Orthodontic Clinical Case Presentation

By: Murad F.Maraqa 3 rd Year Orthodontic Resident”

Supervisors: Dr. Ahmad M. Al TarawnehDr. Raghda ShamoutDr. Ra’ed Al Rbatta

Personal Data

▪ Patient’s Name: R.S▪ Gender: Female▪ Age: 15 Years, 8

Months▪ Career: Student▪ Nationality:

Jordanian

Chief Complain

“ I don’t like how my upper teeth don’t show when I smile ”

Medical & Dental History

▪ Medical History:Denied Any Medical History.

▪ Dental History: RCT UR 6 + Amalgam fillingRestorations on the UL6 , LL6 and LR6

History

▪ Trauma: No history of trauma.▪ Habits: No Habits▪ Motivation: Internal Motivated.▪ Growth status: Passed the growth spurt .

Jaw & Occlusal Functions

▪ Mastication:Normal masticatory function.

▪ Speech:No difficulty.

▪ TMJ:No clicking No Crepitus or tenderness.

No displacementNormal opening.

Extra-Oral Photos

Frontal View

Profile ViewExtra-Oral Photos

Extra-Oral Photos

Oblique View

Intra-Oral Photos

Right side Left side

Orthopantomogram “OPT”

L

Cephalometric Analysis

Angle Measurement

Average

SNA 82 (81)+-3SNB 82 (78)+-3ANB 0 (2)+-2

SN-MAX 9.8 (8)+-3Corrected

ANB-0.5

Wits Apprasial

-3 (0) + 1.77mm

“f”MMPA 26 (27)+-4

AFH Ratio 57% 55%+-2%

UI - MAX 110 (109)+-6LI - MAN 99 (93)+-6

IIA 121 (135)+-10

A. Anteroposterior Assessment

▪ Profile:Convex facial profile.

B. Vertical Assessment

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

C. Transverse Assessment

▪ Facial Symmetry:The patient has

asymmetrical face.Tip of nose deviated to the

right side.Chin deviated to the right.Larger Right medial 1/5s

than Left medial1/5s . Interpupillary distance

larger than the width of the mouth.

E. Soft Tissue Examination

▪ Thin, competent lips.▪ Normal tongue size and

function.▪ Frontonasal angle: “115-

135– 130

▪ Nasolabial angle: “90-110”– 115.

▪ Labiomental angle: “110-130”– 140.

Intra-oral Examination

▪ Asymmetric smile.

▪ Reduced incisors show 30%

▪ Increased Buccal Corridor

Right side Left side

Intra-Oral Examination

▪ Teeth present:

7 77 7

Intra-Oral Examination

▪ Oral Hygiene :Poor

RCT UR 6 + Amalgam fillingRestorations on the UL6 , LL6 and LR6

Intra-Oral Examination

▪ Centerlines:– Upper: shifted to the left

1mm– Lower: shifted to the

right 1mm

▪ OJ: -1.2mm▪ OB: 20%

“decreased”▪ Crossbite on:

▪ Right: 2,1▪ Left: 1

Intra-Oral Examination

▪ Right buccal segment relationships: Canine: Class III 1/4 Molar: Class I

▪ Left buccal segment relationships: Canine: Class I Molar: Class III 1/4

Lower Arch

▪ U- shaped arch form.▪ Symmetrical.▪ No crowding.▪ LL6 needs refilling or

crowning

Upper Arch

▪ U- shaped arch form.▪ Constricted Anteriorly.▪ Palatally displaced

central incisors and right lateral incisor.

▪ Palatally inclined lateral incisors.

