Case tx plan

1. A Clinical Conference Case
Presented in Partial Fulfillment of the
Requirements for the Degree of
Master of Science in Dentistry,
m.s. (Orthodontics)
CHHOM KARATH

2. Chief Complaint:
•I wants to retract anterior teeth
•Don’t like tooth appearance
Medical History:
- Patient denied any medical problems
Dental History:
•Regular check up every 6 month
•Filling #11M,#21M
•Extracted #47
Family History: Unremarkable
Social History and Habit: unconfident on smiling and no self-motivation
Expectation: Realistic expectation
1. Interviews / Questionnaire
Patient Initial: C LV Age: 33 years Sex: M Birth Date: 2-June-1986
Heigh:1.68 m Weigh:64 kg Occupation: company staff

3. 2. Extra-Oral Finding
Evaluation:

4. Soft-tissue assessment
•Frontonasal angle:115.97o
(Normal 115o -135o)
•Nasolabial angle:103.06o
(Normal 90o -110o)
•Labiomental angle:126.04o
(Normal 114o -140o)
•Soft tissue profile:159.87o straight
(165o-175o)
•Full soft tissue profile:146.27o
(M 1470, F 1330 ) convex
•Vertical length: 47%:53% decrease lower
facial profile(45%:55%)
•FMPA: average(17o-28o)=30.06o
2. Extra-Oral Finding: Analysis of the soft tissue lateral profile

5. Soft-tissue assessment
•TVL-G:-0.05cm=-0.5mm
(Normal −5.92 ± 4.75mm)
•TVL-NT:+0.26cm=26mm
(Normal 16.90 ± 1.75mm)
•TVL-A=-0.05cm=-0.5mm
(Normal −0.80 ± 1.13mm)
•TVL-UL:+0.04 cm=+0.4mm
(Normal 1.25 ± 1.79mm)
•TVL-LL:0 mm
(Normal −1.97 ± 2.47mm)
•TVL-B:-0.024 cm=-.0.24mm
(Normal −9.47 ± 3.13mm)
•TVL-pog:-0.32 cm=-3.2mm
(Normal −6.37 ± 3.88mm)
2. Extra-Oral Finding: Analysis of the soft tissue lateral profile

6. Soft-tissue assessment
•Lower facial width=17.7mm
(Min=16.75mm, Max=29.64mm)
•Lower face=50%, middle
face=50%(1/3:1/3:1/3)
•Facial assymetry angle(N’-Fl’)=2o
(Min=0.1o, Max=4.6o) acceptable
•Facial aperture modified
angle=41.07o acceptable
(Min=36.53o, Max=48.76o)
•V-angle=52.59o Unpleasant
(Min=62.51o, Max=80.38o)
•Symmetry of left and right side of
the face=19.27o-13.4o=5.87o Not
asymmetry left and right size
2. Extra-Oral Finding: Analysis of the soft tissue anterior profile
Gl
N’
Exd Exe
End Ene
V
SnAld
Ale
Ls
Fl
EsAbd Abe
Li
Me
b
Zid Zie
a
11
13 14
15
16
17
God’
Goe’
12
Middle face
Lower face
Facial high
13.350
83.780
52.940
41.360

7. 2. Extra-Oral Finding: Analysis of the soft tissue anterior profile
Facial Index
•(n-gn)/zy-zy=2.63/2.91=90.3
•F(N=86.2(4.6)), M(N=88.5(5.1))
•Mesoprosopic- average
•Euryprosopic- broad and short
•Leptoprosopic –long and narrow

8. Soft-tissue assessment
•1/5 x 5 vertical lines=unbalance
•1/3 x 3 horizontal lines=unbalance
2. Extra-Oral Finding: Analysis of the soft tissue anterior lateral profile

9. 2. Clinical Examination
Smile Aesthetics assessment
•Upper lip curvature: downward
•Smile arch: downward-pleasing
•Upper lip and smile arch parallel
•Negative space: right small
•Smile: asymmetry
•Deviation of dental and facial
midline
•Asymmetry face during smile
•High smile
2. Extra-Oral Finding: Analysis of the soft tissue anterior profile

