Case presentation 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: Want to align lower teeth and hide upper gum during smiling.
Medical History: Some Remarkable
Dental History:
•Regular check up every 6 month
•Root canal treatment and crown #46
Family History: Unremarkable
Family History: Unremarkable problem
1. Interviews / Questionnaire
Patient Initial: U SP Age: 32y , Sex: f, Birth Date: August 4,1987
Heigh:1.58 m , Weigh: 48 kg, Career: Pharmacist

3. 3
2. Clinical Examination

4. 4
2. Clinical Examination
Soft-tissue assessment
•Frontonasal angle:125.37o
(Normal 115o -135o)
•Nasolabial angle:91.07o
(Normal 90o -110o)
•Labiomental angle:146.29o
(Normal 114o -140o)
• Lower Lip tonicity
•Thick upper lip
•Soft tissue profile: 168o Slightly(165o-
175o)
•Full soft tissue profile:143o (M 1470, F 1330 )
•Nose: straight
•Increase lower anterior facial heigh
•Dental class II
•<2mm to soft tissue pogonion
•FMPA(25o): Normal angle
168o
143o

5. 5
2. Clinical Examination
Soft-tissue assessment
•Increase upper facial heigh
•Competent lip
•Mild facial Asymmetry face
•Short upper lip length
•Imbalance vertical facial height
•Imbalance vertical lip-chin
•Potentially competent lips
•Body type: Athletic
•Shape of head: Mesiocephalic
•Facial form: Mesoprosopic
•Tip of nose deviation to the right
•Chin deviation to the right side
17mm (1/3)
32mm (>2/3)

6. 6
2. Clinical Examination
Smile Aesthetics assessment
•Gummy smile on upper teeth
•Incisal edges of upper teeth 10%
hidden by lower lip.
• Small on right buccal corrido
•No teeth show on lower teeth
•Smile: wide
•Smile arch: straight
•Smile is not acceptable
•Lower midline to upper midline off
to the right side by 0.5mm
•Contact point: not good(50%,40%,30%)
•Embrassure not well
form(20%,30%,40%,50%)
•Hypertonic lower lip
50%
40% 40%
20%40%

7. 7
2. Clinical Examination
Smile Aesthetics assessment
•Gummy smile(Dento-alveolar etiology)
•Narrow on right buccal corridors(dark buccal corridors)
•Hidden upper incisor edges by lower lip 10%-15% (thick lower lip, thin upper lip)
•Gingival display level left central incisor is higher 0.5mm from right central incisor lateral teeth
0.5mm from central
•Gum color: pink, texture: normal, shape: scalloped
•Normal frenal attachment level
•Tooth width ratio non balance(x,x-1mm,x-2mm)

8. 8
2. Clinical Examination
Smile Aesthetics assessment
•Asymmetry margin of gingival level

9. 9
2. Clinical Examination
Smile Aesthetics assessment
•Volume of interdental papilla formation is 45%(ideal 40%-50% length max incisor)

10. 1
0
2. Clinical Examination(Orthopantomograph-OPT)
TMJ
•No signs of TMD(No clicking, crepitus, and tenderness to palpation)
•Normal range of opening, lateral movement and no displacement.
•No erosion
•Normal opening and side to side openning
•TMJ space obliterated on the right side. Also associated with mild condylar resorption
on the same side.
•Normal condyles

11. Evaluation:
•RCT #46
•Crown #46

12. 2. Clinical Examination(Cervical Vertical Maturation-CVM)
Evaluation:
•Stage 5(>2 years prior to peak growth)

13. Evaluation:
•Mild asymmetry face
ZL
ZL
JL
JR
AG GA
Facial width
occlussal plane
Nasal width
Me
34mm 34m
41mm 44mm
43.8mm
43.8mm
14mm 14.5mm
27mm 29mm

