case presentation

1. Done by : Dr. Salaheddin Dahbour
Supervised by: Dr. Ahmad Al Tarawneh
Dr.Jumana Tbaishat
Dr.Raed Al Rbata
Dr.Bashar Al Momani
Dr. Anwar Al Rahamneh

2.  Patient’s initials: A S
 Gender: Male
 Age: 16 yrs
 Career: Student
 Nationality: Jordanian

3.  opg
• Habits: Mouth breather
• Dental history: Previous visits to dental clinic for check ups multiple fillings
• Medical history: MF

4. “ my canine is sticking out”

6. Anteroposterior:
Class I Skeletal Pattern

7. FMPA HIGH ANGLE

8. Transverse:
• Mild Asymmetry
• Facial midline showing
alignment of the middle part
of the upper lip at the
vermillion border and chin
point

9.  No signs of TMD (No clicking, crepitus,
and tenderness to palpation)
 Normal range of opening, lateral
movement, and no displacement.

10. Lip tonicity and
competence:
• Thin upper lip

11.  Straight facial profile

12.  Frontonasal angle: 132⁰
(Normal 115⁰-135⁰)
 Nasolabial angle: 93⁰
(Normal 90⁰-110⁰)
 Labiomental angle: 131
(Normal 114⁰-140)

13. •Showing mostly lower incisors
•Minimal upper incisors show

14. The golden proportion for maxillary ant.
Teeth is 55%,Height: width 1:0.8

15. Gingival level of
lateral 1.5mm lower
to central incisor
Gingival connectors >
between central and
lateral than lateral
and canine

19. • Fair oral hygiene
•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

20.  U-shaped lower arch
 Anterior segment:
 Well aligned anteriors
 Buccal segment:
 Slightly rotated LR5
 Restored :LR6,LL6

21.  V-shaped arch.
modorate crowding
 Anterior segment:
 Retroclined upper
incisors
UR3 Buccally
erupted (out of the
arch)

22.  Periodontal health:
 Fair oral hygiene, Yellow discoloration
(initial decalcification spots) Around the
buccal side of the teeth
 Carious :
 4
6 6

23.  Class III incisor relationship
 Midlines are not coincident , U shifted to L. 2 mm
 Overjet UR1 0mm, UL – 1 mm
 Overbite = 0%
 Ant. Crossbites on left side (UL1&2)
 No mandibular displacement CO=CR

24.  Molar relationship: L: Class I R: Class I
 Canine relationship: L: Class I R: Class I

27.  Midlines not
coincident
 Upper shifted 2mm
to the left

28.  Vertical
O.B= 0%

29. Right side: 2 mm Curve of
Spee
Left side: 2 mm Curve of
Spee

30. Upper arch
 V shaped arch form
 Dental Asymmetry
 Intermolar width: 40mm
 Intercanine width: 35 mm

31. Lower arch
 U shaped arch form
 Dental Symmetry
 Intermolar width 44 mm
 Intercanine width 29 mm

33. Upper arch:
 symmetric
 Space available=67mm
 Space needed=73 mm

34. Lower arch:
 Asymmetric
 Space available= 67
mm
 Space needed= 66 mm

35.  Bolton Analysis:
 Σ Lower anterior teeth widths = 38.4/46.8= 82% ??
 Σ Upper anterior teeth widths
 n= 77.2 +/- 1.65
 Σ Lower all teeth widths = 86.65/95=72%
 Σ Upper all teeth widths
 n= 91.3 +/- 1.91
6 5 4 3 2 1 1 2 3 4 5 6
10.7 6.
7
6.
7
8.
2
6.
9
8.
1
8.
1
7.
2
8.
3
6.
7
6.
7
10.7
6 5 4 3 2 1 1 2 3 4 5 6
9.97 7.
7
6.
5
7.
3
6.
4
5.
5
5.
5
6.
4
7.
3
6.
5
7.
6
9.98

36. Upper ArchLower Arch
- 6mm0 mmCrowding/Spacing
00Angulation change
0-1Leveling curve of
Spee
-2 mm0Inclination change
+3 mm-Arch width change
+1 mm
-4 mm
-
-1
Incisors A/P change
total

