Name: I.M

DOB: 10/October/2003

Age: 14 yrs 1 mth

Occupation: Student

Marital status: Single

Residence: Amman

Nationality: Jordanian

انا بكره كيف اسناني ”“.العلوية الفة على بعض

“I hate how my upper

teeth are rotated”

Medical and Dental History

Medical History: Fit and healthy

Dental History: Regular dental visits, multiple fillings

Habits: Mouth breather

No signs of TMD (No clicking, crepitus, and

tenderness to palpation)

Normal range of opening, lateral movement,

and no displacement.

Anteroposterior:

Class III Skeletal Pattern

Vertical Assessment:

Slightly increased lower facial

height

Transverse

R-L

Straight facial profile.

frontal facial proportions :

Equal medial and lateral fifths

Interpupillary distance not equal

width of the mouth

The nose & Chin not centered

within the central fifth

Transverse Assessment

Frontal view

Upeer lip length : 21 mm

Lower lip length : 45 mm

Mouth is one-third of the way

between the base of the

nose and the chin

Lip tonicity and competence:

• thin upper lip.

• Normal lower lip.

• Potentially competent

unstrained lips.

1 mm

Norm. (0 +/- 2)

Frontonasal angle: 137

(Normal 115⁰-135⁰)

Nasolabial angle: 84

(Normal 90⁰-110⁰)

Labiomental angle: 126

(Normal 114⁰-140)

Soft tissue pogonion to tip of

the nose

Norm. ( L lip 2mm behined the

line )

• 100% crown show when smiling.

• Slight gingival show upper right

lateral incisor.

• Smile extends to mesial of the

right first premolar to distal upper

left canine.

.

dental midline : upper

shifted to lt 3 mm

• Buccal corridors: wide

• The smile arc: Incisal edges of upper anterior teeth are not

parallel to the upper border of the lower lip

Golden proportion :Visual width of lat. Inc 37 % and canine 75 %

Golden proprotion : 1 : 0.62 : 0.38 : 0.24

Hight width relationship :

Rt central width 93 %

Lt central width 94 %

Of its hight

Norm. ( width of the tooth 80% of it’s height )

Gingival line :

Central incisor and canine show

same gingival level

UR 2 gingival

line below central by 1mm

Dental apperance “ micro esthetic “

• Poor oral hygiene, external staining is evident on the

cervical regions of the teeth.

• Normal oral mucosa with racial pigmentation.

• Teeth Present in oral cavity;

7 6 5 4 3 2 1 1 2 3 4 5 6 7

7 6 5 4 X 2 1 1 2 3 4 5 6 7

U-shaped lower arch

Anterior segment:

› crowding in anterior segment with impacted lower right 3 and rotated lower left 3.

› Lower midline shift to the right 3mm.

Buccal segment:

Rotated lower 4 and 5 bilaterally.

U-shaped arch.

Anterior segment:

Instanding upper

left 2.

Rotated upper

right 1,2, and 3.

And left 1 and 3.

Midline is shifted

to the left 3 mm.

Class II div 1 incisor relationship.

Upper midline shifted to the left 3 mm.

Lower midline shifted to right 3 mm

Overjet = 5 mm

Overbite = 20% incomplete.

Molar relationship: L: Class I R: Class I

Canine relationship: L: ¼ unit Class III

Periodontal health:

poor oral hygiene, plaque and calculus

deposition on the canine to the molars, and

inflamed gingivae.

Carious lower first molars.

Anteroposterior

Canine:?

Molar: Class I

Canine : ¼ unit Class III

Molar: Class I

Transverse

Vertical

Reduced O.B

Upper arch

U shaped arch form

Dental Asymmetry

Intermolar width: 48mm

Intercanine width: 33 mm

Lower arch

U shaped arch form

Dental Asymmetry

Intermolar width= 45 mm

Intercanine width= ?? mm

tanaka and jhonson

Estimated width of mandibular canine and premolars = One half of the mesiodestalwidth of the four lower inc + 10.5

C+ 8+7.5 = 25.7/2 +10.5

Width of canine = 7.85

1177.498.39.49.3897.5711U

654321123456

118.38.37.46.66.666.57.8587.511L

Anterior Bolton ratio= 77 %

(normal value: 77.2± 1.65%)

Overall Bolton ratio= 91.4 %

(normal value: 91.3± 1.91%)

Upper ArchLower Arch

-9.8 mm-14 mmCrowding

--Angulation change

-0Leveling curve of

Spee

--Inclination change

--Arch width change

--Incisors A/P change

Grade 5.i› Impeded eruption of teeth

due to crowding.

Variable Pre-

Treatment

Normal value

SNA 83º 81 ± 3

SNB 82º 78 ± 3

ANB 1º 3 ± 2

S-N/MX 3.5º 8 ± 3

ANB* - -

MMPA 28.8º 27 ± 3

FMPA 20˚ 28 ± 3

LFH 59% 55 ± 2

Jarabak ratio 66% 61± 2

U1/Mx 116º 109 ± 6

L1/Mn 89º 93 ± 6

IIA 132.5º 133 ± 10

Wits

Appraisal

0 mm 1 ±1.9

All teeth are present including all third molar buds.