14. 1. Molar class I, canine class I, lower arch: asymmetric constricted arch
2. Incisor class III(edge to edge)
3. Molar class I, canine class I
4. U-shape arch form, attrition #16,26,staining #17,18,27,28. Rotate #14,15, assymetry arch form
5. Over jet 2mm, over bite 10%
6. Crowding #41,#42,#32,z#32. Rotate #34,#44. U shape arch form
7. Soft tissue: good, Normal tongue size and function
8. Attached gingival scaring
9. Fair oral hygient, good oral mucosa, no teeth missing, no mid line shift, crack #13,#23
10. Normal tongue position, Normal palate
11. IOTN: grade 2
1 2 3
4 5 6

15. 12. Teeth present
12. Caries: clinically caries free
1 2 3
4 5 6
87654321 12345678
87654321 12345678

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

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

18. Bo
Po
Co
S pt
Go
PNS
ANS
Or
N
A
B
Me
Gn
Pog
Ba
Facial angle(84.04 3.42)=91
Y-axis(66.36o+-3.85o)=58o
Gonial angle(118o+6.10o)=112o
FMA(30o)=17o
IMPA(103o)=104o
FMIA(47o)=61o
SNA(80o)=81o
SNB(74o)=80o
ANB(6o)=5o
OCC(13o)=3o
Z(74o)= 75o

19. Soft tissue analyis
•Z-angle(80±5)=75o
•Upper pharynx=8mm
•Lower pharynx=4mm

20. AREA OF STUDY YAS MEASUREMENT STANDARD INITIAL INTERPRETATION
Cranial Base BA–S-n 130o 141o
Long face
Maxilla to Cranial Base SNA 82 o 81o
Prognathic maxilla
N-A-FH 90 o 97o
A-Nas Vert. (mm) -2mm 10mm
Mandible to Cranial Base SNB 80 o 76o
Retronathic
mandible
NPog-FH 88 o 91o
Po-N Vert. (mm) -6mm 0o
Maxillo-Mandibular Relationship ANB 2 o 5o
Class IIA-NPog 1mm 2mm
Wits 2mm 5mm
Vertical Height SN-MPA 32 o 32o
Mandibular plan height
angle
Normal facial heigh
FMA 25 o 15o
N-ANS (%) 45% 42%
ANS-Me (%) 55% 58%
Maxillary & Mandibular Incisor Position U1-SN 104 o 106o
proclination of upper
incisor
proclination of lower
incisor
U1-NA (mm) 4mm 2mm
U1-NA 22 o 27o
IMPA 90 o 101o
L1-NB (mm) 4mm 3mm
L1-NB 25 o 31o
L1-APog 2mm 6mm
U1-L1 130 o 119o
Soft Tissue E-line-Lower lip -2mm 0mm Protrusion of the lip

21. ODI=FH pl. to palatal plan angle + AB to mandibular plan angle=8.5O+78O=86.5O
Openbite tendency<(74.5O±6.07O)<Overbite tendency
=> Overbite tendency
Bo
Po
Co
S pt
Go
PNS
ANS
Or
N
A
B
Me
Gn
Pog
Ba

22. •APDI=FH to palatal plane angle(8O)+Facial angle(91O)+AB plane
angle(7O)=8O+91O+7O=106O => Class III tendency
(Class II tendency<(81.4O±3.79O<Class III tendency)
•Facial angle(84.04O±3.42O)=FH to Npog=91O => Prominance of chin
•Y-axis(66.36O±3.85O )=FH-SGo=54O=> Class III facial pattern
•Gonial angle: Ar-Go to Go-Me=119O (122+-6.9 for female, 119.1+-6.5 for male)=>Open bite tendency
Bo
Po
Co
S pt
Go
PNS
ANS
Or
N
A
B
Me
Gn
Pog
Ba
Ar

24. 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 8.5 10 7 7 6.5 6 8 8 6 7 7 6 10 9 106
Man 9 11 6.5 7 6 6 5 5 5.5 6 7 7 10.5 9.5 101
2. Arch segments lengths
7-6 5-4 3-2 1-1 2-3 4-5 6-7 sum
Max 19 13.5 12 16 13 13 20 106.5
Man 20 13.5 10 9.5 10.5 13.5 20 97
Total max ant=41.5mm
Total man ant=33.5mm

