Sorry for any mistake

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

2. Chief Complaint: Want to correct upper teeth backward and difficulty
in chewing
Medical History: Unremarkable
Dental History: Never check-up
Family History: Unremarkable
1. Interviews / Questionnaire
Patient Initial: T S Age: 32y , Sex: f, Birth Date: July 10,1986

3. 3
2. Clinical Examination
Evaluation: convex profile , imbalanced vertical lower, middle
,upper facial proportion, imbalanced faced upper and lower,
No gingival display on smiling, asymmetrical face, lip tonicity
and incompetent lips.
1/3 X
1/3 X
1/3 X
1/3
2/3

4. 4
2. Clinical Examination
Soft-tissue assessment
•Frontonasal angle:
(Normal 115o -135o)
•Nasolabial angle:
(Normal 90o -110o)
•Labiomental angle
(Normal 114o -140o)

5. 5
2. Clinical Examination
Smile Aesthetics Assessment
•No gingival shown
•70% crown of incisor show
•Smile extend to canine
•No lower teeth show
•Not acceptable smiling

6. Evaluation:
•impacted #18
•secondary caries #28

7. 7
Evaluation: increased overjet(7mm) , deep overbite(80%) , Incisor class II div I,
Canine Relation : Cl I on Right side and Cl I on left side. Caries #37o, #47o,#28o
crowding #41,#42,#34 , Rotated #43,#47,#34,#38,#44,#12, asymmetric lower and
upper arch, small maxillary torus

8. 8
2. Clinical Examination
Lower arch
•v-shape of lower arch
•Arch form asymmetry
•Crowded #41,42,31
•Rotated #43,#47,#34,#38

9. 9
2. Clinical Examination
Lower arch
•U-shape of upper arch
•Proclined upper incisor
•Slight lingually #14

10. 1
0
2. Clinical Examination
Periodontal health and teeth health
•Periodontal health: fair oral hygient
•Dental health: staining on upper teeth bucally and labially,
decalcification on buccal upper and lower teeth

11. N
Or
ANSPNS
pt
Co
Ba
Po
Bo
Me
Gn
Pog
B
A
S
Go

12. N
Or
ANSPNS
pt
Co
Ba
Po
Bo
Me
Gn
Pog
B
A
S
Go

13. MAXILLO-MANDIBULAR:
ANB- 10
A-NPOG- -1.5mm
WITS- -5.5mm
 Skeletal class I
AREA OF STUDY YAS MEASUREMENT STANDARD INITIAL INTERPRETATION
Cranial Base BA–S-n 130o 140o
Long face
Maxilla to Cranial Base SNA 82 o 82o
Prognathic maxillaN-A-FH 90 o 95o
A-Nas Vert. (mm) -2mm 5mm
Mandible to Cranial Base SNB 80 o 77o
Prognathic
mandible
NPog-FH 88 o 90o
Po-N Vert. (mm) -6mm 0o
Maxillo-Mandibular Relationship ANB 2 o 5o
Class IIA-NPog 1mm 5o
Wits 2mm 1.5mm
Vertical Height SN-MPA 32 o 37o
Mandibular plan
hiegh angle
Normal facial heigh
FMA 25 o 25o
N-ANS (%) 45% 47%
ANS-Me (%) 55% 53%
Maxillary & Mandibular Incisor
Position
U1-SN 104 o 114o
proclination of
upper incisor
proclination of lower
incisor
U1-NA (mm) 4mm 9mm
U1-NA 22 o 33o
IMPA 90 o 102o
L1-NB (mm) 4mm 8mm
L1-NB 25 o 34o
L1-APog 2mm 6o
U1-L1 130 o 107o
Soft Tissue E-line-Lower lip -2mm 5mm Protrusion of the lip

14. N
Or
ANSPNS
pt
Co
Ba
Po
Bo
Me
Gn
Pog
B
A
S
Go
ODI=FH pl. to palatal plan angle + AB to mandibular plan angle=8O+76O=84O
Openbite tendency<(74.5O±6.07O)<Overbite tendency

