orthodontic case presentation dr-wessam alsaadi

Orthodontic Case Presentation

Done By :- Dr Wesam Alsaadi

Supervised by :- DR Ahmad Altarawneh

Dr Ragdah Shamout

Dr Anwar Rahamneh

Personal Data

Patient's Initials:- F.B

Age:- 16 years, and 3 months

Ocupation :- Student

Residency :-Al-Fhais

Nationality:-Jordainian

Cheif Complain

“ I don't Like the apperance of my teeth

upon Smiling Specially my Upper

Right canine”

Medical & Dental History Medical History:

Food Hypersensitivity,

Dental History

- Extracction of upper left second Molar

- Amalgam Filling in the Upper Right 6

- History of Failed previous orthodontic Treatment Using URA ( 4years ago)

Habits: No habits noticed or mentioned

Motivation: Highly motivated, Internal (self-motivation)

Expectations: realistic expectations

Oral Health Carious Upper left Second

Premolar Poor Oral Hygine with inflamed

Swolen REd Gingival MARGIN

Jaw and Occlusal Function

Speech

Normal flow of speech. No difficulties detected habbit

mouth breathig TMJ

- Clicking on Right Side upon Closure

-Deviation of the mandible to the right upon closure

-Displacement present:- there is a discrepancy between CR and CO

Extra oral ExaminationsFrontal View

Extra oral ExaminationsProfile View

Extra oral ExaminationsOplique View

Facial Propotions “Macro Esthetic”

Frontal View

1) Symetry

No gross asymetry “within normal”


2) Frontal facila proprtion

Fifths :

Sepration of the eye and width of the nose are equal

the nose and the chin are centered within central fifth

inter pupillary distance equal the width of the nose


Frontal view

3) Lower Facial Hight:-

slightly increased

The mouth one third of the way between the base of the nose and the chin

1/3

2/3


profile analysis

soft tissue profile:-

Slightly Convex Profile, “ mild Class II”


Profile Analysis

Naso-Labial Angle “normal 90-110”

- 93 degree “within normal”

Labio-Mental Fold “ normal 110-130”

- 162 degree “obtuse” Fronto-Nasal Angle“

normal 114-140”

- 140 “within normal

Smile Framework “ Mini Esthetic”

Profile Analysis

mandibular plane angle

is within normal nither too steep nor too flat

Tooth - Lip relationship “Mini-Esthetic'

Mini-Esthetic are affected by size of the view and they are best viewed in full face

1. Dental midlines

minimal shift in the upper dental center line to the right

2. Buccal Corridors

buccal corridor (as % black space of intercommisure width) “normal 13% and Max 17%

- pt has 25% “wide buccal corridor, narrow smile”

Tooth - Lip relationship “Mini-Esthetic'

3. Teeth and Gingival Display

full incisal show upon smiling and within normal gingival display “ up to 4mm gingival display”

4. Smile Arc

smile arc of upper teeth is not parallel to lower lip arc since the pt has hight bucally erupted right canine

Dental Apperance: Micro-Esthetic

micro esthetic are not affected by size of the view

the deviation from normal is seen on the right side in the gingival hight

the canine gingival hight should be at same level of Central incisor, but for the pt it is higher

Intra Oral Examination

Lower Arch

Large tongue size

All teeth present From LL7 to LR7

u shaped broad arch

slightly proclined lower labial sigment

upright canines

minimal rotation in the LR 2nd Pm and LL 1st PM

Upper Arch all teeth present except UL7

carious UL5

constrected comparec to the lower arch

mild crowding” mainly anteriorly”

upright upper Central Incisors

severly rotated UL 5

Bucally erpted UR3

rotated UL and UR 6s

In Occlusion Very poor O.H

class III incisal relation

Upper center line shifted to the right 0,5 mm

Lower centerline shifted to the left 1mm

Oj =1 mm

OB = 10% “reduced”

anterior cross bite UL2

Left Buccal Segment in Occlusion

cross bite from the canine to UL6

1/4 unit class II canine relation

1/2 unit class II molar relation

Right Buccal Segment in Occlusion

Cross Bite From UR 4 to UR6

Class I canine relation

1/4 unit Class II Molar relaTION

Upper center line shifted to the right 0,5 mmLower centerline shifted to the left 1mmOj =1 mmanterior cross bite UL2

