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

Name:Sai Kumar



Age: 15 yrs






Sex : M
Address:KSNB Singh,Nellore
Chief complaint :
Patient complaints of forwardly placed
upper front teeth .

GENERAL HISTORY
Reason for taking orthodontic treatment: Esthetics
PHYSICAL STATUS
BUILD

: Mesomorphic

BODY TYPE : Athletic
HEIGHT

: 5.8 inches

WEIGHT

: 60 kgs


EXTRA ORAL EXAMINATION


Shape of the head: Mesocephalic



Facial form : Mesoprosopic



Facial profile

:Convex



Clinical FMA

: Average angle


Inter labial gap : 0mm
 Smile Arc :Consonant
 Lip posture and tonicity :Potentially
competent.
 Lip length :
At philtrum : 17 mm
At corner of mouth : 22 mm



Functional examination










Respiration :Nasal
Amount of incisor exposure
At rest
: 0 mm
During speech : 8 mm
During smile : 9 mm
Free way space: 2 mm
Curve of Spee = Rt 2mm & Lt 2 mm
Range of Motion
1) Maximum Opening 50mm 2) Protrusion 8mm
3) Rt Excursion 8mm
4) Lt Excursion 8mm










Jaw function/TMJ complaint now : (No)
History of Pain
: (No)
History of Sounds
: (No)
Joint tenderness to palpation
: (No)
Muscle tenderness to palpation : (No)
click on
Deflection of Mandible
Anterior disk displacement -


Right side

Left side

Class - I Molar relationship.

Class – II Molar relationship

End on Canine relationship.

Endon Canine relationship

Class –II Incisor relationship

Class –II Incisor relationships


• ‘V’ shaped arch
• symmetrical

• Midline diastema present

• ‘U’ shaped arch

• symmetrical
• Severe lower anterior
crowding

Over jet -8 mm
Overbite – 5mm
Mid line not coinciding(maxillary
dental midline shifted to right)

NO. of teeth present
87654321

12345678

87654321

TMJ
Rt & Lt condyles appears normal
Rt & Lt articular eminence appears normal

12345678

CEPHALOMETRIC ANALYSIS


CVMI

COMPLETION STAGE: GROWTH
COMPLETED

HARD TISSUE

PRE-TREATMENT
Normal

ANB

Measured

Class

2˚

5°

II

A ⊥ to B ⊥ on FH

4mm

8mm

II

AO to BO

0 – 1mm

4mm

II

Beta angle

27˚ to 35˚

30°

I

NA – Pog

0 - 5˚

7°

I

-4˚

-4°

II

Max : Mand(ANS>PNS,GoGn)

2:3

2.26:2.73

II

Harvold’s unit length difference

Chart

14

II

AB – N.pog

Skeletal Class

II

Soft tissue Profile Angle

161˚

151°

II

Total tissue Profile angle

133˚(males)
137˚(female
)

123°

II

97 + 10

87°

I

Soft tissue facial angle

Subnasale ⊥ to chin

-2.5±2.6
-15mm

II

Effects of soft
tissues if any&

I
N
F
E
R
E
N
C
E

Basic Upper lip Normal, Thick, Thin
(14+1

17mm

Soft Tissue
chin

8mm

Normal, Thick, Thin
(10+12)

Class – I

SKELETAL

Class – II

√

Class – III
Mild (2_4)

SEVERITY

Moderate
(4_6)

√

Severe (>6)
Matching

SOFT TISSUE

Compensati
ng
Aggravating

√

MAXILLA
Norms

Max apical base

Pre Rx

iPost growth
modulation
Normal maxilla

SNA

82±2˚

81˚

⊥A–N⊥

2mm

0mm

Normal maxilla

CAUSE

57.7±3.5

Max size- ANS – PNS

58mm

Normal maxilla

Max effective length Co – ANS

100.9 ±3.9

90mm

Decreased

Max placement S ⊥ NF – PTM ⊥
NF

18mm

18mm

Normally placed

MANDIBULAR APICAL BASE
SNB

80±2˚

76˚

B⊥-N⊥

-2mm

Retrognathic
mandible

-9 mm

Chin
N –Pog –FH (facial angle)

CAUSE

87˚

87˚


Normal

Norms

131.6±4.5

Mand eff. Length

Pre Rx

Post growth
modulation

104mm

MANDIBULAR PLACEMENT
Saddle angle

123±5˚

124 ˚ N

Post cranial base

32 – 35

40mm

Effect of gonial angle

128±7˚

126˚

Effect of ramus
orientation S – Ar –
Go

143±6˚

141˚

I
N
F
E
R
A
N
C
E

Maxilla

Fault
with

Size ( N )