15. N
Or
ANSPNS
pt
Co
Ba
Po
Bo
Me
Gn
Pog
B
A
S
Go
•APDI=FH to palatal plane angle(8O)+Facial angle(93O)+AB plane
angle(7O)=8O+93O+7O=108O
(Class II tendency<(81.4O±3.79O<Class III tendency)
•Facial angle(84.04O±3.42O)=FH to Npog=93O
•Y-axis(66.36O±3.85O )=58O
•Gonial angle: Ar-Go to Go-Me=122O

17. 3. Model Analysis
1. M-D width of tooth
6 5 4 3 2 1 1 2 3 4 5 6 Sum
Max 12 8 8 9 8 10 10 8 9 8 8 12 110
Man 12 8 8 8 7 6 6 7 7 9 9 12 106
Anterior tooth Ratio
= Sum of (M-D) width of mandubular anteriors x 100
Sum of (M-D) width of maxillary Anterior
= 41/54x 100 = 93 %
Result>72.2%= Mandibular excess.

18. Overall tooth Ratio
= Sum of (M-D) width of mandubular anteriors x 100
Sum of (M-D) width of maxillary Anterior
= 75/86x 100 = 87 %
Result>72.2%= Mandibular excess.
Mandibular excess= Actual mandibular 12 – Correct mandibular 12
= 94-106 = -10mm

19. Diagnosis summary
• T S is a 16 year olds female, denied any medical problem , complains of
upper teeth forward and crowding lower anterior teeth. She has a class II
div 1 incisor relationship base on class II skeletal pattern, increased lower
facial height incompetent thick lips, and a convex facial profile. Over jet of
7mm, deep complete over bite 90%, lower midline shift to the right 2mm,
mildly crowed lower anterior teeth. Canine is class II on both side,
actually molar class I on both sides.

20. Diagnosis
3. Transverse
•Anterior Cross bite
•Mid line shift
4. sagital(A-P)
•Dental class II
•Canine class II
•On both sides
•Increase over-jet
1. Dentofacial Appearance
Assymmetric
Disproportionate
2. Teeth/Arch form
CrowdingProfile
Convex
Lips
Protrusive Incisor display
Excessive
5. Vertical
•Deep bite

21. Problem list
• increased overjet(7mm) , deep overbite(80%) , Incisor class II div I, Canine Relation : Cl II on Right side and
Cl II on left side.
• Caries #37o, #47o,
• Protrude upper incisor and crowding #41,#42,#31
• Rotated #43,#47,#34,#38
• Asymmetric lower and lower arch form
• Small maxillary torus
• Mid line shift to right 2mm
• Skeletal
– Class II skeletal pattern ANB=5o, retrude chin
– Increase lower facial height
– Mild Asymmetry
• Soft tissue
– Convex profile
– Incompetent lips
• Dental
– Lower mid line shift 2mm to the right
– Increased over jet 7mm
– Deep complete over bite 95%
– Out of the arch lower right canine
– Rotated lower right
– Procline upper incisor
– Lingually position right canine
– Lower incisor crowding
– Anterior bolton discreapancy
– Mandible accessive
• Other
– Condyle errosion

22. Treatment Aims
• Scaling, prophy and OHI
• Filling caries #37(o), #47(o)
• Leveling and alignment
• Relieve crowding #41,#42,#31
• Correct the anteroposterior relationship
• Develop an ideal overjet & overbite.
• Skeletal
– Retrude chin
– Increase lower facial height
– Mild Asymmetry
– Maintain good profile
• Soft tissue
– Straight facial profile
– Achieve lip competence and reduce the labiolmental fold
• Dental
– Correct lower mid line shift 2mm to the right
– Correct Overjet
– Correct Overbite
– Correct mal-position of teeth
– Alignment rotated teeth,
– Closing space and level of curve of spee
– Correct lower mid-line shift
– Class I of canine on both sides(Maxillary canine retraction) class I canine and molar relationship

23. Treatment Plan
1. OHI
2. Filling teeth #37o, #47o
OPTION 1
1. Leveling and alignment
2. Extraction #14,#24
3. Upper TPA
4. Maxillary and mandibulary retraction
5. Correct mid-line shift
6. Correction deep bite
7. Final settling of the occlusion and arch coordination.
8. Upper and lower fixed appliance(MBT)
9. Fixed appliance with class II elastic
10. Retention(upper Hawley retainer, lower fixed retainer)
OPTON 2
1. Standard bracket
2. First order bend, third order bend and second order bend
3. High pull headgear upper and lower teeth