10. 2. Dental appearance: Micro-esthetics
Smile Aesthetics assessment
•Unlevel on left canine , central incisor
•Unwell contact area(50%,40%,30%)
•Embrassure not well(20%,30%,40%,50%)
•Bad Tooth width ratio(x,x-1mm,x-2mm)
•IOTN: 2(Moderate/borderline need)
65% 65% 50% 50%50%50%50%
Cervical line
Papillary line
Contact points line
Incisal line

11. 3
2. Intra-Oral Examination: Intra-oral assessment
•Oral hygiene: Fair
•Buccal exostosis
•Gingival condition: Normal
•Incisor proclination
•Upper: average
•Lower: average

12. 2. Clinical Examination: Intra-oral assessment
18 17 16 15 14 13 12 11 21 22 23 23 25 26 27 28
48 X 46 45 44 43 42 41 31 32 33 34 35 36 X 38
Maxilla
•Soft-Tissue: Normal
•Deep palatal vault
•V-shape narrow arch
•Bucoversion #17,#18,#27,#28
•Labioversion #11,#21
Mandible
•Soft-Tissue: Normal
•V-shape narrow arch
•Missing #37,#47
•Crowding #31,32,33
•Partial eruption #34
•Mesioversion #36,#46

13. • Incisor Relationship: class 2
•Exostosis on upper both buccal parts
• Canine relationship
 Right: class 2
 Left: class 2
• Molar relationship: class 1
 Right: class 1
 Left: class 1
• Over jet: 9mm
• Over bite:120%
2. Intra-Oral Examination: Inter-Arch/Occlusion

14. 1
4
TMJ
•No signs of TMD(No clicking, crepitus, and tenderness to palpation)
•Normal range of opening, lateral movement and no displacement.
•No erosion
•TMJ space obliterated on the left side. Also associated with mild
condylar resorption on left side.
3. Intra-Oral Examination: Intra-oral assessment

15. Evaluation:
•Missing #47, #37
•Impacted #35, #45
•Filling #11M, #21M
3. Intra-Oral Examination: Panotomograph

16. Evaluation:
•Extracted #47
•Impacted #35
•Filling #11M, #21M
3. Intra-Oral Examination: Panotomograph

17. Evaluation:
•Extracted #47
•Impacted #35
•Filling #11M, #21M
3. Intra-Oral Examination: Panotomograph

18. 4. Clinical Examination: Cervical Vertical Maturation-CVM
Evaluation:
•Stage 6(>2 years prior to peak growth)

19. ZR
ZL
Facial width
Nasal width
AG GA
JR JL
occlussal plane
Evaluation:
•Mild asymmetry face(acceptable)
5. Clinical Examination: Posterior Anterior Cephalomatric

20. ZR
ZL
Facial width
Nasal width
AG GA
JR JL
occlussal plane
Evaluation:
•Mild asymmetry face(acceptable)
5. Clinical Examination: Posterior Anterior Cephalomatric