25. 3. Model Analysis
3. Arch length determination
Max Man
Intercanine width 34mm(N=39) 25mm(N=23-24.7)
Intermolar width 43mm(N=47) 40mm(N=43)
Arch length 36mm 32mm
Arch form U form V form(tapered)
Arch length discrepancy Avialable –Required=
106.5-106=0.5mm(spacing
0.5mm)
Avialable –Required=
97-101.5=-4mm(crowding
4.5mm)
Overbite 1mm
Overjet 1mm
Curve of spee 2 mm

26. 25mm
27mm
40mm
49mm
32mm

27. 36mm
34mm
27mm
43mm
49mm
39mm

28. 3. Model Analysis
Standard Patient’s index
Overall ratio 87.5-94.8 97/106.5=91.07%
(Man/Max)
Anterior ratio 74.5-80.4 33.5/41.5=80.7%
(Man6/Max6)
4. Bolton Index
Mandible:Maxilla(12
teeth)
Mandible(6 teeth)>Maxilla(6
teeth)

29. 3. Model Analysis
5. M-D width of tooth
Anterior tooth Ratio
= Sum of (M-D) width of mandubular anteriors x 100
Sum of (M-D) width of maxillary Anterior
= 41/33.5 x 100 = 122 %
Result>72.2%= Mandibular excess.
Overall tooth Ratio
Mandibular excess= Actual mandibular 12 – Correct mandibular 12
= 82.5-87 = -4.5mm

30. 3. Model Analysis
6. Pont’s Analysis
ON MAXILLA
•SI=sum of incisor 4= 6+8+8+6=28mm
•MPV(Mesured premolar value)=39mm
•MMV(Mesured molar value)=43mm
•CPV(Calculated premolar value)=SIx100/80=28 x 100/80=35mm
•CPV(35mm)<MPV(39mm) Arch form is normal so no need to expand the arch
on incisor and premolar area
•CMV(Calculated molar value)=SI x 100/64=28 x 100/64=43.75mm
•CMV(43.75mm)>MMV(43mm) Arch form is normal so need to expand the
arch abit or no need on molar area
ON MANDIBLE
•SI=sum of incisor 4= 6+5+5+5.5=21.5mm
•MPV(Mesured premolar value)=35mm
•MMV(Mesured molar value)=45mm
•CPV(Calculated premolar value)=SIx100/80=21.5 x 100/80=21.8mm
•CPV(21.8mm)<MPV(35mm) Arch form is normal so no need to expand the
arch on incisor and premolar area
•CMV(Calculated molar value)=SI x 100/64=21.5 x 100/64=33.59mm
•CMV(33.59mm)<MMV(45mm) Arch form is narrow so need to expand the
arch abit

31. 3. Model Analysis
7. Korkhaus analysisis
Man Value=Max value -2mm
18mm=21-2mm=19mm
=> Procline upper incisor 1mm
32mm
39mm
21mm
18mm

32. Diagnosis summary
• U PS is a 31 year olds female, denied any medical problem , complains of
upper teeth forward, crowding lower anterior teeth and gummy smile.
She has a class I incisor relationship as edge to edge incisor base on class
II skeletal pattern, increased lower facial height. Over jet of 1mm, deep
over bite 5%, lower midline shift to the right 0.5mm, mildly crowed lower
anterior teeth. Canine is class I on both side, actually molar class I on
both sides.