Study Models

• Lower incisors occlude anterior to Upper Incisor Cingulum “class III”

• Over bite Only 10% complete with the Teeth

Study Models

Curve of Spee

Right Side Curve of spee:-1mm

Left Curve of Spee:-zero mm

Lower Study Model

Wide Lower Arch

Inter Canine Width :-

- 40 mm “ normal 27.58 for M”

Inter Molar Width :-

-53 mm “ 44.7 mm fot Males”

Upper Cast

Constricted Upper Arch

Inter-Canine Width:-

- 36 mm “normal 34 for Males”

Inter-Molar Widt1h :-

- 47 mm “ 50.45 mm for Males”

Space Analysis Lower Arch

Space Available = 74 mm

Space Required = 73.5 mm

Extra Space OP 0.5 mm

well aligned lower arch with minimal

25

12 12

25

Upper ArchSpace Analysis

Space Available = 74 mm

Space Required = 76 mm

Defeient Space = 2mm

mild upper crowding

22

1616

20

Tooth Size Analysis “Bolton”

5 4 3 2 1 1 2 3 4 5

8 8 8 6 6 6 6 8 8 8

LR

5 4 3 2 1 1 2 3 4 5

7 7 8 7 9 9 7 8 7 7

LR

Tooth Size Analysis “Bolton”

Bolton Analysis:

Σ Lower anterior teeth widths

Σ Upper anterior teeth widths

83% increased “n= 77.2 +/- 1.65”

Σ Lower all teeth widths

Σ Upper all teeth widths

94% increased “ n= 91.3 +/- 1.91”

This indicates excess of tooth material in the lower arch

Royal London Analysis

Lower Arch Upper arch

Crowding/Spacing + 0.5 mm - 2 mm

Angulation /inclination change

0 0

Leveling curve of Spee

0 0

Arch width change 0 4mm

Incisors A/P change - 1 mm 0

Total - 0.5 mm + 2mm

Panoramic X-Ray

No Bone Pathology Left Side Opening of the condyle not the same as on the right side Unerupted Conical Supernumeary tooth between roots of UR2 and 3 all teeth are present except UL 7 tooth Buds of all third molars are present

Cephalpmetric AnalysisSNA 84 81⁰ ±

3⁰ Orthognathic

SNB 78 78⁰ ± 3⁰

Orthognsthic Mandible

ANB 6 3±2SN-

MAX 6 5±3 need Eastman Correction

ANB* 4.5 mild Class II Sk

MMPA 28 27⁰ ±

4⁰ Within Normal

UI-MX 106 109⁰

± 6⁰ Normal

InclinationLI-

MD 98 93⁰ ± 6⁰

Normal Inclination

LFH % 56% 55-

60%within Normal

LFHwits zero

IOTN - Dental Component

4c “Srevere / Need of Treatment

Anterior or Posterior crossbite with greater than 2mm discripancy Between Retruded Contact &iNTERCUSPAL POSITION

IOTN - Esthetic component

Pic 7:-Moderat Need for Orthodontic Teatment

Diagnostic Summary F.B 16 years old ,male patient, with history of Food Poisining,mouth breathing,

and History of Failed Orthodontic Treatment with Removable Appliance 4 Years ago, and Very Poor O.H with Gingivitis Plus Carious UL5, also he has newly extracted his UL7, Complaining of unesthetic smile Especially because of the position of UR3.

F.B has Class III incisal relation Based on mild Class II Skeletel Relationship with Competent Lips and Large Tounge, wide buccal corridors complicated by unerupted conical Supernumerary tooth between the roots of UR 2 and 3, Plus Bilateral Posterior Cross bite with displacement, and anterior Cross Bite On UR2, which could be the reason for the clicking on the right side of his jaw upon opening his mowth

F.B Molar Relation is 1/2 unit class II on the left side for both molar and canine, while his Molar relation on the right side is 1/4 II and the canine is class I. Oj=2mm and reduced OB to 10% with lower center line shifted 1mm to the left, mild crowding in the upper arch, mild rotations in L & U R5, both U 6s while his UL5 is severly rotated.