21. Po
Ba
S
Co
N
Or
pt
ANS
PNS
Go
A
B
Me
Gn
Pog
Bo
6. Clinical Examination: Lateral Cephalomatric

22. Po
Ba
S
Co
N
Or
pt
ANS
PNS
Go
A
B
Me
Gn
Pog
Bo

23. AREA OF STUDY YAS MEASUREMENT STANDARD INITIAL INTERPRETATION
Cranial Base BA–S-n 136o 133.5o
Normal face
Maxilla to Cranial Base SNA 82 o 83.56o
Pragmatism of maxilla
N-A-FH 90 o 96.52o
A-Nas Vert. (mm) -2mm 3mm
Mandible to Cranial Base SNB 80 o 78.69o
Orthognathic mandible
NPog-FH 88 o 91.91o
Po-N Vert. (mm) -6mm -8mm
Maxillo-Mandibular Relationship ANB 2 o 4o
Class II TendencyA-NPog 1mm 2.5mm
Wits 2mm 3mm
Vertical Height SN-MPA 32 o 30.96o
Normal facial
proportion with skeletal
deep bite
FMA 25 o 18.67o
N-ANS (%) 45% 46%
ANS-Me (%) 55% 54%
Maxillary & Mandibular Incisor Position U1-SN 104 o 112.28o
Procline Upper and
lower normal relation
U1-NA (mm) 4mm 4mm
U1-NA 22 o 28.33o
IMPA 90 o 99.22o
L1-NB (mm) 4mm 4mm
L1-NB 25 o 30.66o
L1-APog 2mm 4.21mm
U1-L1 130 o 117o
Soft Tissue E-line-Lower lip -2mm 2mm Protrusion of lip

24. Facial angle(84.04 3.42)=91o
Y-axis(66.36o+-3.85o)=56.53o
Gonial angle(118o+6.10o)=120o
FMA(30o)=17.77o
IMPA(103o)=99.88o
FMIA(68o)=62o
OCC(13o)=3.73o
Z(74o)= 69.5o
Po
Ba
S
Co
N
Or
pt
ANS
PNS
Go
A
B
Me
Gn
Pog
Bo
Ar
FMIA=62o
FMA=17.77o
IMPA=99.88o
6. Clinical Examination: Tweed’s Analysis

25. Po
Ba
S
Co
N
Or
pt
ANS
PNS
Go
A
B
Me
Gn
Pog
Bo
Ar
ODI=FH pl. to palatal plan angle + AB to mandibular plan angle=17.5O+77.11O=94.61O
Openbite tendency<(74.5O±6.07O)<Overbite tendency
=> Overbite tendency
17.5o
77.11o

26. Po
Ba
S
Co
N
Or
pt
ANS
PNS
Go
A
B
Me
Gn
Pog
Bo
Ar
17.5o
77.11o
•APDI=FH to palatal plane angle(17.5O)+Facial angle(91O)+AB plane
angle(7O)=7.5O+92O+6.21O=105.71O => Class III tendency
(Class II tendency<(81.4O±3.79O<Class III tendency)

28. 3. Model Analysis
1. M-D width of teeth
7 6 5 4 3 2 1 1 2 3 4 5 6 7 Sum
Max 9.5 9.5 7 7 7.5 5.5 9 8.5 6.5 7.5 7 7 10 10 111.5
Man 8 11 7 0 7 6 5.5 5.5 5.5 6.5 7 3 11.5 3.5 87
2. Arch segments lengths
7-6 5-4 3-2 1-1 2-3 4-5 6-7 sum
Max 19.5 14 13.5 16 14.5 14 21 112.5
Man 19 7 13 10.5 12 10 14 85.5
Total max ant=44.5mm
Total man ant=36mm

29. 3. Model Analysis
3. Arch length determination
Max Man
Intercanine width 27.5mm(N=39) 20mm(N=23-24.7)
Intermolar width 43mm(N=47) 35mm(N=43)
Arch length 30mm 23mm
Arch form V form V form(tapered)
Arch length discrepancy Avialable –Required=
111.5-124(floss m)=-12.5mm
(severe crowding)
Avialable –Required=
87-95(floss m)=-7mm
(severe crowding 7mm)
Overbite 12mm
Overjet 9mm
Curve of spee 5.25 mm=(5.5+4.5+0.5)/2

30. 19.5mm
14mm
13.5mm
16mm
14.5mm
14mm
21mm
27.5mm(N=23-24.7)
33mm(N=23-24.7)
41mm(N=23-24.7)
44mm(N=50.5)
40mm(N=47.5)
Constricted upper arch
Avialable –Required=111.5-124(floss m)=-12.5mm
(severe crowding)

31. 3. Model Analysis
Standard Patient’s index
Overall ratio 87.5-94.8 87/111.5=78%
(Man/Max)
Anterior ratio 74.5-80.4 36/44.5=80%
(Man6/Max6)
4. Bolton Index
Mandible<Maxilla(12 teeth)
Mandible(6 teeth)=Maxilla(6
teeth) normal ratio