37.  Grade 4 d
Severe displacement > 4mm

38.  Not applicable

40. SNA 79.5 81⁰ ± 3⁰
SNB 80 78⁰ ± 3⁰
ANB -0.5 3⁰ ± 2⁰
Sn-Mx 1.2 8⁰ ± 3⁰
Corrected
ANB
Wits
appraisal
-0.8 mm 1(+-1.9)
mm (M)
MMPA 30 27⁰ ± 4⁰
FMPA 28.3 28⁰ ± 4⁰
UAFH
LAFH 79
AFH Ratio 60 % 55% ± 2%
UI-MX 100 109⁰ ± 6⁰
LI-Mn 89.7 93⁰ ± 6⁰
IIA 129 135⁰ ± 10⁰
Jarabak
ratio
66.6 59-63%

43. A.S is a 16 year old male, mouth breather , complains of his canine
sticking out. He has a class III incisor relationship based on class
III skeletal pattern, slightly increased lower facial height,
Constricted maxilla ,competent lips, straight facial profile. Average
NL & LM angles. O.J of 0 to -1, 0%O.B. Class one buccal
segment on both sides, moderate crowding in upper arch & well
aligned lower. Complicated by Ant. Crossbites on left side
(UL1&2) upper mildline shift 2mm to left side.

44.  Carious UR6, UL6.
 C/C “My canine is stuck out”
 Skeletal:
Mild Asymmetry.
Mild Class III skeletal base
Constriced maxilla
 Soft tissue:
Thin upper lip
 Dental:
 V shaped upper arch
moderate crowding in upper arch
Retroclined upper incisors
Class III incisors relationship
OJ 0 to-1, 0% OB
Ant. Crossbites on left side (UL1&2)
posterior Crossbite on left side
Upper Midline shift to left 2mm
Anterior bolton discrepancy

45.  Treat carious UR6,UL6, 6, LR4
 Improve oral hygiene
 Address patients chief complaint (stuck out UL3)
 Skeletal:
Accept Mild skeletal class III
Expansion in the maxillary arch
 Soft tissue:
Improve smile esthetics
 Dental:
 Relief crowding
Alignment and leveling
Correct moderate crowding in upper
Correct inclination of upper anteriors
Correct Overjet
Correct Overbite
Correct Midline shift
Correct cross bite

46. Camouflage, non-extraction:( expansion by
RME)
1. OHI
2. Refer to ENT department for consultation about mouth
breathing
3. Banded RME
4. Upper and lower fixed appliance (MBT slot 0.022).
5. Retention Short term Upper Hawley retainer ,lower VFR
6. Long term upper and lower fixed

47.  Camouflage:
 Patient is non grower
 Mild Skeletal class 3
 Constricted upper arch
 Lower and upper incisors are not compensated
 Expansion by RME:
Skeletal expansion ( trial in opening the mid palatal suture if not fully fused )
Dental tipping
 Fixed Appliance
 Alignment of teeth
 Bodily movement
 Upper and lower arch coordination
 Open space for UL3
 MBT prescription slot 0.022:
 Maximum upper incisors palatal root torque, lower incisors lingual crown torque to maximize
compensation )
Upper Hawley retainer:to preserve the expansion done
 Retention ( Upper and Lower fixed retainer ),
 Upper fixed retainer: to prevent relapse of buccally erupted UL3
 Lower fixed retainer: prevent late anterior mandibular crowding

48. 1. Full records
2. Placement of separators around 6s.
3. Band selection and impression for RME appliance, cementation of lower
bands.
4. Cementation of RME and instructions given to open twice daily for 10 days .
5. after adequate expansion , keep RME, then Upper and lower direct bonding
of fixed appliance.
6. Start with alignment phase with upper 0.014 NiTi ( give light elastics with class
3 vector.) and lower 0.016 NiTi.
7. Level upper arch with 0.017*0.025 NiTi.
8. Reach working arch wires (lowe 0.018 SS upper 0.019*0.025 SS).
9. Place open coil spring between UL2 and UL4 to open space for UL3.
10. When sufficient space is present for UL3 star piggy-back traction with 0.014
NiTi.
11. After canine is leveled and aligned place 3rd order bend on it to add buccal
root tourqe.
12. Finish and detail occlustion with 0.019*0.025 TMA
13. Debond and impressions for retainers.

49. 1. Swap lower canine brackets.
2. Early lace back in lower arch.
3. Place brackets more gingivally on upper incisors.
4. Use early light elastics with class 3 vector.
5. Invert bracket of UL2 (palataly erupted )