case presentation

1. Done by : Dr. Lana Obeidat
Supervised by: Dr. Ahmad Al Tarawneh
Dr. Jumana Tbaishat
Dr. Bashar Al Momani

2. Name: R.H
Age: 29 years
Occupation: orthodontic res.
Marital status: Single
Residence: Amman
Nationality: Jordanian

3. Medical History: Denied any medical history
Dental History: Extraction of UR6,LR6
Endo ttt of UL6,UR4
Crown on UL6
Dilaceration of LL4
Habits: Mouth breather

4. “ I want to improve my
profile and correct the
shape of my centrals.”

6. Anteroposterior:
Class II Skeletal Pattern

7. Vertical Assessment:
Increased lower facial
height

8. Transverse:
Mildly Asymmetric face
Deviated nose to the
right side

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 strained upper lip
• Thicker normal lower lip
• Competent lips

11. ¡ Convex facial profile

12. ¡ Hypoplastic Zygoma
¡ Signs of a mouth
breathing

13. § Frontonasal angle: 118⁰
(Normal 115⁰-135⁰)
§ Nasolabial angle: 101⁰
(Normal 90⁰-110⁰)
§ Labiomental angle: 123⁰
(Normal 114⁰-140)

14. • 95% crown show when smiling
• normal gingival show
• Smile extends from mesial of first
molar to the mesial of first molar
on the other side

15. Commissure height > philtrum height
Tooth show at rest more than 9 mm

16. • Upper lip length 28 mm
• Lower lip length 50 mm
• Upper lip thickness 13 mm
• Lower lip thickness 23 mm

17. • Buccal corridors: narrow
• The smile arc: Incisal edges
of upper anterior teeth are
somewhat parallel to the
upper border of the lower
lip

18. The picture can't be displayed.
• Golden proportion for
maxillary anterior teeth
is 80% between central
and lateral
70% between lateral and
canine
• Height: width
14: 10

19. The picture can't be displayed.
§ Gingival level of lateral
0.5 mm lower to central
incisors
§ Gingival connectors
between lateral and central<
connectors between canine
and lateral

21. The picture can't be displayed.
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22. • Good oral hygiene
• Normal oral mucosa
• Teeth Present in oral cavity
7 X 5 4 3 2 1 1 2 3 4 5 6 7
7 X 5 4 3 2 1 1 2 3 4 5 6 7
The picture can't be displayed.

23. The picture can't be displayed.
¡ U-shaped lower arch
¡ Anterior segment:
ü Mild crowding in anterior segment
¡ Buccal segment:
ü Lingually tipped LR7,LL6,LL7
ü LL5,LR5 rotated
ü Extracted LR6

24. ¡ U-shaped arch.
¡ Anterior segment:
ü Proclined upper incisors
ü UL5 is lingually tilted
ü UR7 is mesially tipped
ü UR5 is distally tipped
ü Extracted UR6

25. ¡ Periodontal health:
Good oral hygiene
¡ Carious :
¡ Extracted UR6,LR6
¡ Endodontically treated UR4,UL6
¡ Crown on UL6
8 7 6

26. — Class III incisor relationship
— Midlines coincident
— Overjet = Zero mm (edge to edge)
— Overbite = Zero % ( reduced complete to teeth)
— UL5 & UL6 in cross bite
The picture can't be displayed.

27. ¡ Molar relationship: L: Class III 1/4 R: N/A
¡ Canine relationship: L: Class III 1/2 R: Class III 1/2
The picture can't be displayed. The picture can't be displayed.

29. ¡ Anteroposterior
Canine: Class III 1/2
Molar: N/A
Canine : Class III 1/2
Molar: Class III 1/4
The picture can't be displayed. The picture can't be displayed.