32. Avialable –Required=
87-95(floss m)=-7mm
(severe crowding 7mm)
-7mm-7mm(impacted 2nd premolar)=-14
(severe crowding 14mm)

33. 3. Model Analysis
6. Pont’s Analysis
ON MAXILLA
•SI=sum of incisor 4= 5.5+9+8.5+6.5=29.5mm
•MPV(Measured premolar value)=33mm
•MMV(Measured molar value)=44mm
•CPV(Calculated premolar value)=SIx100/80=29.5 x 100/80=36.87mm
•CPV(36.87mm)>MPV(33mm) Arch form need to expand the arch on incisor
and premolar area
•CMV(Calculated molar value)=SI x 100/64=29.5 x 100/64=46mm
•CMV(39.3mm)<MMV(44mm) Arch form on molar area no need to expand
the arch
ON MANDIBLE
•SI=sum of incisor 4= 6+5.5+5.5+5.5=22.5mm
•MPV(Mesured premolar value)=23mm
•MMV(Mesured molar value)=30mm
•CPV(Calculated premolar value)=SIx100/80=22.5 x 100/80=28mm
•CPV(28mm)<MPV(30mm) Arch form is normal so no need to expand the arch
on incisor and premolar area
•CMV(Calculated molar value)=SI x 100/64=22.5 x 100/64=35mm
•CMV(35mm)>MMV(30mm) Arch form is narrow so need to expand the arch

34. 3. Model Analysis
7. Korkhaus analysisis
Man Value=Max value -2mm
19.5mm=29mm-2mm=27mm
=> Procline upper incisor 7mm
30mm
19.5mm
34mm
23mm

35. Diagnosis summary
C L is a 31 year olds Male, denied any medical problem , complains of crowding on upper and lower anterior
and posterior teeth. He has a class II incisor relationship bi-protrusion base on class I skeletal pattern, normal
upper and lower facial height. Over jet of 9 mm, deep over bite 120%, incompetent lip, impacted on #45,#35
and missing #37,#47. Canine is class II on both side, actually molar class I on both sides.
3. Transverse
- Anterior Cross bite
- Increase over-jet
4. Sagittal (A-P)
- Canine class II both side
1. Dentofacial Appearance
- Mild asymmetric
Disproportionate
2. Teeth/Arch form
- Constricted v shape upper
and lower arch
Crowding
- Moderate lower
- Inadequate lower
incisor display
Profile
- Straight
Lip
- Incompetent lip
5. Vertical
- Increase dental over bite
- LFH ratio: decrease lower
facial profile

36. Aim of treatment
1. Improve patient’s oral hygiene, esthetic and function
2. Impacted remove #18,#28
3. Accept non extraction to maintain patient’s facial profile and fill buccal
corridors
4. Achieve class I incisors relationship
5. Relieve crowding #41,#42,#43,#31,#32,#33 and align
6. Upright #47,#37
7. Correct procline upper anterior teeth
8. Achieve right canine class 1
9. Flatten curve of spee
10. Archive positive overbite
11. Archive positive over-jet
12. Retain corrected result

37. Mechanotherapy
4 mm
8 mm
4 mm
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm
4 mm
3.5 mm
3.5 mm

38. Mechanotherapy
8 mm
4 mm
Stage :
• Scaling and prophy + oral hygiene instruction
• Extraction #18,#28
• Standard Bracket position on prescription, stainless steel round 0.012
• Leveling ,alignment, distally and upright by using Vertical loop
4.0mm 4.0mm 3.5mm
4.5mm
3.5mm
3.5mm
3.5mm
3.5mm
4.5mm
3.5mm
3.5mm
3.5mm
3.5mm
3.5mm 3.5mm 3.5mm
3.5mm
4.0mm
3.5mm
4.0mm
3.5mm
3.5mm
3.5mm
3.5mm
3.5mm

