Case presentationPrepared by:

Dr. Ali M. Alsayani3rd year orthodontic resident

Personal data Patient’s name : A. BGender : Male Age: 14 years Occupation : StudentAddress : Marj alhamamNationality: Jordanian

Medical & Dental History Medical History: Denied any medical problems . Dental History: Refer from routine clinic. Habits: No habits. Motivation: Internal motivated.

Chief Complaint I don’t like the appearance of my

upper anterior teeth.

Extra-Oral PhotosFrontal view

Profile view

Oblique view

Extra-Oral examination Skeletal assessment:

Anteroposterior assessment:

Class III Skeletal pattern

Skeletal assessmentTransverse

assessment :

Symmetrical face

Skeletal assessmentVertical

assessment :

Average LAFH .

Soft Tissue Examination

Asymmetrical face.

Straight profile.

Competent lips.

Soft Tissue Examination

Frontonasal angle: 130˚ (Normal 115⁰-135⁰) Nasolabial angle: 98˚ (Normal 90⁰-110⁰)Labio-mental angle 135˚ (Normal 114⁰-140)

Intra-oral photos

Intra-oral Examination : Teeth present

76543X1 1X34567 7654321 1234567

Fair oral hygiene.High frenum attachment

between upper centrals

Lower Arch: U shape arch. Anterior segment : well aligned teeth

except LL3 rotated.

Posterior segment: rotated Lt 2nd premolar. lingually tilted Rt 1st molar.

Upper Arch: U shape Arch Anterior segment: Well aligned central

incisors with diastema. Missing lateral incisors. Upright Lt canine. Rotated Rt canine . Posterior segment: Rotated Rt & Lt 1st

premolars. Rotated Rt & Lt 1st molars.

Anterior segment

• Class III incisor relationship.

• Midline is coincident• Overjet: 1mm.• Overbite: reduce

overbite 10%.

Buccal segment

Molar relationship : class II full unit Rt side & class II ½ unit Lt side.

Canine relationship : class II ¾ unit Rt & Lt sides.

Study Models Views

Frontal View

• Class III incisor relationship.

• Midline coincident.

• Overjet: 1mm.

• Overbite: reduce overbite 10%.

Right Lateral View

Molar relation : Cl II full unit.

Canine relation : Cl II ¾ unit.

No crossbite .

Left Lateral View

Molar relation : Cl II ½ unit. Canine relation : Cl II ¾ unit. No crossbite .

Posterior Anterior View

Incomplete reduce overbite 10 % .

Lower Occlusal View U shape arch .

Inter canine width (3—3 ) = 27 mm.

( Increased )

Intermolar width (6-6) = 42 mm.

( Normal )

Upper Occlusal View

U shape Arch.

Inter canine width (3 – 3) = 28mm ( Reduced )

Inter molar width (6 – 6) = 45mm ( Normal )

Curve of Spee

Normal flat curve of spee in both sides.

Space analysis Maxilla

Right Left7 7 8 x 8.5 8.5 x 8 7 7

Mandible

5 4 3 2 1 1 2 3 4 57.5 7 7 6 5.5 5.5 6 7 7 7.5

Lower arch: space available = 65 space required = 66 (-1) Mild crowding

Upper arch : in case of open space to replace the missing laterals ,

according to anterior bolton ratio ; 37 = 2X + 33 x 0.772 so, X= 11.55/2 = 5.8mm.

space available =67 space required=61 + 11.55(space for laterals) = 72.55 (-5.55) Moderate crowding

Index Of Orthodontic Treatment Need (IOTN) - Aesthetic Component-

Not available

Index Of Orthodontic Treatment Need (IOTN) - Dental Health Component-

Grade 4 4h.less

extensive hypodontia (one tooth per

quadrant)

-All teeth are present except upper laterals.-Condyles are in normal shape and position.-No bony pathology.

OPT

Cervical Vertebral Maturation

CS4 :Peak of mandibular growth has occurred within 1 or 2 yrs.' before this stage .10% - 25% remaining.

Cephalometric Analysisnormal Pre-

treatment

variable

81-/+ 3 78 SNA

78-/+ 3 77.2 SNB

3-/+ 1 0.8 ANB

8-+3 4 SN-MX

1mm -1.5mm

Wits appraisal

27 -/+4 24 FMPA

109-/+ 6 110 UI/Mx plane

93-/+ 6 97 LI/Mand plane

133-/+ 10 126 Interincisal angle

27-/+ 4 25.5 MM angle

55_/+2 57% Lower Face height ratio

59-63% 61% Jaraback ratio

Diagnostic summaryA 14 years old male, denied any medical problem,

presented with concern about the appearance of his upper anterior teeth , fair oral hygiene and high frenum attachment .

