orthodontic case presentation - dr luma najada
TRANSCRIPT
Done by : Dr. Luma Najada – 2nd year resident.
Supervised by: Dr. Ahmad Tarawneh
Dr. Jumana Tbaishat
Dr. Bashar momani
Dr. Anwar Rahamneh
Name: Samah issamAge: 29 yrsOccupation: dental technicianMarital status: Single Residence: AmmanNationality: Jordanian
Medical History: M.F
Dental History: Previous orthodontic treatment 12 years ago
Routine dental procedures ( fillings)
Habits: None
“ I don’t like the
apperance of my
teeth upon smiling.”
Variable Pre-
Treatment
Normal value
SNA 80.7º 81 ± 3
SNB 76.5º 78 ± 3
ANB 4.2 3 ± 2
S-N/MX 8.3º 8 ± 3
ANB* 4.5 -
MMPA 29.7º 27 ± 3
FMA 30 28 ± 3
LFH 56% 55 ± 2
Jarabak ratio 53% 61± 2
U1/Mx 102º 109 ± 6
L1/Mn 88.4º 93 ± 6
IIA 135º 133 ± 10
Wits
Appraisal
0 mm 1 ±1.9 F
Anteroposterior:
Class II Skeletal Pattern
Vertical Assessment:
Slightly increased lower
facial height
Transverse:
Asymmetrical face
Lip tonicity and competence:
• Thin strained upper lip
• normal lower lip
• High lower lip line
• competent lips
Convex facial profile
Frontonasal angle: 143⁰(Normal 115⁰-135⁰)
Nasolabial angle: 119⁰
(Normal 90⁰-110⁰)
Labiomental angle: 87⁰
(Normal 114⁰-140 ⁰)
• 100% crown show when smiling
• gingival show on upper centrals
approx. 3 mm
• Smile extends from 5 to 6
• Buccal corridors: narrow
• The smile arc: straight
related to lower lip
• Poor oral hygiene
•Teeth Present in oral cavity (permenant dentition)
7 6 5 4 3 2 1 1 2 3 X 5 6 7
7 6 5 4 3 2 1 1 2 3 4 5 6 7
U-shaped lower arch
Anterior segment:
moderate crowding in anterior
segment
Buccal segment:
Lingually inclined
u-shaped arch.
Anterior segment:
retroclined upper
incisors
Mild cowding
Periodontal health:
poor oral hygiene.
Carious :
fillings :
6 1 1 6 7
7 6 6 7
7 2
4
Previous abscess related to UR2
Impacted upper 8’s.
Class II div. 2 incisor relationship
Midlines : upper deviated to the left by 4 mm
lower deviated to the right by 2 mm
Overjet = 3.5 - 4 mm
Overbite = Deep 70 % Incomplete .
Molar relationship: L: Class II R: Class II 3/4
Canine relationship: L: Class III 1/4 R: Class II 3/4
Anteroposterior
Canine: Class II 3/4
Molar: Class II 3/4
Canine : Class III 1/4
Molar: Class II
Transverse Midlines deviated
Vertical O.B= deep bite incomplete
Right side: flat Curve of Spee Left side: flat Curve of Spee
Upper arch
u shaped arch form
Dental Asymmetry
Intermolar width: 40 mm
(normal : 43.9 mm)
Intercanine width: 31 mm
(normal: 31.2)
Lower arch
U shaped arch form
Dental Symmetry
Intermolar width : 37 mm
(normal: 41.7 mm )
Intercanine width : 22 mm
(normal: 23.1 mm)
117X878.5877.576.511U
654321123456
117.
5776.55566.577.511L
Anterior Bolton ratio= 36/46*100%= 78.2%
(normal value: 77.2± 1.65%)
Overall Bolton ratio= 87/88.5*100%= 98%
(normal value: 91.3± 1.91%)
Upper ArchLower Arch
-2.5 mm-6.5Crowding/Spacing
--Angulation change
00Leveling curve of
Spee
+1.5+1Inclination change
+2+2.5Arch width change
--Incisors A/P change
+1mm-3.5total
Grade 3 d
contact point
Displacement greater than 2 less
than 4
Grade 3
Variable Pre-
Treatment
Normal value
SNA 80.7º 81 ± 3
SNB 76.5º 78 ± 3
ANB 4.2 3 ± 2
S-N/MX 8.3º 8 ± 3
ANB* 4.5 -
MMPA 29.7º 27 ± 3
FMA 30 28 ± 3
LFH 56% 55 ± 2
Jarabak ratio 64% 61± 2
U1/Mx 102º 109 ± 6
L1/Mn 88.4º 93 ± 6
IIA 135º 133 ± 10
Wits
Appraisal
0 mm 1 ±1.9 F
All teeth are present except UL5, lower 8’s
S.O is a 29 years old female, medicaly fit, with history of failed orthodontic treatment with fixed appliance, with multiple fillings and carious teeth, extracted UL4. Presented complaining of “ I don’t like my smile “ . she has class II/II incisor relationship based on class II skeletal pattern,slightlyincreased LFH, she has asymmetrical face with chin deviated to the right side with compromised smile esthetics.
O.J of 4 mm, deep Incomplete O.B. complicated by extracted UL4, upper midline deviated to the left by 4 mm and the lower to the right by 2mm, moderate crowded lower arch (localized anteriorly), mild crowding in the upper arch. upper 7’s are in scissor bite, molar on left side is class II , on right side class II 3/4. Canine on left side is class III ¼, and on right side class II ¾.