Impacted lower right 3.

Clinically :

Palpation no labial or lingual bulge

X ray : parallex techinique

SLOB within the line of the arch

I.M is a 14 yrs 1mo old Female, medically fit and healthy

patient, complains of “I hate how my upper teeth are rotated”

. she has a class II div 1 incisor relationship based on class

III skeletal pattern, slightly increased lower facial height,

potentially competent lips, and a straight facial profile.has

compromised smile esthetic ,complicated by impacted LR3 ,

O.J of 5 mm, reduced O.B, Molar relationship is class I on

both sides, canine relationships is ¼ unit class III on LEFT

side, upper midline shifted to LT 3mm and lower midline

shifted to RT 3mm , rotated UR 1,2 UL 1 3, palatally

instanding UL2 , Rotated LL3 LR 4 5 , severely crowded

upper and lower arch

PATHOLOGICAL PROBLEM

Carious LL6 .

Poor oral hygiene

Gingivitis with plaque accumulation.

Yellow discoloration on upper anterior teeth

SOFT TISSUE : Potentially competent lip

DEVELOPMENTAL PROBLEM :

Patient’s chief complaint; “I hate how my upper teeth are rotated”

smile esthetic : compromised smile

Aligment and symmetry :

¼ class III canine relation on lt side

Severe Lower arch crowding.

Severe upper arch crowding.

Rotated lower right 4 5 and left 3 .

Rotated upper right 1 2 and left 1 3

Palatally instanding ul 2

Impacted LR3

Skeletal and dental problems in transverse plane :

Lower midline shifted to rt 3mm and upper midline shifted to left by 3 mm

Skeletal and dental problem in A-P plane

Straight profile

o.J 5 mm

Skeletal and dental problem in vertical plane

Slightly increased LFH

Reduced O.B

Treat carious LL6.

achieve optimal oral health through appropriate calculus removal and plaque control

as well as motivation.

Accept Mild Asymmetry

Improve smile esthetics

Correct crowded lower and upper arches

Correct rotated teeth

Preserve CL I molar relationships

Achieve CL I incisor relationship

Correct canine relationships

Correct midline shift

open space of impacted LR3

Achieve 2 mm O.J

Achieve normal O.B

Finishing and detailing the occlusion

Retain correct result

( Extraction case)

1. OHI.

2. Treatment of carious teeth.

3. Refer to conservative department for LL6 .

4. Refer to ENT clinic to manage mouth breathing

5. Upper & lower fixed appliance (Roth.0 22)

6. Anchorage : upper nance + lower LLA

7. Extraction of upper and lower first premolars

8. CSF

9. Retention.

short term :

Modified Upper and lower hawley retainer

long term :

Upper and lower permenant retainer from 3-3 (

braided steel wire )

• OHI & referal to perio & cons clinic:

Obvious plaque deposition and carious tooth

Fixed Appliance

Alignment of teeth

Bodily movement

Upper and lower arch coordination

Anchorage

anchorage required for the retraction of upper and lower canines and achieving cl 1 canine relationships and preserving class 1 relationship

Retention (Lower fixed retainer )

Lower fixed retainer: prevent late anterior mandibular crowding

Upper fixed and CSF to reduce postretention relapse of derotated teeth.

DENTAL:

CRITERIA VALUE NORMAL VALUE PRO/CON

EXTRACTOION

Tooth size- arch length Upper :9.8 mm

Lower: 14

8-11 mm crowding PRO

Curve of Spee L:0 mm, R:0 mm More than 6 severe CON

Bolton discrepancy 90.4% Normal 91.3 % CON

Peck & Peck L1:100%

L2: 83%

L1:88-92 (if less

extract)

L2: 90-95 (if less

extract)

CON

PRO

Irregularity index 2 mm X>6.5 mm extract CON

Incisor-Man. Plane angle 89˚ 85˚-95˚ CON

Frankfurt-Man. Incisal

angle

73 60˚-75˚ CON

Upper incisor to NA 30˚ 4mm anterior, (22-25) PRO

Lower incisor to NB 28˚ 4 mm anterior ( 22-25) PRO

Lower incisor to A-pog 1.5 1-3 mm anterior to it CON

OTHER FACTORS

CRITERIA VALUE PRO/CON EXTRACTION

GROWTH Non-Growing patient PRO

MIDLINE Uncoincident PRO

PATIENT PEREFERENCE Indifferent -

Full records

Separators on upper and lower 6’s

Band selection on upper and lower 6’s

Impression of nance And LLA

Cementation of the nance and lower lingual

arch

direct bonding of the brackets

Invert upper left 2 bracket

Referral for extraction upper and lower first

premolars. (first extract upper RT 1st

premolar to correct upper midline and LL4

to correct lower midline then extract UL 4

AND LR4 )

start alignment and leveling of the whole

arch using 0.012 NiTi through 0.017*0.025

NiTi archwires.

Space closure at working AW 19*25 ss

Upper and lower TMA archwires for finishing

and settling.

Debonding

Impression for retainer

Upper and lower bonded retainers from 3-3