case presentation

1. Orthodontics Case Presentation
Supervised by:
Dr. Ahmad Al-Tarawneh
Dr. Jumana Al-Tbeishat
Dr. Raed Al-Rbata
Dr. Bashar Al-Momani
Dr. Anwar Al-Rahamneh
Done By : Dr. Yasmin Hzayyen – 3rd Year Resident
October 2017

2. Personal Data
• Patient’s initials: I. S
• Gender: Female
• Age: 13yrs, 3months
• Career: Student
• Nationality: Jordanian

3. Chief Complaint
“ I don’t like my smile; my teeth are too forward”

4. Medical & Dental History
• Medical History:
Denies any medical problems
• Dental History:
History of trauma on her upper centrals at the age of 9.
Upper left central root-canal-treated as the tooth became
non-vital with a composite filling.
She has fissure sealants on her first molars.

5. History
• Habits: No previous or on going habits mentioned or noticed
• Motivation: Patient is motivated (self- motivation)

6. Extra-oral Photos

7. Intra-oral Photos
OJ=
Rt 1= 4mm
Lt 1= 5mm
0B=
30%
overlap
Incomplete
½ Unit Class II Molar
Relationships
½ Unit Class II Molar
Relationships

8. Intraoral Photos

9. Study Models

10. Study Models

11. Panoramic View

12. CEPHALOMETRIC
ANALYSIS
SNA 80 81⁰ ± 3⁰
SNB 74 78⁰ ± 3⁰
ANB 6 3⁰ ± 2⁰
Sn-Mx 8 8⁰ ± 3⁰
Corrected ANB 6.5
Wits appraisal +3 0 (+-1.9) mm
(F)
MMPA 35.3 27⁰ ± 4⁰
FMPA 36 28⁰ ± 4⁰
UAFH 52mm
LAFH 72mm
AFH Ratio 58% 55% ± 2%
UI-MX 112 109⁰ ± 6⁰
LI-Mn 101 93⁰ ± 6⁰
IIA 113 135⁰ ± 10⁰
Jarabak ratio 60% 59-63%

14. Cervical Vertebral Maturation

15. Facial and Dental Appearance
• 1. The face (macro-esthetics)
• 2. Smile Frame (mini-esthetics)
• 3. Teeth (micro-esthetics)

16. Extraoral Examination (Macro-esthetics)
• Anteroposterior assessment:
Maxilla to mandible relationship
• Vertical assessment:
Facial thirds
Angle of lower border of mandible to the maxilla
• Transverse assessment:
Facial asymmetry
• Soft tissue assessment

17. Anteroposterior Assessment
• Convex facial profile

18. Vertical Assessment
Clinical increase in LFH
Upper lip in the upper 1/3
lower lip in the lower 2/3 of lower third
FMPA

19. Transverse Assessment
• The pt has symmetrical face
• Facial midline showing
alignment of the middle part
of the upper lip at the vermillion border and
chin point

20. Transverse Assessment
• Equal medial and lateral
Fifths
• -Inter-pupillary distance slightly wider than
the width of the mouth.
• -The width of the nose slightly wider than the
central fifth

21. Soft Tissue Examination
• Normal tongue size and function
• Frontonasal Angle:(115-135)
130 normal
• Nasolabial Angle: (90-110)
100 normal
• Labio-mental Angle: (110-130)
150 obtuse

22. Facial and Dental Appearance
1. The face (macro-esthetics)
2. Smile Frame (mini-esthetics)
3. Teeth (micro-esthetics)

23. Smile Analysis
The smile index =
inter-commisure width/ inter-labial gap on smiling
=7.0/ 2.0= 3.5 cm
(Ackerman et al )1998
** The lower the smile index, the less youthful the smile appears
The buccal corridor ratio=
Inter commissure width-visible maxillary dentition)/inter
commissure width x 100%
(7.0-6.2)/7%=11%
Medium- Broad smile
(Frush and Fisher) 1958

24. Facial and Dental Appearance
1. The face (macro-esthetics)
2. Smile Frame (mini-esthetics)
3. Teeth (micro-esthetics)

25. Teeth (micro-esthetics)
Incisal show at rest slightly more than normal
4mm
(Normal= 0-3)
Display of all maxillary incisors and some gingiva is showing
Around 2mm from the centrals and canines 3.5mm from the
laterals
The upper left central is intruded and proclined compared
To the incisers next to it
The upper incisors don’t create a parallel arc with
the lower lip

26. Tooth Proportions
• Gingival lines:
• Central incisors show different
gingival levels
• UL2 low gingival line

27. Intraoral Examination

28. Intraoral Examination
• Dentition status: Permanent dentition
• Teeth present: 654321 123456
7654321 1234567
• Caries: X

29. Intraoral Examination
• Poor Oral Hygiene.
• Gingivitis & Plaque
accumulations on the buccal
surfaces of posterior teeth.