39. Mechanotherapy
0
8 mm
4 mm
Stage :
• Extraction #14,#24
4.0mm 4.0mm 3.5mm
4.5mm
3.5mm
3.5mm
3.5mm
3.5mm
4.5mm
3.5mm
3.5mm
3.5mm
3.5mm
3.5mm 3.5mm 3.5mm
3.5mm
4.0mm
4.0mm
3.5mm
3.5mm
3.5mm
3.5mm
3.5mm

40. Mechanotherapy
0
8 mm
4 mm
Stage :
• Extraction #14,#24
4.0mm 4.0mm 3.5mm
4.5mm
3.5mm
3.5mm
3.5mm
3.5mm
4.5mm
3.5mm
3.5mm
3.5mm
3.5mm
3.5mm 3.5mm 3.5mm
3.5mm
4.0mm
3.5mm
3.5mm
3.5mm
4.0mm
3.5mm
3.5mm

41. Mechanotherapy
Stage :
• Extraction #14,#24

42. Mechanotherapy
Stage :
• Extraction #14,#24

43. Mechanotherapy
Stage :
• Lower teeth, open coil spring between #34 and #35 to open space,
T-loop to upright #38 0.017 × 0.025 stainless steel wire
• Set 1 (0.017 x 0.022 maxillary)
 First molar not banded and lateral incisor not ligated
 1 st order bends: small lateral inset, cuspid curvature
 3 rd order bend: -12 -12 -12 -7 +7 +7
Teeth #7 #6 #5 #3 #2 #1
 2 nd order bends: 20 0 0 0 0 0 degree
10 mm
10 mm
2 mm
1 mm

44. Mechanotherapy
Stage :
• Upper arch
• Retract #13,#23, and maximum anchorage continue tie from #5 to #7
• Elastic chain #3 to #5
• Read-out: confirm 20o on 2nd molar tip
10 mm
10 mm
2 mm
1 mm

45. Mechanotherapy
Stage :
• Maintained incisor position
• Processing open space and uprigh on lower teeth
• Set 2 on maxilla 0.019 x 0.025, Readout: confirm 20o second molar tip,
ligate incisor, 10o 1st molar distal tip;
5 2nd bicuspid distal tip
• Finish cuspid retraction; 7,6,5 continuous tie, place the elastic chain 5 to 3
• Incisor position has been maintained
• A curve of occlusion is present
10 mm
10 mm
2 mm
1 mm

46. Mechanotherapy
Stage :
• Maxillary arch 0.020 x 0.025 closing loop
• Closing loops 1.5 mm distal to lateral
• Loop stop distal to the 1st molar bracket
• Place 1st, 3rd , and 2nd order bend
• 1st order bends: 1. lateral insets, 2. Cuspid curvature(no offset), 3. 1st molar offset distal to 2nd bicuspid
bracket, 4. small amount of 2nd molar toe in
• 3rd order bends:closing loop 1.5mm distal lateral bracket, omega loop stop distal flush to 1st molar bracket
• Prescription 20 10 5 0 0 0 degree
#7 #6 #5 #3 #2 #1
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm
1 mm
1 mm
1 mm
150 gm-200gm

47. Mechanotherapy
Stage :
• 4 incisor single ties
• Active closing loop 1mm
• Tie rest of teeth with single ties
• Anterior vertical elastic: Maxilla and mandible closing loops at night
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm
1 mm
1 mm
1 mm
150 gm-200gm 150 gm-200gm

48. Mechanotherapy
Stage :
• Anterior protrusion reduction
• Anterior space closure
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm

49. Mechanotherapy
Stage :
• Anterior protrusion reduction
• Anterior space closure
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm

50. Mechanotherapy
Stage : Set 3
• 0.020 x 0.025 archwire
• 1st order bends: 1. lateral insets, 2. Very small cuspid offset, 3. 1st molar offset: just mesial to mesial
bracket of the first molar; 3rd order ends: incisor 7o LRT, cuspid 7o LCT, Molar 12o LCT;
• Second order bend: 20 10 5 0 0 0
#7 #6 #5 #3 #2 #1
• Helical bulbous loops contact with 2nd molar tubes: 20o distal tip, Gingival spir: 1mm distal 2nd bicuspid
• Archwire need to reactivated 1mm each month
• After 2nd molar distalized into class I, open coil spring is trapped between
2nd bicuspid spur and 1st molar bracket to move 1st molar distally into class I
4 mm
8 mm
4 mm
3.5 mm
3.5 mm
3 mm
3 mm
3 mm
4 mm
4 mm

51. Mechanotherapy
Stage : Set 3
• Helical bulbous loop move the 2nd molar distally
• Archwire need to reactivated 1mm each month
• After 2nd molar distalized into class I, open coil spring is trapped between
2nd bicuspid spur and 1st molar bracket to move 1st molar distally into class I
• Sequential distal movement of maxillary buccal segment is supported by mandibular stabilizing arch wire
and proper directional force system.
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm
4 mm
3.5 mm
3.5 mm
3 mm
3 mm
3 mm
4 mm
4 mm

52. Mechanotherapy
Stage : Set 3
• Open each bulbous loop 1mm
• Increase bulbous opening 1mm per month until maxillary 2nd molar in class 1
• Class 2 elastic, anterior vertical elastics
• Open coil spring between second bicuspid and 1st molar to make 1st molar relationship
• Chain elastic from #6 to #7
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm
4 mm
3.5 mm
3.5 mm
3 mm
3 mm
3 mm
4 mm
4 mm

53. Mechanotherapy
Stage : Set 3
• Continuous tie from #5 to #7
• Chain elastic from #3 to #5
• Open coil spring from #2 to #3
10 mm
10 mm
2 mm
1 mm
4 mm
8 mm
4 mm
3.5 mm
3.5 mm
3 mm
3 mm
3 mm
4 mm
4 mm

54. Mechanotherapy
Stage : Set 4
• The same arch wire set 3, 0.020 x 0.025 closing loop wire
• 1st order bends: 1. lateral insets, 2. cuspid curvature, 3. 1st molar offset distal to 2nd bicuspid bracket
small amoung of 2nd molar toe in; 3rd order bend: incisor 7 LRT, cuspid 7 LCT, Molar 12 LCT
• Second order bend: 20 10 5 0 0 0
#7 #6 #5 #3 #2 #1
• Omega loop stop distal flush to the 1st molar bracket
4 mm
8 mm
4 mm
3.5 mm
3.5 mm
3 mm
3 mm
3 mm
4 mm
4 mm

55. Mechanotherapy
Stage : Set 5
• The same arch wire set 3,4 maxillary arch 0.0215 x 0.28
• 1st order bends, 2nd order bends, 3rd order bends
• Class 2 elastic, anterior vertical elastics, 0.028 spir distal to lateral for anterior elastic
• Ligate mesial bracket of 1st molar to 2nd bicuspid bracket
• Ligate and cinch around the molar tube to omega loop and continue tie to distal bracket of 1st molar
1 mm
4 mm
8 mm
4 mm
3.5 mm
3.5 mm
3 mm
3 mm
3 mm
4 mm
4 mm

56. Mechanotherapy
Stage : Set 6
• The same arch wire set #3,4,5
• Attachments add cusp seating spir distal to cuspid
• 1st order bends, 2nd order bends, 3rd order bend
• Cusp seating and anterior vertical elastic first month 24 hours, then reduce at night
• Over correction
4 mm
8 mm
4 mm
3.5 mm
3.5 mm
3 mm
4 mm
4 mm

57. Stage
•Mandibular
•Lingual bonded retainer from canine to canine
•Removable retainer to be worn during night time only for 1-year.
•Maxillary
•Removable retainer with anterior inclined plane to be worn full time for initial 6-month followed by
night time wear for another 6-month

58. Before
Treatment
K SN
F,
39 years old
Before
Treatment
C LV
M,
33 years old