30. ¡ Transverse
Midlines coincident

31. ¡ Vertical
OB= edge to edge

32. Right side: 0 mm Curve of
Spee
Left side: 0.5 mm Curve of
Spee

33. Upper arch
¡ U shaped arch form
¡ Dental Symmetry
¡ Intermolar width 47mm
¡ Intercanine width 35 mm

34. Lower arch
¡ U shaped arch form
¡ Dental Symmetry
¡ Intermolar width 50 mm
¡ Intercanine width 30 mm

35. 1199971010799811U
654321123456
12998766788912L
Anterior Bolton ratio= 42/52*100%= 80.7%
(normal value: 77.2± 1.65%)
Overall Bolton ratio= 101/109*100%= 92.6%
(normal value: 91.3± 1.91%)

36. Upper ArchLower Arch
--2 mmCrowding/Spacing
--Angulation change
--Leveling curve of
Spee
1.5 mmInclination change
--Arch width change
--Incisors A/P change
Arch parameter
Upper 84 mm
Lower 82 mm
Upper arch total space needed 4.5
Lower arch space available 3 mm

37. ¡ 3e

38. ¡ Not applicable

40. Variable Pre-
Treatment
Normal value
SNA 86º 81 ± 3
SNB 82º 78 ± 3
ANB 4º 3 ± 2
S-N/MX 7º 8 ± 3
ANB* 1.5 -
MMPA 43º 27 ± 3
FMA 39˚ 28 ± 3
LFH 57% 55 ± 2
Jarabak ratio 61% 61± 2
U1/Mx 125º 109 ± 6
L1/Mn 86º 93 ± 6
IIA 107º 133 ± 10
Wits
Appraisal
- 8 mm 1 ±1.9 F

42. All teeth are present including all 8’s

43. ü R.H is a 28 year old male, medically fit with a mouth breathing habit,
complains of his profile and upper centrals shapes . He has a class III
incisor relationship based on class III skeletal pattern, mildly Asymmetric
face with increased lower facial height, competent lips, and a slightly
convex facial profile.O.J of 0 mm, edge to edge O.B, spaced upper arch
and mildly crowded lower arch (localized anteriorly) , and spaced
posteriorly. Molar relationship is class III ¼ on left side, N/A on right side,
canine relationships is class III ½ unit on both sides, presence of bilateral
open bite 3 mm with a coincident midline, over erupted centrals on upper
and over erupted lower incisors with extracted UR6,LR6 Endo ttt of UR4
with a crown and Endo ttt of UL6 and a carious LR8,LR7,LL6 , LR4
dilacerated, Proclined upper incisors UL5 is lingually tilted ,UR7 is mesially
tipped,UR5 is distally tipped, LR7,LL6,LL7 Lingually tipped, LL5,LR5
rotated crossbite on UR 5,6 and an anterior Bolton discrepancy

44. § Pathology:
Carious LR7, LR8, LL6
§ C/C “I want to improve my profile and correct the shape of my
centrals.”
§ Skeletal:
Class III skeletal
Convex profile
Mild Asymmetry
Increased LFH
§ Soft tissue:
Thin upper lip
Deviated nose
Narrow buccal corridor
Mouth breather

45. Endodontic treatment of UL6,UR4 molar relationship L: CL III ¼
Crown on UL6 Canine relationship Cl III ½ both sides
Spaced upper arch( extracted UR6) Crossbite on UL 5,6
Mild Lower incisor crowding located anteriorly Bilateral open bites (mm)
Over eruption of upper and lower
incisors
Extracted LR6 Lingually tipped LR7,LL5,LL6,LL7,UL5
Dilacerated LL4
Proclined upper incisors Mesially tipped UR7
Reduced Overjet 0mm Distally tipped UR5
Reduced overbite (edge to edge) Bolton discrepancy
Dental:

46. § Treatment of Carious LR7,LR8,LL6
§ Address C/C “I want to improve my profile and correct the shape of my
centrals.”
§ Skeletal:
Correct Class III skeletal
Correct mild skeletal Asymmetry
Improve LFH
§ Soft tissue:
Accept thin upper lip
Correct diviated nose
Improve buccal corridore width and smile esthetics

