Orthodontic Clinical Case Presentation

By: Shareef M.T. Al Shanableh “2’nd Year Orthodontic Resident”

Supervisors: Dr. Ahmad M. Al TarawnehDr. Raghda ShamoutDr. Ra’ed Al RbattaDr. Nancy Al Sarayrah

Personal Data

▪ Patient’s Name: Haneen Nabil▪ Gender: Female▪ Age: 13 Yrs, 4

Months▪ Career: Student▪ Nationality:

Jordanian

Chief Complaint

“ My teeth are overlapped, especially on palatal area”

« حلقي سقف عند خصوصا بعض فوق طالعين «سناني

Medical & Dental History

▪ Medical History:Impaired breathing, undergone Adenoidectomy 1 year ago.

▪ Dental History:Never been to dental clinic.

History

▪ Trauma:No history of trauma.

▪ Habits:Mouth breather.

▪ Motivation:Motivated.

▪ Growth status:Still growing patient.

Jaw & Occlusal Functions

▪ Mastication:Normal masticatory function.

▪ Speech:No difficulty.

▪ TMJ:No clicking No Crepitus, or tenderness.Normal opening, and side to side movement.

Extra-Oral Photos

Intra-Oral Photos

Study Model Examination

Orthopantomograph “OPT”

Cephalometric Analysis Angle Measurement

Average

SNA 82.5 (81)+-3SNB 75.5 (78)+-3ANB 7.5 (2)+-2

SN-MAX 6.1 (8)+-3Corrected

ANB6.5

Wits Apprasial

Zero (0) + 1.77mm

“f”MMPA 40.5 (27)+-4FMPA 32 (28)+-4UAFHLAFH 58 mm

AFH Ratio 60% 55%+-2%

UI - MAX 110 (109)+-6LI - MAN 83.1 (93)+-6

IIA 125 (135)+-10

Cervical Vertebral Maturation “CVM”

▪ CVM: Stage “3”– Less than 1 year prior to peak growth.

Facial and Dental appearance

1. The Face“Macro-esthetics”.

2. Smile Frame “Mini-esthetics”.

3. Teeth “Micro-esthetics”.

1.The Face “Macro-esthetics”

A. Anteroposterior assessment:

Maxilla to mandible relationship.

B. Vertical Assessment:a. Facial thirds.b. Angle of lower border to

mandible.

C. Transverse assessment:D. Facial symmetry.E. Soft tissue Assessment.

A. Anteroposterior Assessment

▪ Profile:Convex facial profile.Skeletal Class 2Increased Lower anterior facial height.

A. Anteroposterior Assessment

▪ Zero Meredian Line:

> 2mm to soft tissue pogonion.

B. Vertical Assessment

▪ Increased LAFH▪ Upper lip in the upper 1/3▪ Lower lip in the lower 2/3

▪ Increased FMPA angle.

C. Transverse Assessment

▪ Facial Symmetry:The patient has asymmetrical

face.Tip of nose deviated to the

left side.Chin deviated to the right.Equal medial & lateral 1/5s.Width of the nose equals the

central 1/5. Interpupillary distance larger

than the width of the mouth.

E. Soft Tissue Examination

▪ Thin, competent lips.▪ Normal tongue size and

function.▪ Frontonasal angle: “115-

13– 110 “obtuse”

▪ Nasolabial angle: “90-110”– 96.

▪ Labiomental angle: “110-130”– 121.

2. Smile Frame “Mini-esthetics”

▪ Smile index:– “intercomissure

width/interlabial gap on smiling”.

– 32.07/10.76= 2.9

▪ Asymmetric smile.

▪ Buccal corridor ratio:– 12.07% (between medium & medium-broad)

Incisor and Gingival display & smile arc

▪ Upper incisors are not parallel with lower lip.▪ Upper incisors are not touching lower lip▪ Whole length of upper incisors are visible.▪ More than 0.5 mm gingival margin display. “increased”▪ Non constant smile.

3. Teeth “Micro-esthetics”

I. Tooth proportions.II. Width relationship and

golden ratio.III. Connectors and embrasures.

I. Tooth Proportions

▪ Square centrals.▪ Central height: 9.5mm▪ Central width: 8 mm▪ Ratio: 84%

II. Width relationship and the Golden Ratio

▪ Golden Ratio:1.0 : 0.62 : 0.38 : 0.24UL1 : UL2 : UL3 : UL41.0 : 57% : 137% :

73%

III. Connectors and Embrasures

▪ Connectors height is greatest between central incisors.

▪ No black triangles, as gingival embrasures are filled with interdental papillae.