Placement (Normal)

Mandible

Size ( )

Placement (Normal)


Pre Rx

Normal

Normal

45:55

43:57

SN – Go – Gin

32°

30°

F–M–A

25°

Post growth modulation

Mid/Lower face ht

High

Low

Soft tissue vert. prop

20

Jarabak ratio

62-65%

75%

BJORK sum

396±6°

391

Saddle angle

123±5°

124o

Articular angle

143±6°

141o

U- Gonial angle

52-55°

560

L- Gonial angle

72-75°

700

Y- axis N –S – Gin

66°

660

Y- axis FH – S – Gn

59°

580

Facial axis (Ricketts)

90°

Compensated by Ramus Ht ?


850

Basal plane angle
occlusal

to

25°

NF

11°

MP

14°

25°
110
140

Vert max placement

Nasion to ANS

62±2;50±4

52mm

Maxillary rotation

85°

89o


Per Rx

Anterior Divergent
Anterior convergent
Upward anterior rotation of
both max and mand

√

Downward anterior
rotation of both max and
mand


Post growth modulation

Pre.Rx
Sagittal affected by vertical

Sagittal caused by

Retrognathic
mandible

Sagittal worsened by
Sagittal compensated

Horizontal growth
pattern
UPPER INCISOR EXPOSURE
U1 exposure at rest

0mm

U1exposure in smile

9mm

ANS to Incisor (33±3/30±3)

32mm

U lip length (22-24/20)

17mm

INFERANCE

No excessive
exposure

P.Gr.Mod

UPPER
normal

Pre Rx

P. Gr. Mod

U1 – SN

102˚

116°

U1 – NA

22˚, 4mm

33°, 10mm

U1 - N⊥

2 – 4mm

10 mm

U1 – A Pog

25˚ , 4mm

39°, 13 mm

U1 – N Pog

10mm

15 mm

normal
Nasolabial angle

90-110°

Pre Rx
120°

Nasal angle
Labial angle

12°

U lip thickness

15 mm

17mm

5mm

11mm

Basic U lip thickness
Lip Strain


INFERENCE

Incisor
retraction
needed

In relation to
cranium and
maxilla
For camouflage
treatment

Nasolabial angle
Lip strain

SUPPORTE
D BY

Lip thickness
Lip in relation to esthetic line


6mm

9mm

LOWER
normal

Pre Rx

L1 – FH

65°

57°

L1 – MP

95°

102°

L1 – NB

25°,4mm

25°, 4mm

L1 – A Pog

25°,4mm

P. Gr. Mod

23°,1mm

L1 – N Pog

3mm

L1 – NB – NB – Pog

1:1

2:1

Mentolabial angle

120±10°

104°

L – lip thickness

12±3

20 mm

L – lip length

40±5

45 mm

INFERENCE

Lower incisor
retraction needed

In relation to mandibular

0mm

For camouflage Rx

-3mm

Mentolabial sulcus
Supported
by

Lower lip thickness
Holdaway ratio
Lip in relation to esthetic line

LAND MARKS

Facial angle

Upper lip curvature

MEAN

90º

PATIENT
VALUES

87º

INFERENCE

Convex profile

2.5 mm

3mm

Average

-2 ± 2

+3mm

Class II skeletal

7º to 15º

20º

Increased lip thickness

Nose tip to H – line

12 mm (max)

2mm

Normal

Upper sulcus depth

5 mm

6mm

Increased

Upper lip thickness

15 mm

17mm

Decreased

Upper lip strain

14 – 16

6mm

Lower lip to H – line

-1 to +2 mm

5mm

Increased LL

Lower sulcus depth

5 mm

6mm

Deep ML sulcus

10 – 12 mm

8 mm

decreased chin thickness

Skeletal convexity at A
H – line angle

Soft tissue chin thickness


lip strain present

MODEL ANALYSIS
UPPER

LOWER

Right

Left

Right

Left

10

10

6

6

7.5

7.5

6

6

8

8

7.5

7.5

7.5

8

7

7

7

7

7.5

7.5

10

10

11

11

11.5

12 TM

100.5

90

ANT 6 TM

51

39


BOLTON TOOTH RATIO
OVERALL RATIO: Mand 12 TM x 100 =89.55%
Max 12 TM
1.5mm of Maxillary tooth material excess

Ant. RATIO: mand 6 TM x 100 =76.47% ,
max 6 TM
.0427 mm of maxillary tooth material excess
ARCH PERIMETER ANALYSIS
Tooth Material

:

Arch length

:

Difference

:

Upper
81mm

Lower
68 mm

83mm

61mm

2mm
(spaceavailable)

7mm
(space required)

ASHLEY-HOWE ANALYSIS


UPPER
PMD = 40 mm



PMBAW = 42 mm PMBAW > PMD

Expansion possible

PMBAW 100;
TM

Boderline case







42100 = 41.7%
100.5



LOWER
PMD = 34 mm



PMBAW = 35mm PMBAW >PMD



Expansion possible





PMBAW 100;
TM

35100 = 38.88%
90

Boderline case















LINDER-HEARTH ANALYSIS

UPPER
MPV = 36mm
INDICATED.