47. Close space of UR6
Achieve class I molar
Align lower arch Achieve class I canine
Open space of lower right 6 Correct crossbite on UL 5,6
Accept dilacerated LL4
Correct length of upper and lower
incisors crowns
Correct inclination of upper incisors Close bilateral open bites
Achieve normal OJ Correct angulation of
LR7,LL5,LL6,LL7,UL5
Achieve normal OB Correct angulation UR7,UR5
Correct molar relationship on the left side correct Bolton discrepancy
Dental:

48. (Orthognathic case , Extraction UL6, LL8,LR8)
1. Presurgical orthodontic phase (extraction of upper left 6 )
2. Tads between 7 and 5 both sides in upper arch
3. Upper and lower fixed orthodontic appliance ( ROTH 22”)
4. opening space for LL6
5. Surgical phase: ( upper segmental surgery and lower BBSO)
6. Rhinoplasty
7. Post surgical phase: finishing and detailing of occlusion,
Retention: upper and lower permanent retainers upper and
lower VFR

49. ¡ Orthognathic:
1. Patient’s profile is his main concern
2. Profile is class III ( wits is -8 mm)
3. Increased LFH
4. Correct nose deviation
¡ Extraction:
1. Upper left 6 is endodontically treated with a crown
2. Maximize decompensation
3. Increase the reverse OJ
¡ Tads:
1. to allow closure of space by movement of 7 and also to provide enough anchorage and space for anterior retraction and retroclination
2. To control the lower facial height when moving the 7 by bodily movement without extrusion
¡ Fixed Appliance:
1. Surgical decompensation to maximize surgical movements.
2. Alignment of teeth and levelling of teeth
3. Bodily movement of rotated teeth
4. Opening extraction space in the lower arch
5. Upper and lower arch coordination
¡ ROTH prescription:
1. Gives proper tip and torque needed
2. Metal brackets are better for surgical treatment
¡ Retention:
1. VFR to provide 3D retention
2. Permanent retainer is always a must after orthognathic treatment

50. 1. Full records
2. Refer to psychologist to assess patients’ status and willingness for surgery
3. Seperators
4. Band selection and cementation
5. Direct bonding ( swap brackets of Upper canines L&R, Lower canines L&R) ,
invert brackets on lower incisors to achieve high torque, while on upper start
with low torque brackets then after operation change into high torque, position
brackets more incisally both upper centrals and lower incisors to intrude those
teeth, place brackets on upper centrals more incisally, and lower incisors more
incisally too) Ealry laceback and cinch back on upper arch
when proclining lowers, expect intrusion
1. Refer to extract UL6
2. Tads midway between 7 and 5 upper both sides in the upper arch (6 mm, 1.4
diameter)
3. Aligment by A-Niti .014 , .018 in upper and lower ( stripping on lower incisors to
correct bolton discrepency)
4. Regtangular Niti 17 *25 for leveling in upper and lower arches
5. uprightening the LR7 17*25 NiTi wire since it’s mildly tipped
6. Working arch wire 19*25 SS (expanded) to correct crossbite

51. 12. Orthodontic –surgical-implantology joint clinic to discuss final
plan.
13. Consultation with the implantology department to initiate final
implant as soon as possible post orthodontic treatment
14. Surgical wafers done ( both intermediate and final wafers)
15. Refer to surgery
16. Once a range of motion is achieved and the surgeon is
satisfied with initial healing resumption of orthodontic
treatment

52. 17. 2-4 weeks post surgery wires are replaced with more
resilient ones , light vertical elastics . (keep space
maintained in LL6 using A-Splint 19*25 ss intercoronal wire)
Elastic regime :
¡ 4 weeks full time
¡ 4 weeks full time except for eating
¡ 4 weeks night time only
18. Finishing 17*25 TMA arch wire
19. Consultation with the implantology department to initiate
final implant as soon as possible
20. impression for retainers :upper and lower fixed retainer by
multistranded SS wire aided with impressions for VFR

53. Mandibular arch should be fully levelled
before surgery because the aim is to
decrease LAFH , intrusion of over erupted
Premolars should be done in the
decompensation phase by bracket
positioning
Metal brackets and .022 slot are good a
option for Surgical treatment