30. Intraoral Examination
• Central Lines:
Lower teeth <1mm shifted to the right
• Incisors classification:
class II, div1
• OJ:
Rt central= 4 mm, Lt central 5mm
• OB:
30% overlap; incomplete
• Crossbites: X
• No Displacement

31. Intraoral Examination
½ Unit Class II Molar Relationships ½ Unit Class II Molar Relationships

32. Upper Arch
• Slightly v-shaped
• UL2 palataly inclined crowded
• UL1 proclined
• Upper premolars palataly
inclined and slightly rotated

33. Lower arch
• Symmetric
• Almost aligned
• Proclined LLS

34. Study Models Examination

35. Front View
Lower midline shifted to the
Right <1mm

36. A-P view
• Class II,div1 Incisal relationship
• Average incomplete overbite.

37. Upper Cast Occlusal
• Interpremolar width =
34mm (average)
• Intermolar width =
45mm (average)

38. Lower Cast Occlusal
• Interpremolar width =
30mm (average)
• Intermolar width =
40mm (average)

40. Curve Of Spee
Rt : 2mm Lt: 1mm

41. Space Analysis
• Upper arch:
• Symmetric
• Space available= 74 mm
• Space needed= 76 mm
• Space needed 2mm

42. Space Analysis
• Lower arch:
• Symmetric
• Space available= 63.5 mm
• Space needed= 65 mm
• Space needed of 1.5 mm

43. Tooth Size Analysis (Bolton)
• Bolton Analysis:
• Σ Lower anterior teeth widths = 36 mm
• Σ Upper anterior teeth widths = 48 mm
• Σ Lower all teeth widths = 87
• Σ Upper all teeth widths = 96
• Overall ratio= 87/96 * 100%= 90.6%
n= 91.3 +/- 1.91
• Anterior ratio= 36/48 *100% = 75%
n= 77.2 +/- 1.65
6 5 4 3 2 1 1 2 3 4 5 6
10 7 7 8 7 9 9 7 8 7 7 10
6 5 4 3 2 1 1 2 3 4 5 6
11 7 7 7 6 5 5 6 7 7 8 11

44. Royal London
Lower arch Upper arch
Crowding/Spacing -1.5 -2
Angulation /inclination
change
-1/0 0/0
Leveling curve of Spee -1 -1
Arch width change +0.5 +1
Incisors A/P change 0 -5
Total -2 -7

45. Panoramic Interpretation
- Lower wisdom teeth buds are present
-No other apparent pathologies

46. Radiography : Periapical of the UL1

47. Radiography : Periapical of the UL1
•RCT in the UL1 no opacity, no radiolucency
•Shorter root
•No obliteration of periodontal space
•Symptomless
•Physiologically mobile
•Upon percussion no sharp/solid sound
•Incisal edge is above the incisal plane
•Gingival margin is more apically positioned
•No signs of replacement resorption

48. IOTN-dental health component
3a increased oj
>3.5mm but
<=6mm with
incompetant lips

49. IOTN- Esthetic component
• 3

50. Diagnostic Summary
• I.S 13yrs, 3 months old female pt , MF. Patient has poor OH,
complaining of the position of her anterior teeth that are too
forward. History of trauma on her anterior upper teeth when she
was 9, UL1 RCTreated.
A class II,div1 malocclusion on a class II skeletal base with increased
vertical dimension. She has a symmetrical face with incompetant
lips, obtuse labiomental fold and compromised smile esthetics.1/2
unit Class II M.R and C.R on both sides.
OJ is 4.5mm, OB is average incomplete. Complicted by lower
midline shifted 1mm to the Rt side. Upper arch has mild crowding,
and lower arch very mild crowding, with 1.5mm curve of spee

