health Component

Grade 4 a

Increased Over jet greater

than 6 mm and less than 9 mm

Pre-Treatment IOTNAesthetic Component

Grade 2

Radiography Analysis

Variable Pre-

Treatment

Normal value

SNA 85º 81 ± 3

SNB 79º 78 ± 3

ANB 6º 3 ± 2

S-N/MX 4º 8 ± 3

ANB* - -

MMPA 24º 27 ± 3

FMA 21˚ 28 ± 3

LFH 56% 55 ± 2

Jarabak ratio 64% 61± 2

U1/Mx 116 109 ± 6

L1/Mn 106º 93 ± 6

IIA 110º 133 ± 10

Wits

Appraisal

+4 mm 1 ±1.9 F

Panoramic Radiograph

All teeth are present including all 8’sRight side ramus length = 69.1Left side ramus length =69.3

Diagnostic Summary

R.K is a 14 year old female, denied any relevant medical problem and multiple dental fillings with fair oral hygiene, complains of “My upper teeth are protruding and overlapping”.

She has a class II/I incisor relationship based on class II skeletal pattern, average lower facial height, incompetent lips, and a mildly convex facial profile, acute labiomental and nasolabial angles with slight facial asymmetry.

Cant of maxilla ,O.J of 6.5 mm, O.B average complete to the teeth, mild crowded upper arch. Upper midline shift to the left 1 mm and lower midline shift to the right 3 mm. Scissor bite on the lower left 4,5. Molar relationship is class I on the left side and class II on the right side, canine relationships is class I on the left side and class II on the right side.

Complicated by lower dental displacement to the right, Proclined lower labial segment, Rotated upper left 1,2 and right 2, lower right 5. Lingualy tilted lower left 4,5, Deep curve of spee in the lower Lt. side, and anterior Bolton discrepancy .

Problem List…

Pathological:

Gingivitis and plaque deposition, white spot lesion on upper Rt. 5

C/C “Protruding and overlapping my upper teeth”

Skeletal:

Class II skeletal pattern

Soft tissue:

Slight facial asymmetry

Incompetent lips

Convex facial profile

Acute labiomental and nasolabial angles

Problem List

Dental:

Cant of maxilla

Class II div. I incisor relationshipOverjet 6.5 mm.Scissor bite on the lower left side 4,5,.Displacement of lower arch.

Upper midline shift to the left 1 mm and lower midline shift to the right 3mm

Lower incisor proclinedLingually tilted lower left 4,5

Rotated upper left 1,2, right 2 and lower right 5Class II full unit molar and canine on the Rt.side.

Mild upper arch crowdingDeep curve of spee on the lower left side of arch.Anterior bolton discrepancy

Treatment Aims

Improve oral hygiene.

Address c/c of the patient’s

Skeletal:

Accept mild class II SK pattern

Correct maxilla cant.

Soft tissue:

Accept Slight facial soft tissue asymmetry

Achieve competent lips

Accept convex profile

Correct labiomental and nasolabialangles

Dental:

correct dentoalveoular Cant of maxilla

Achieve class I incisor relation.

Correct Over jet.

Correct scissor bite and displacement .

Correct rotated teeth.

Correct mild crowding in upper.

Correct upper and lower midline shift.

Correct inclination of lower anterior segment.

Achieve class I canine in the Rt. Side and

maintain class I in the Lt. side.

Achieve class II molar in left side and

minatine class II in the Rt. Side.

Level curve of spee.

Correct Bolton discrepancy.

Maintain the correct result.