33. Diagnosis
3. Transverse
•Mid line shift
4. sagital(A-P)
•Decrease over-jet
1. Dentofacial Appearance
Asymmetric
Disproportionate
2. Teeth/Arch form
CrowdingProfile
Slightly convex
Lips
Gummy smile Incisor display
Excessive
5. Vertical
Unproportion vertical facial

34. Treatment Aims
• Improve O.H
• Relief crowding on lower arch and align teeth
• Correct midlines shift
• Correct skeletal discrepancy
• Achieve incisor class 1
• Achieve normal OJ & OB
• Obtain flat curve of spee
• Finishing and detailing of occlusion
• Correct gummy smile
• Correct smile arch and gummy asymmetry
• Retain corrected results

35. Treatment progress
Problem list Treatment Auxiliaries' and times
1. Staining#17,18,27,28, plaque and
calculus, crack #13,#23
1. Scaling, polishing ,oral hygiene
education, observation on #13,23
2. Straight smile arch and gummy smile 2. Low bracket position(x-1mm)
2. Severe crowding #41,#42,#31,#32,
slightly protrusion of upper lip
2.1. Extraction #18,#28
2.2. Extraction #38
3. Rotate #14,15, asymmetry arch form,
Crowding #41,#42,#32,z#32. Rotate
#34,#44
3. Leveling and alignment, TPA
intrude posterior segment to reduce
gummy smile
3. Niti 012, 014, 016
upper and lower (3
months), TPA
4. Space after extraction #46 4.1.Rectraction upper teeth
4.2. Retraction lower teeth
4.3. Intrude and distalization #16
with headgear
4. Maximum anchorage
Lower lingual arch,
0.028 x 0.025, TPA,
Headgear

36. Treatment progress
Problem list Treatment Auxillaries and times
6. Gummy smile correction 6. Gingival reshape
- Maxillary incisor intrusion
6. Mini-screw anchorage
6.1. Gummy smile correction 6.1. Two mini-screw implant billateral
Inserted between central and lateral
incisor teeth
6.1. SS 0.016 x 0.022, closed
coil spring attached to
segment arch
6.2. Asymmetry margin of gingival level 6.2. Gingival reshape position Blade No.11 and
measurement
7. Retention 7. 1. Lower Hawley’s retainer
7.2. Upper Hawley’s retainer
Hawley’s retainer

37. Treatment progress2
Problem list Treatment Auxiliaries' and times
1. Staining#17,18,27,28, plaque and
calculus, crack #13,#23
1. Scaling, polishing ,oral hygiene
education, observation on #13,23
Redo-RCT #46 and temporary crown
2. Straight smile arch and gummy smile 2. Low bracket position(x-1mm)
2. Severe crowding #41,#42,#31,#32,
slightly protrusion of upper lip
2.1. Extraction #18,#28
2.2. Extraction #38,#48
2.3. Stripping #33=>#43
3. Rotate #14,15, asymmetry arch form,
Crowding #41,#42,#32,z#32. Rotate
#34,#44
3. Leveling and alignment, TPA
intrude posterior segment to reduce
gummy smile
•Arch wire on lower teeth skip
#31,32,41,42. lower holding arch
3. Niti 012, 014, 016
upper and lower (3
months), TPA, lower
holding arch

38. Treatment progress2
Problem list Treatment Auxillaries and times
6. Gummy smile correction 6. Gingival reshape
- Maxillary incisor intrusion
6. Mini-screw anchorage
6.1. Gummy smile correction 6.1. Two mini-screw implant billateral
Inserted between central and lateral
incisor teeth
6.1. SS 0.016 x 0.022, closed
coil spring attached to
segment arch
6.2. Asymmetry margin of gingival level 6.2. Gingival reshape position Blade No.11 and
measurement
7. Retention 7. 1. Lower Hawley’s retainer
7.2. Upper Hawley’s retainer
Hawley’s retainer

39. Before
Treatment
UN SOPHEAP
F,
31 years old

40. Treatment progress
Problem list Treatment & link to photo Date Lecturer
1. Staining#17,18,27,28, plaque
and calculus, crack #13,#23
1. Scaling, polishing ,oral
hygiene
education, observation on
#13,23
30/5/2019 Dr. Anan
2. Release crowding, leveling
and alignment with
MBT(bracket 0.022)
2. Upper and lower bracing 30/6/2019 Dr. Anan
3. Release crowding, leveling
and align ment with
MBT(bracket 0.022)
3. Upper 0.014, lower 0.012 22/8/2019 Dr. Anan

41. Thanks in depth

42. Patient’s Intention