▪ Incisal embrasures is getting larger as moving posteriorly.

Intra-Oral Examination

Intra-Oral Examination

▪ Teeth present:

▪ Upper and lower 7s are still erupting.

6 66 7

Intra-Oral Examination

▪ Oral Hygiene: Fair▪ Caries:Class I on UR 6Class II on LR 6

Intra-Oral Examination

▪ Centerlines:– Upper: ▪ shifted to the left by 1

mm.– Lower:▪ shifted to the right by 1

mm.▪ OJ: 5mm▪ OB: 10% “decreased”▪ Crossbite on:

▪ Right: 4,5,6▪ Left: 5

Intra-Oral Examination

▪ Right buccal segment relationships: Canine: Class I Molar: Class II ‘3/4’

▪ Left buccal segment relationships: Canine: Class III ‘1/2’ Molar: Class I

Lower Arch

▪ U- shaped arch form.▪ Asymmetric / constricted.▪ Moderate crowding.▪ Mesially inclined canines.▪ Lingually displaced:– LR 2 & LL 2

▪ Lingually inclined: – LR & LL 4,5s

▪ Class II on LR 6

Upper Arch

▪ V- shaped arch form.▪ Constricted.▪ Overlapping central incisors.▪ Palatally inclined lateral

incisors.▪ Palatally erupting 2’nd

premolars on both sides.▪ Rotated:

▪ UR 4, 6▪ UL 4, 6

▪ Class I caries on UR 6.

Study Model Examination

Frontal View

▪ Class II div 1 incisor relationship.

▪ OJ: 5mm▪ OB: 10%

Posteroanterior View

Right Side

▪ Molar: Class II ‘3/4’▪ Canine: Class I▪ Crossbite: 4,5,6

Left Side

▪ Molar: Class I▪ Canine: Class III ‘1/2’▪ Crossbite: 5

Lower Cast Occlusal

▪ Intercanine width:– 23 mm “more decreased” (A decrease in intercanine

width “esp females from 13 – 20”.)

– Sinclair and Little 1983

▪ Intermolar width:– 42 mm “normal”

Upper Cast Occlusal

▪ Intercanine width: – 27.5 mm “decreased”

▪ Intermolar width:– 41 mm “decreased”

Curve of Spee

▪ Right side: 1 mm

▪ Left side: 1.5 mm

Space Analysis:

▪ Upper arch:– Symmetric.

▪ Space available=– 17+19.5+19.5+16.5=

72.5mm▪ Space needed = 75.5▪ Crowding:▪ 72.5-75.5 = -3 mm “Mild

crowding”

Space Analysis:

▪ Lower Arch:▪ Asymmetric.

▪ Space available=– 21+8+10+20= 59 mm

▪ Space needed= 64.5▪ Crowding:▪ 59-64.5 = -5.5

“Moderate crowding”

Tooth Size Analysis (Bolton Ratio)

▪ Over all ratio = 87.5/98▪ 89.2% “Decreased”– Normal: 91.3%

▪ Anterior ratio = 36.5/45.5▪ 80.2% “increased”– Normal: 77.2%

11 7 8 8.5 6 9 8 6 8 8 7 11.5

98 45.5

6 5 4 3 2 1 1 2 3 4 5 6 overall

anterior

11.5

7 7.5 7 5.5 5.5 6 6 6.5 7 6.5 11.5 87.5

36.5

Royal London Space Analysis

Lower Arch Upper ArchCrowding \ Spacing -5.5 -3

Angulation \ Inclination Change

0 -2

Levelling curve of Spee -1

Arch Width change 0 +2

Incisor A\P change 0 -3

Total -6.5 -6

VTO “Visualized Treatment Objectives”

▪ Chart 1: Midline – Molar position

Right Left1 mm

1 mm

5 mm Zero

VTO “Visualized Treatment Objectives”

▪ Chart 2:–Lower Arch

Discrepancy

Right Left

Crowding 3*3 6*6

-4-0.5

-1.5-0.5

Protrusion +2 +2

Curve of Spee -1 -1

Midline +1 -1

Total 3*3 6*6

-1-1.5

-0.5-0.5

VTO “Visualized Treatment Objectives”

▪ Chart 3: –Anticipated treatment change

Right Left

1 mm

1mm

6.5 mm

6.5 mm

1 mm

1 mm 0.5 mm

2 mm

4.5 mm

7.5 mm

▪ All third molar buds are present.▪ No apparent pathology.▪ Caries on:

▪ UR 6 Class I▪ LR 6 Class II

• Normal condyles.• Approximately equal

length of rami.