Frontal View

▪ Class III Incisor relationship

▪ OJ: -1.2mm▪ OB: 20%

Posteroanterior View

Right Side

▪ Molar: Class I▪ Canine: Class I▪ Crossbite: 1,2

Left Side

▪ Molar: Class I▪ Canine: Class I▪ Crossbite: 1

Lower Cast Occlusal

▪ Intercanine width: 26 cusp tip –cusp tip

▪ Intermolar width:▪ 46 MB-MB

Upper Cast Occlusal

▪ Intercanine width: 33 mm cusp tip – cusp tip

▪ Intermolar width:▪ 46 mm from the MB-MB▪ Normal

Curve of Spee

▪ Left side: 1 mm

▪ Right side: 1 mm

Tooth Size Analysis (Bolton Ratio)

▪ Over all ratio = 87.5/98▪ 90% Normal: 91.3%▪ Anterior ratio = 36.5/45.5▪ 80% “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 6 6 6 6 6.5 7 6.5 11.5 87.5

36.5

▪ All third molar buds are present.▪ No apparent pathology. RCT UR 6 + Amalgam filling Restorations on the UL6 , LL6 and LR6▪

IOTN Dental Health Component

▪ Grade:

IOTN Esthetic Component

▪ Not Applicable

Diagnostic Summary▪ R.S is a 16 years old, female, denied any medical history. She came complaining that her upper teeth don’t show while smiling.She has poor oral hygiene.Class III Incisors relationship based on mild skeletal Class III with Average anterior facial height.She has asymmetrical face with chin deviated to the Right side. Compromised smile esthetics.She has Class I molar with Class I canine relationships on right side and a Class I molar with ClassI canine relationships on left side. OJ is -1.2mm with decreased OB to 20% “incomplete”Upper midline shifted to the left by 1 mm and lower shifted to the right by 1 mm.Mild crowding in the upper and well-aligned lower arch.Crossbite on UR 1,2and UL 1.

Problem list

Pathological problems:– Poor O.H. Visible Plaque Accumulation– LL6 needs refilling or crowning Patient’s concern I don’t like how my upper teeth don’t show when I smile

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

1mm.– Lower midline shifted to the right by

1mm.▪ Skeletal and dental problems

in A-P :– Skeletal Class III prognathic mandible

– OJ -1.2 mm▪ Skeletal and dental problems

vertically – Decreased OB. 20%

Treatment Aims

▪ Improve O.H.▪ Restorative treatment LL6.▪ Accept skeletal discrepancy.▪ Accept facial asymmetry ▪ Correct Anterior crossbite.▪ Correct centerlines shift.

▪ Achieve and maintain Class I molar and canine relationships.

▪ Achieve Positive OJ ▪ Increase OB.▪ Finishing and detailing of

occlusion.▪ Retain corrected results

Treatment Plan “Non-Extraction”

1. O.H. improvement.2. Upper and Lower Fixed MBT 0.22 slot.3. Bite raising on the lower Incisors .4. Stripping in the lower arch6. Conventional Retention Upper/Lower Hawley Retainer.

Justification

▪ OHI : Visible Plaque ▪ Camouflage :1. Patients chief complaint2. Age of the patient 3. Good vertical facial proportions4. Mild Class III skeletal within orthodontics treatment limits5. Normal soft tissue features ▪ Non –Extraction :1. Space will be provided by proclination of the upper incisors and stripping in the lower incisors ▪ Fixed appliance using MBT prescription:

– For 3D tooth movement .– Maxillary incisors palatal torque.– Retroclination of the lower incisors .

Justification

▪ Bite Raising : Disoclussion allow freedom in movement of upper incisors

▪ Lower stripping to gain space to retrocline lower incisors .

▪ Conventional Retention :Upper and Lower Hawley 6month full time wear and 6 month night time . After Achieving overbite the results are generally stable

Mechanics

▪ To get further proclination of ULS, use MBT in the ULS▪ Lingual crown torque on LLS ▪ Contra-lateral canine brackets (to avoid LLS

proclination)▪ Lacebacks in LA (to avoid LLS proclination)▪ Cinch back in LA (to avoid LLS proclination)▪ Closing space created by stripping on a round wire in

the lower arch will facilitate retroclination of the lower incisors.

Thank You