24. Treatment Progress
OPTION 1
1. Leveling and alignment
2. Maxillary first premolars were extracted on both side
3. Upper and lower fixed appliance(MBT)
4. Upper TPA
5. Fixed appliance with class II elastic
6. Maxillary and mandibulary retraction with elastic class II
7. Correction deep bite
8. Final settling of the occlusion and arch coordination.
9. Retention(upper Hawley retainer, lower fixed retainer)
OPTON 2 (10-2 system)
1. Leveling and alignment
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment

25. Treatment Progress
OPTON 2 (10-2 system)
Wire (.017 x .022 upper arch and .018 x .025)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200 .017 x .022
50 .018 x .025

26. Treatment Progress
OPTON 2 (10-2 system)
Wire (.017 x .022 upper arch and .018 x .025)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200
.017 x .022
50 .018 x .025
High Pull Headgear
High Pull Headgear
50100
Change to mini screw
Change to mini screw

27. Treatment Progress
OPTON 2 (10-2 system)
Wire (.017 x .022 upper arch and .018 x .025)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200
.017 x .022
50 .018 x .025
High Pull Headgear
High Pull Headgear
50100
Change to mini screw
Change to mini screw

28. Treatment Progress
OPTON 2 (10-2 system)
Wire (.017 x .022 upper arch and .018 x .025)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200
.017 x .022
50 .018 x .025
High Pull Headgear
High Pull Headgear
50100
Change to mini screw
Change to mini screw

29. Treatment Progress
OPTON 2 (10-2 system)
Wire (.017 x .022 upper arch and .018 x .025)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200
.017 x .022
50 .018 x .025
High Pull Headgear
High Pull Headgear
50100
Change to mini screw
Change to mini screw

30. Treatment Progress
OPTON 2 (10-2 system)
Wire (.017 x .022 upper arch and .019 x .025)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200
.017 x .022
50 .019 x .025
High Pull Headgear
High Pull Headgear
50100
Change to mini screw
Change to mini screw

31. Treatment Progress
OPTON 2 (10-2 system)
Wire (.020 x .025 for upper arch and .019 x .025 for lower arch)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200
.020 x .025
50 .019 x .025
High Pull Headgear
High Pull Headgear
50100
Change to mini screw
Change to mini screw

32. Treatment Progress
OPTON 2 (10-2 system)
Wire (.0215 x .028 for upper arch and .0215 x .028 for lower arch)
1. Leveling and alignment with multiple loop or Niti 0.012
2. Maxillary and mandibular first premolars were extracted
3. Retraction both maxillary and mandibuar canines with high pull headgear
4. Prepare for terminal molar for stress resistance
5. Make closer space on maxillary and mandible canine with power chain
6. Sequence anchorage preparation in mandibular and maxilla molar
7. Retract canine with power chain and make closing loop on 1.5mm distal incisor bracket
8. Use class 3 elastic and esthetic arrangement
9. Recovery on functional and static muscular element of environment
200
.020 x .025
50 .019 x .025
High Pull Headgear
High Pull Headgear
50100
Change to mini screw
Change to mini screw

33. Treatment progress
Tweed Technique
Problem list Treatment Date lecturer
1. Staining, plaque, calculus and
gingivitis
1. Scaling, polishing ,oral
hygiene education
25/3/2019 Dr. Anan
2. Severe crowding
#41,#42,#31,#32,
#11,#12,#21,#22
2. Multiple loop (0.012 ss) to
release #41,#42,#31,#32,
#11,#12,#21,#22 severe
crowding
25/4/2019 Dr. Anan
2. Severe crowding
#41,#42,#31,#32,
#11,#12,#21,#22
2. 0.012 Niti to release #31
crowding teeth
25/5/2019 Dr. Anan
3. Procline #11,#21,#31,#41 3. 0.012 Niti upper and
lower
20/8/2019 Dr. Anan
4. Spacing #14,#24,#34,#44 4. Upper set 1
NITI lower 0.012
29/8/2019 Dr. Anan

34. Thanks in depth