He has a class III incisors relationship on class III skeletal base, with straight profile, average lower anterior facial height , competent lips and asymmetrical soft tissue face.

Dentally, he has missing upper laterals , reduce over jet 1mm, incomplete reduce overbite 10% ,mild crowding lower arch , moderate crowding upper arch, rotated LL 3&5 , lingually tilted LR6, rotated UR 3,4&6, UL 4&6 , midline coincident .

He has cl II full unit in RT molar, cl II ½ unit in LT side & cl II ¾ unit in canines both sides and normal curve of spee.

Problem list

Pathological problems:◦ Fair O.H. ◦ High frenum attachment

Patient’s concern:◦ I don’t like the appearance

of my upper anterior teeth.

Skeletal problems:◦ Class III skeletal pattern.

Soft tissue problems:o Asymmetrical face.

Dental problems:• Missing upper laterals .• Reduce overjet 1mm.• Reduce overbite 10%.• Mild crowding lower arch• Moderate crowding upper

arch.• Rotated UR 3,4,6 & UL 4

and 6.• Rotated LL 3&5 .• Lingually tilted LR 6.• Class III incisor

relationship.• Molars are cl II full unit Rt

side and cl II ½ unit in Lt side .

• Canines are cl II ¾ unit in both sides .

Treatment Aims Improve oral hygiene and correct high frenum attachment. correct the patient complaint. Accept skeletal cl III pattern. Accept soft tissue problem. Open space for prosthetic replacement of upper missing laterals. Correct overjet and overbite. Relief crowding in upper and lower arches. Achieve class I incisor relationship. Achieve class I molar and canine relationship. Correction of rotated teeth and lingually tilted

LR6.

Treatment plan:- “ Non Extraction Case” “ camouflage case ”

Oral hygiene instructions. Modified TPA appliance. Upper & Lower Fixed Appliance: using SWA

technique. “ Pre-adjusted edgewise, MBT prescription, slot 0.022” Open space for upper missing teeth. Stripping in the lower anterior teeth. Distalization of upper first molars (by pendulum ). Refer to perio. clinic for frenectomy. Retention:-o Lower fixed retainer (3-3) and upper fixed retainer (1-

1). o Conventional lower and upper Hawley retainer.

Justification:-I. Non extraction : In lower arch with mild crowding, space can be

gained by correction of rotated teeth and IPR. In upper arch with moderate crowding, space

can be gained by correction of rotated teeth, distalization of molars and arch wire expansion.

II. Camouflage : Patient pass the peak of growth. Mild cl III skeletal. Good vertical facial proportion. No dental compensation. Minimal overbite and overjet. Normal SNA &SNB value.

III. Modified TPA appliance : Derotation of upper 1st molars . Control vertical movement of upper1st molars. As anchorage to retract canines in class I.

IV. Fixed appliance using MBT prescription : For 3D tooth movement. Maxillary centrals palatal torque. Retroclination of lower incisors.

V. Open space for missing upper laterals: according to patient willing. Class III skeletal pattern. More esthetic. Age of the patient.

VI. Stripping in lower ant. teeth to retract the lower anterior teeth to correct overbite and over jet.

VII. Refer patient to perio. clinic for frenectomy (before debonding).

VIII.Retention : Long term : Lower fixed retainer (3-3) to stabilize the

position of anterior teeth. Upper fixed retainer (1-1) to stabilize the

position of central incisors. Short term : Lower Hawley retainer. Upper Hawley retainer with temporary

prosthetic replacement to preserve space of laterals.

For more settling and stability of incisor relationship.

Upper and Lower Hawley 6month full time wearing followed by 6 month night time wearing.

Mechanics : Chinch back and laceback in lower arch to avoid

proclination of lower labial segment. Use MBT to get further proclination of ULS and

Lingual crown torque on LLS. Swapping of lower canines brackets to avoid

mesial tipping of canines. Distalization of upper 1st molars to get CL I molar

relationship (by pendulum). Push-pull mechanics involving open-coil spring in

the 2 region (push) and lacebacks to retract the canine (pull).

Stripping on a round wire in the lower arch will facilitate retroclination of the lower incisors.

Use of anterior elastic to correct reduce overbite.

THANK YOU