Pathological problems :1. poor oral hygiene2. carious UR7, UR2, LR4. 3. unesthetic composite fillings on upper centrals.
Developmental problems :Patients’s concern : the unesthetic smileAlignment and symmerty: Asymmetric lower arch with with 6.5 mm crowding.lingually inclined lower molars.rotated LR4, LR2,LL2.Asymmetric upper arch with 2.5 mm crowdingextracted UL4retroclined upper incisorsupper 7’s scissor biterotated UL2, UR2Skeletal and dental problems in transverse plane:Asymmetric skeletal upper midline deviated to the left by 4mmlower midline deviated to the right by 1-2 mm
Skeletal and dental problems in A-P plane: Mild class 2 skeletal base (retrognatheic mandible)insicor class 2 div 2right Canine: Class II 3/4right Molar: Class II ¾left Canine : Class III ¼Skeletal and dental problems in vertical plane:slightly increased LFH increased incomplete OBSoft tissue problems : high lower lip lineobtuse nasolabial angleacute labiomental fold.
Improve OH Treat carious teeth Redo composite fillings on upper centrals. Root canal treatment for UR2 Improve her smile by creating more normal gingival relationships , and smile
symmetry Relief crowding in upper and lower arches , and align the teeth Correct rotated teeth Corret retroclination of upper teeth Correct bolton discrepancy Correct upper and lower midline shift Correct scissor bite on upper 7’s. Accept class 2 skeletal base Accept Asyymetrical face. Achieve 2mm OJ Achieve class II molar and class I canine relationship Achieve class 1 incisor relationship Achieve normal OB Finishing and detailing of occlusion. Retain corrected results
(Camouflage, extraction case)
1. OHI.2. Treatment of carious teeth, redo composite
fillings.3. Anchorage : TPA with midpalatal miniscrew. 4. Extraction UR45. Lower and Upper fixed appliance6. Bite raising on post. Teeth.7. Consider stripping in lower ant. Teeth to
provide space 8. Retention.
Short term:
Upper modified Hawley retainers and
lower hawley (full time wear for 6 months,
night time wear for another 6 months).
Long term :
Upper and lower permenant retainers from
3-3
DENTAL:
CRITERIA VALUE NORMAL VALUE PRO/CON
EXTRACTOION
Tooth size- arch length Upper : 2mm
Lower: 6.5 mm
8-11 crowding CON
Curve of Spee L:0mm,R:0mm More than 6 severe CON
Bolton discrepancy 78.2% If 4* more then extract CON
Irregularity index 5 mm X>6.5 mm extract CON
Incisor-Man. Plane angle 88.4 85˚-95˚ CON
Frankfurt-Man. Incisal
angle
61˚ 60˚-75˚ CON
Upper incisor to NA 0 MM 4mm anterior, (22-25) CON
Lower incisor to NB 4 mm, 4 mm anterior ( 22-25) CON
Lower incisor to A-pog -1.2 1-3 mm anterior to it CON
SKELETAL
CRITERIA VALUE NORMAL VALUE PRO/CON NON-EXTRACTION
FMA 30 20˚-30˚ CON
SOFT TISSUE
CRITERIA VALUE NORMAL VALUE PRO/CON
EXTRACTION
NASOLABIAL ANGLE 118 90˚-115˚ CON
OTHER FACTORS
CRITERIA VALUE PRO/CON EXTRACTION
GROWTH Non-growing patient PRO
MIDLINE deviated PRO
PATIENT PEREFERENCE Non-extraction PRO
Camouflage:
Skeletal is class mild 2 , wits 0.
Chief complain is mainly related to malaligned teeth,
Fixed Appliance
Alignment of teeth
Bodily movement
Upper and lower arch coordination
Upper MBT :to avoid retroclination of the incisors while retraction
Lower roth: average torque needed
TPA with Midpalatal miniscrew :
Maximum anchorage is needed on right side, and aboslute anchorage
on left side.
To preserve space to retract the canine and correct midline
Molar relationship ¾ and class II fill unit.
Bite raising : Disocclusion allow freedom of movement of upper 7’s Lower stripping : To gain space in lower arch MBT prescription slot 0.022: High torque is needed to proclined the retracted anterior teeth Extraction : To correct the midline To achieve full unit molar and canine Retention ( Upper and Lower fixed retainer ), Upper fixed retainer: presence of rotated teeth Lower fixed retainer: prevent late anterior mandibular
crowding rotation
1. Full records.
2. Separators around 6’s , upper 7’s.
3. Bands selection on 6’s , upper 7’s.
4. Impression for TPA.
5. Cementation of TPA.
6. direct bonding of fixed appliance ( upper MBT, lower ROTH)
with bite raising on post teeth.
7. Aligning by 0.016 NiTi, .0 017*0.025 NiTi
8. Insertion of midpalatal miniscrew
9. Refer to surgery for extraction of UR4
10. Start space closure and correction of midline
11. Interdental stripping on lower anterior teeth with Working arch
wire 0.019*0.025 SS .
12. Finishing and detailing
TMA wire .021* .025
Settling by posterior elastics using light wires
13 . Debonding :
Impression for retainers
Short term: modified Hawley
Long term upper , lower permanent