Treatment Plan

(GROWTH MODIFICATION)

(Hybrid Appliance)

1. OHI.

2. Modified Twin block appliance(Hybrid Appliance).

3. Upper and lower fixed app.

4. Re-evaluation for Extraction pattern.

5. Retention:

Long term: Upper and lower fixed retainer from 3-3 &(SCF )

Short term: Upper and Lower H.R

Justification (Extraction)

DENTAL:

CRITERIA VALUE NORMAL V. PRO/CON

Tooth size- arch length Upper : -3.5 mm Lower: +1

8-11 mm crowding CON. Ext

Curve of Spee L:3mm,R:1mm More than 6 severe CON. Ext

Bolton discrepancy 85% If 4* more then extract CON. Ext

Peck & Peck L1:80%L2: 75%

L1:88-92 (if less extract)L2: 90-95 (if less extract)

PRO. Ext

PRO. Ext

Irregularity index 0 mm X>6.5 mm extract CON. Ext

Incisor-Man. Plane angle 105˚ 85˚-95˚ PRO. Ext

Frankfurt-Man. Incisal angle 55 60˚-75˚ PRO. Ext

Upper incisor to NA 6mm, 27.5˚ 4mm anterior, (22-25) PRO. Ext

Lower incisor to NB 7 mm, 37˚ 4 mm anterior ( 22-25) PRO. Ext

Lower incisor to A-pog 4 1-3 mm anterior to it PRO. Ext

Justification (Extraction)

SKELETAL

CRITERIA VALUE NORMAL VALUE PRO/CON NON-EXTRACTION

FMA 21˚ 20˚-30˚ CON. Ext

SN-MP 31˚ 31˚-34˚ CON. Ext

Justification (Extraction)

SOFT TISSUE

CRITERIA VALUE NORMAL VALUE PRO/CON NON-EXTRACTION

POSITION OF UPPER LIP –E LINE

3.5mm 2mm ±3 CON. Ext

POSITION OF LOWER LIP- E LINE

2 mm 2mm ±3 CON. Ext

NASOLABIAL ANGLE

85 90˚-115˚ PRO. Ext

UPPER LIP MORPHOLOGY

12mm≠15mm

(strained)

3 mm belowe sk A point =

Vermilion to labial surface of teeth ±1

PRO. Ext.

Justification

OTHER FACTORS

CRITERIA VALUE PRO/CON NON-EXTRACTION

GROWTH Non growing patient PRO. Ext

MIDLINE In-coincident PRO. Ext

PATIENT PEREFERENCE Extraction PRO. Ext

Justification

Growth Modification: (Modified twine block)

Mild Skeletal class II.

Cant maxilla

Dentoalveoular effect

Fixed Appliance

Alignment and leveling of teeth

3-D tooth movement( bodily movement)

Closing of spaces and retraction of anterior teeth

Upper and lower arch coordination

MBT prescription slot 0.022:High torque is needed to retract the anterior teethLess anchorage demand.

Justification

Retention:

Upper fixed retainer: crowding ,rotation and midline shift.

Upper CSF: rotated incisors

Upper H.R: to prevent re opening Ext. space and improve settling.

Lower H.R.: stabilize dental arch and improve settling.

Lower fixed retainer: prevent late anterior mandibularcrowding and midline shift.

Treatment Details and Mechanics

1. Full records

2. Impression for modified twin block

3. Delivery of modified twin block(wear full time)

After we get true molar and canine relationship by dentoalveoular effect:

11. Separators on upper and lower 6’s

12. Band selection and cementation on upper and lowe6’s

13. Upper and lower direct bonding of fixed appliance MBT slot 22.

Treatment Details and Mechanics 15. Aligning and leveling upper and lower arch using wires

0.014, 0.018 and 0.017*0.025 NiTi

16. Working upper wire 0.019*0.025 SS (expanded)

17. Re-evaluat for extraction pattern

18. Retraction of upper anterior teeth into class 1 by close coil spring.

20. Steel ligation from 3-3 in the upper arch.

21. Close remaining space from post- anterior.

22. Interproximal reduction of lower ant. teeth and reshaping of upper incisors.

23. Finishing and detailing using 0.021*0.025 TMA wire

Treatment Details and Mechanics

25. settling .

26. Retention:

Upper and lower fixed retention from 3-3 using multistranded 17.5 mil SS.

Debonding of upper and lower fixed app.

Upper impression for upper and lowerH.R.

26. Insertion of upper and lower H.R.

The End

Thank You...