Problem List

Problem List Pathological problems:

1- Mouth breathing

2- Very Poor Oral Hygine

3- Carious UL5

4-Unerupted SN bet Roots of Ur 2,3

Developmental problems:

A) Patients concern:- “i don't like my smile sepically me upper right 3”

B) Smile esthetics: bucally erupted UR3, wide bucal corridors

C) Alignment and symmerty:-

1- Asymetric arch,mild rotation LR5

2- Asymetric Upper arch with Costricted Max, rotations in both U6s and UL5

D) Skeletal and dental problems in transverse plane:

1-No skeletal asymmetry

2- Upper midline shifted 0.5mm to the Right

3- Lower Midline shifted 1mm to the left

4-Bilateral posterior Cross bite with displacement

E)Skeletal and dental problems in A-P plane:1- Convex Profile

2- Mild Class II Skeletal relationship

3- 1/2 Unit class II Molar, Canine on left side

4- 1/4 II moal on RT, with class I canie

5- class III incisal relation with 2mm OJ

F)Skeletal and dental problems in vertical plane:

1- Reduced Over Bite 10%

Treatment Aims Improve patients' breathing through the

nose Improve pts O.H treat carious UL5 Surgical Removal of the SN Improve pts' Smile Esthetic and alighn

upper Right 3 Correct Posterior and Anterior cross

Bite and removing the displacement Achieve class I Molar and Canine

relationship on both sides correct rotated Teeth Achieve class I Incisal relation, and

correct centerline shift on both arches

Tratment PLan Camoflage

Treatment

Non Extraction

EXPANSION

1- Referr pt to ENT clinic to detect and mansge his mouth breathing problem, and to perio Clinic for consultation and mangment of Pts Periodental Health

2- Treat Carious UL5

3-Surgical Removal of Unerupted SN bet Roots Of UR 2 , 3

4- Banded RME with Extended Armes

5- Modefied TPA with extended Arms “zakirson type” to Derotate U6s

6- Upper and Lower Fixed Appliance “SWA “, MBT prescription slot 0.022

7- Consider Stripping In Lower Anterior Teeth to Correct Bulton Discripancy

8- Retention

Short Term : Upper Hawely retaine.

Long Term: Upper and Lower Fixed Retainers with CSF to rotated teeth mainly UL5”

Justification refreeal to ENT to improve pt'

breathing inorder to have stable results with maxillary expansion.

Patient is non-grower whose Consirned only about Dental problems, with class I Skeletal, good vertical facial proportions,and normal soft tissue features

Surgical Removal of the Unerupted SN to avoir its interferance with tooth movement

No Need for Extraction Niether to Relief Crowding, nor to Correct Molar relation , nor Incisal inclination, space will be gained From expansion and IPR

We need Expansion to Correct Cross bite and improving smile esthetics, getting benefit from the extra space to align the Upper Teeth, although intercanine width and intermolar width are within normal we are expansion to camoflage the extra wide mandible, which its constriction will be more difficult

Justification Zakirson TPA with extended

arms is important to maintan the Expansion and To Derotate U6, To help in Acvieve Class I Molar Relation

Fixed Applincs is essencial to correct reotated teeth and to have precise 3D posiotion of Teeth

MBT prescription is used , since it has Less Tipping to menimize Class III incisal relation and Prevent Further Inclination Of lower incisors.

Stripping to reduce lower incisor Proclination and achieve positive OJ and OB.

short Term Retention Uper Hawely Retainer “ to maintain Expansion”, and Lower VFR

Long Term Retention which is Fixed Retainer to Avoid Late Lower iNcisor Crowding, and Upper Fixed To avoid relapse of the UR3

orthodontic case presentation dr-wessam alsaadi

Health & Medicine