CPV = 41 mm CPV >MPV EXPANSION IS

MMV = 49 mm CMV = 54 mm CMV >MMV EXPANSION IS
INDICATED.
LOWER
MPV = 31mm CPV = 28.23 mm
IS INDICATED.
MMV = 44mm
INDICATED.

CPV <MPV EXPANSION NOT

CMV = 37.5 mm CMV < MMV EXPANSION IS NOT


Upper arch
 Space discrepancy ( Arch perimeter)
= 2mm(available)
 Space obtainable by Derotation of Molars
= 0 mm
 Space required for correcting Canine rotations = 0mm
Incisor Proclination
UI to NA
= 33º
For ANB of 5º
= 19º
To retrocline
= 14x0.8 = 11.2mm
►Total space required
= 11.2-2=9.2 mm
►Discrepancy
= 9.2mm
►Space required for molar correction on RT ___mm LT___ mm
►Hence space required on
RT 4.6 mm LT 4.6 mm


Lower arch

Space discrepancy ( Arch perimeter) = 7 mm(required)
 Space required for Derotation of 34
= 0mm
 Space required for correcting Incisor =0mm

Proclination
L I to NB
= 25 º
For ANB of 5º
= 28º
To procline = 3X 0.8 = 2.4mm

►
►
►

Leveling Curve of Spee = 3 mm (normal)
Space required to establish class I molar relation =4mm on RT
Discrepancy
= 7+2.4+4=13.4mm
Hence space required on RT _8.7__mm LT_ 4.7_ mm


DIAGNOSIS AND TREATMENT PLAN
DIAGNOSIS:

ACKERMAN-PROFFIT CLASSIFICATION:
Evaluation of Facial Proportions and Esthetics:

Convex profile,
Potentially competent lips
Normal maxilla
Retrognathic mandible
Decreased chin thickness
Proclined upper and lower incisors
Protruded upper and lower incisors
Low LAFH
Obtuse nasolabial angle
AcuteMentolabial sulcus
Intra-Arch alignment and symmetry
symmetric U & L Arch
lower anterior crowding



Angle’s Class-II subdivision Dentoalveolar
malocclusion on class I skeletal base with Class – II soft
tissue profile with proclined upper and lower incisors
and severe lower anterior crowding











To level & align upper and lower arches
To correct over jet & over bite
To correct the mid line shift
To attain class I molar ,canine and incisor
relationship
Establishing soft tissue harmony
To stabilize the corrections achieved


Upper 4s and lower 5s
 PAE with MBT Mechanotherapy
 Leveling and Alignment.
 Type A anchorage on all sides except lower right
quadrant.
 Class II elastics on right side
 After achieving class I molar relation maintain Type
B anchorage in all quadrant
 Finishing & Detailing.
 Stability and Retention.



PHASE – I







0.016 round NiTi - 1 Month
0.016 X 0.022 NiTi – 1Month
0.017 X 0.025 NiTi – 1 Month
0.017 X 0.025 SS - 1 Month

4 Months

PHASE – II



0.017 X 0.025 SS Individual canine retraction - 3 Month
0.017 X 0.025 SS 4 incisors as 1 unit- 3 Month



PHASE – III








0.018 X 0.025 SS
0.019 X 0.025 SS
0.021 X 0.025 SS

- 1 Month
- 1 Month
- 1 Month

6 Months

3 Months
13 Months

SURGICAL PHASE
RETENTION & STABILITY



Permanent Upper and Lower Lingual Canine to Canine bonded Retainer





1.
2.
3.
4.
5.

6.
7.
8.
9.
10.

Retention begins with Diagnosis and
Treatment planning.
Treatment goals include

Growth
Balanced soft tissue profile

Non extraction treatment when possible 
Mandibular incisors upright on basal bone 
Good Interincisal angle

Normal root artistic positioning

Mandibular molars upright
Cuspids not expanded
Normal overjet and overbite
Class – I cuspids , cuspid protected occlusion.

Patient is non growing.
Normal MPA
Decreased Interincisal angle.
Retroclination of maxilla
Auto rotation of mandible
Down ward and backward
growth rotation of body of
mandible


Thank you
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