IOTN Dental Health Component

▪ Grade: 4.d (Severe need)

IOTN Esthetic Component

▪ 7 : Moderate/ Borderline

Diagnostic Summary▪ H.N is a 13 years, 4 months old, female, undergone adenoidectomy with no serious

medical condition. With mouth breathing habit claiming that it was stopped one year ago.She came complaining of teeth overlap, especially on posterior area.She has fair oral hygiene.Class II div 1 incisor relationship based on skeletal Class II with increased anterior facial height.She has asymmetrical face with chin deviated to the left side. Compromised smile esthetics.She has Class II “3/4” molar with Class I canine relationships on right side and a Class I molar with Class 3 “1/2” canine relationships on left side. OJ is 5mm with decreased OB to 10% “incomplete”Upper midline shifted to the left by 1 mm and lower shifted to the right by 1 mm.Severe crowding on upper arch and moderate crowding on lower.Crossbite on UR 4,5,6 and UL 5. Palatally erupting UR&UL 5s with lingually displaced lower laterals. Rotated UR & UL 4,6. Palatally inclined upper laterals.Carious lesions on UR and LR 6s.

Problem list

▪ Pathological problems:– Fair O.H.– Carious lesions on UR 6 & LR 6

▪ Developmental problems:– Mouth breathing.– Patient’s concern about the overlapped

teeth.– Smile esthetics: overlapped central

incisors.– Alignment and symmetry:▪ Asymmetric lower arch with crowding of -6

mm with lingually displaced laterals .▪ Symmetric upper arch with crowding -7mm

with palatally erupting upper 5s and rotated UR 4&6 UL 4&6.

▪ Skeletal and dental problems in transverse plane:– Constricted maxilla.– Chin deviated to the left side.– Upper midline shifted to the left by 1mm.– Lower midline shifted to the right by

1mm.– UR 4,5,6 UL 5 on crossbite.

▪ Skeletal and dental problems in A-P :– Convex profile “class II skeletal”– Molars: RT: Class II “3/4”. LT: Class I– Canines: RT: Class I. LT: Class III ‘1/2’– OJ 5 mm

▪ Skeletal and dental problems – Increased LAFH– Decreased OB. 10%

Treatment Aims

▪ Improve O.H.▪ Treat the carious teeth.▪ Assess mouth breathing. ▪ Relief crowding on upper and

lower arches. And align the teeth.▪ Correct centerlines shift.▪ Correct crossbites on UR: 4,5,6

and UL 5.▪ Correct skeletal discrepancy.

▪ De-rotate rotated teeth.▪ Achieve Class I molar and

canine relationships.▪ Achieve normal OJ &OB.▪ Obtain flat curve of spee.▪ Finishing and detailing of

occlusion.▪ Retain corrected results

Treatment Plan: “Growth modification”“Non-Extraction”

1. O.H. improvement.2. Assess breathing pattern. “If still mouth breathing, treat with

oral screen from 3-6 months. Or by referral to ENT specialist.3. Upper and lower Fixed appliance with T.P.A.4. High pull head gear.5. Rapid maxillary expansion.6. Permanent retention on upper from 5 – 5 & lower from 3 – 3.

using sandblasted S.S 0.030 – 0.032 inch. With upper Hawley retainer and lower vacuum formed.

Justification

Why growth modification?The patient is still growing and on stage 3 CVM so we can benefit from mandibular growth on peak of growth modification.

Why non extraction?Due to moderate crowding on upper and lower arches, no need for camouflage as growth can be modified. Space can be gained from different aspects such as Bolton discrepancy and de-rotation of rotated teeth.

Justification

▪ Oral screen: in case the patient is still mouth breather. ▪ Fixed appliance : – For 3D tooth control “Derotation, intrusion, extrusion & torque”.– Maxillary incisors palatal torque.– Buccal crown torque of lower posterior teeth as they are lingually inclined.– 0.022 better sliding mechanics.– For alignment of upper second premolars.

▪ Headgear to strain maxillary forward growth and allow mandibular auto rotation.

▪ Rapid palatal expansion, due to presence of maxillary constriction and V shaped arch form.

Justification

▪ Transpalatal arch: derotation of 1’st molars.▪ Permanent retention: due to severely displaced upper

2’nd premolars and lower lateral incisor.▪ Hawley retainer: to get maximum interdigitation,

preserve MMPA angle. Full time wearing on 1’st 3-4 months then part time at least 12 months or until growth cease.

▪ Vacuum formed: full time wearing on the 1’st 48 hrs then 12 hrs daily for 3 months, and gradually decrease the wearing days during the next 9 months.

Thank You