51. Problem List
Pathological problems:
– Pathological problems:
• Poor OH
• Plaque accumulations on the buccal surfaces of posterior teeth
• Poor UL 1 composite filling
• History of trauma; UL1 intruded
• Developmental problems:
Patient’s concern: the position of teeth ( too forward)
• Smile esthetics: compromised smile complicated by intruded UL1
• Soft tissue: Clinically convex profile
• Obtuse labiomental angle
• Incompetant lips
Alignment and symmerty:
o Slightly proclined lower incisors
Upper arch with mild crowding
o Rotated upper first premolars
Skeletal and dental problems in A-P plane:
• class II skeletal relationship
• OJ= 4.5mm
o Incisor class II, div 1
o ½ unit class II canine relationship both sides
o ½ unit class II molar relationship both sides
Skeletal and dental problems in transverse plane:
lower midine shift to the right <1 mm
Skeletal and dental problems in vertical plane:
o Increased LFH

52. Treatment Aims
• Improve Oral hygiene
• Correct position of anterior teeth AP (C/C) (( Achieve class I Incisor Relationship))
• Correct position of anterior teeth Vertically ; align them on the same level
• Correct skeletal relationship into class I
• Correct high vertical dimension
• Correct incompetant at rest lips
• Improve the smile by creating more normal gingival relationships (gingivoplasty UL2) and less incisal show
• Relief crowding in upper and align the teeth
• Achieve 2mm OJ
• Achieve class I canine relationship
• Achieve class I molar relationship
• Correct midline shift
• Finishing and detailing of occlusion.
• Retain corrected results
• Improve the appearance of the UL1 by restorative replacement

53. Treatment Plan
Growth modification; Non-Extraction
1. OHI
2. Refer to conservative department to redo UL1 filling
3. High pull headgear with TPA
4. Upper & Lower fixed appliance
5. Lower incisor stripping
6. Retention
7. Refer to periodontics department to do gingivoplasty

54. Retention Protocol
• Short term:
• Upper and lower Hawley retainers (full time wear for 6
months, night time wear for another 6 months)
• Long term:
• Upper and lower permenant retainers from 3-3 (braided steel
wire of 17.5 mil)

55. Justification
Growth modification:
Pt. is still growing
To restrain maxillary growth
Allow for mandibular autorotation and correct class II skeletal
relationship

56. Justification
High-pull headgear:
Increased LFH ( gummy smile)
Autorotation of the mandible
The pt. is motivated
Transverse anchorage prevent buccal rolling of upper 6s using headgear (TPA)

57. Justification
Non-Extraction :
• Depend on the growth modification for providing of space
• Minimal space required
• Almost aligned lower arch; space provided by lower anterior stripping and retroclination
• Mild crowding in upper arch; space provided by arch expansion by archwire
Fixed Appliance
• Bodily teeth movement is required.
• Alignment of teeth.
• Preserve / correct teeth torque.

58. Justification
• Lower incisor stripping :
Minimal space needed in the lower arch
Slightly proclined lower incisors

59. Justification
• RETENTION:
Long term (permenant retainer U 3-3 L 3-3)
Late mandibular crowding
To prevent relapse of the UL1 (intruded) and UL2 (rotated)
A-P change of the anterior teeth upper and lower

60. Treatment details and mechanics
1. Full records
2. Separators around 6’s
3. Band selection: impression for T.P.A , band selection and cementation for lower bands
4. Cementation of T.P.A
5. High-pull headgear delivery and instructions of how to wear;
500gm/side for 12-14 hrs/day
6. Direct bonding of the brackets( 0.022 roth)
7. Monitor UL1 PA x-rays ; check for any resorption throught treatment, every 6 months

61. Treatment details and mechanics
7. Leveling and aligment :
0.014 NiTi superelastic
0.018 NiTi superelastic
0.017* 0.025 NiTi superelastic
8. Working arch wire
0.019*0.025 SS wire
with lower anterior stripping

62. Treatment details and mechanics
9. Finishing and detailing
TMA wire 0.021* 0.025 with UL2 labial root torque bend
10. Settling
11. Debonding
Impression for retainers
Short term: U&L Hawley
Long term: U&L Permanent .0175 inch SS wire

63. Thank You