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1. Case Presentation
Done By: Dr. Hanan Abu Mnaizel
Supervised By:
Dr. Ahmad Al-Tarawneh
Dr. Raghda Shamout
Dr. Raed Rabta
Dr. Anwar Rahamneh

2. Personal Data
Patient’s Name : R.S
Gender: F.
Age: 13 yrs,
Occupation: Student.
Nationality: Jordanian

3. History
Trauma:- No History of Trauma.
Habits :- No Habits .
Growth status: grower.

4. Medical and Dental History
 Medical History:
Medically fit.
Previous tonsillectomy.
 Dental History :-
- Extraction of Primary teeth

5. Chief Complaint
“my upper teeth are sticking out
(pointing to her upper centrals)“

6. Extra – Oral photos
( Frontal View )

7. Extra – Oral photos
( Profile View )

8. Extra – Oral photos
( Oblique View )

9. Intra – Oral photos

10. Extra – Oral Examination
A. Skeletal Assessment
Antero-posterior assessment:
Straight proofile.

11. B. Vertical Assessment:
Average lower anterior
facial height.

12. C.Transverse Assessment
No gross facial
asymmetry .

13. Smile Aesthetics:-
On full smile the whole length of maxillary incisors show.
At rest only 3mm of the maxillary incisor show.
- Upper incisors edges do not run parallel to the lower lip ( improper
smile arc ).
- Asymmetric dental arrangement.
- Upper midline is coincident with the facial midline.
- Lower midline is shifted to the right side 1mm.
- Wide Buccal corridor.
- On smile upper incisors don’t touch the lower lip.

14. E - Line
-E- Ricket's line : a line dropped
from tip of the nose
to the chin.
-Both upper and lower lips should
behind this line. Upper lip: (2-
3mm).
Lower lip: (1-2 mm).
-Normal

15. Soft tissue Examination:-
- Equal thirds of the face.
-Upper lip in the upper third of the lower part .
-Lower lip in the lower two thirds of the lower
part.
13
23

16. Soft tissue Examination:-
- Nasal tip deviated
to the right side.
- Interpupillary
distance equal
mouth width.
- Competent lips.

17. Soft tissue Examination:-
- Frontonasial angle : 130.
“ normal 115 – 135 “
--Naso labial angle : 90 . “
normal 90 – 110 “
-- Labiomental angle 150 . “
normal 114 – 140 “

18. Intra oral Examination
- Oral hygiene: fair
- Oral Mucosa:NAD.
- Upper first molars are carious.

19. Teeth Present :-
7654321 1234567
7654321 1234567

20. Lower arch
- U-shaped arch and symmetric.
- severly crowded lower arch with lower left
central incisor displaced labially.
- Rotated RT & LT canines.
- Upright lower incisors.
- -lingually tipped RT & LT lower buccal segment.
- flat curve of spee.

21. Upper arch:-
- V-shaped arch and symmetric.
- Narrow arch.
- Severly crowded upper arch.
-palataly instanding upper laterals.
-buccaly erupting RT & LT canines.
-mesially inclined RT & LT canines.
- Buccally erupting upper second molars.
Carious upper first molars.
- Flat curve of spee.

22. Teeth in occlusion
- Incisor relationship: classI.
- Overjet: RT: 2mm. LT: -1mm.
- Overbite: 40%. On both sides : average, complete to the tooth,
atrumatic.
Midline: upper midline coincident with the facial midline.
Midline: lower midline shifted to the right
side by 1mm of facial midline.
Midline discrepancy between the upper and lower midlines

23. Buccal segment in occlusion
Molars:-
Rt: class 1 Lt: class 1
Canines:
Rt: Lt: ¼ unit class II
Cross bite:
lower left central incisor in cross bite .
.lower right canines in cross bite.
Lateral open .
Displacements:
None detected.

24. Study model analysis in occlusion
Anterioposterior:
OJ: Rt: 2mm Lt:
1mm.
Right Left
-Molar: C1
-Canine:
-Molar: C1
-Canine:1/4 unit class
II

25. Transverse
Midline discrepancy 1mm
( the lower to the right side)

26. Vertical:
average overbite 40%

27. Curve of Spee
Right Left
Flat Flat

28. Upper arch
- V- shaped arch.
- symmetrical arch.
- Intercanine width:
31mm.
- Intermolar width :
. 39mm (decreased)

30. Lower Arch
- U shaped arch.
- Symmetrical.
- Intercanine width:
(25) increased.
- Intermolar width:
(43) decreased.

31. Radiographical examination
Orthopantomogram “OPT” Analysis
no pathology.
-All teeth are present including the tooth buds of all 8 ‘s.
- Canine roots & second molar teeth are not completely formed (upper & lower
both sides).
- More radio-opacity on the distal surface of the upper central incisors due to
overlapping between the crowns of the centrals & laterals due to crowding.

32. Cephalometric Analysis
Cephalometric Analysis
83.8 ( 81 ) + -
3
SNA
82.3 ( 78 ) + -
3
SNB
1.5 ( 3 ) + - 1ANB
28 ( 27 ) + - 4MMPA
105 ( 109 ) + -6UI- MAX
97 ( 93 ) + - 6LI- MAN
125 ( 135 ) + -
10
IIA
2 ( 8 ) + - 3SN- MAX
.57 (.55) + - 2LFH
--- ---ANB*
0 .4 ( 0 ) + - 1.77WITS
Appraisal
Skeletal relationship: CL III

33. Cephalometric Interpretation
This Malocclusion can be classified as pseudoclass
III.
Pseudo class III:
Bilateral class 1 buccal occlusion and anterior
crossbite.(Lin 2007)
The pseudo class III malocclusion is either due to
(caries collapse) or small, missing or (IMPACTED
TEETH)(Perimeter collapse).

34. Interpretation
The best cephalometric discriminator between
true class III and pseudo class III is lower incisor
to mandibular plane angle. (97 proclined no
compensation). (Lin 2007).

35. CVM
CVMS 2

36. Space Analysis
Lower arch:
Space needed: 99 mm.
Space available: 97 mm.
Upper arch:
Space available:100mm
Space needed:104mm

37. Space Analysis ( continued )
53.510411778.5810.51088.576.511
AnterOverall654321123456
409711.58.58.57766778.58.511.5
Over all ratio = 93%
Normal: 91.3% + - 1.9
Anterior ratio: 74.8%
Normal: 77.2% + - 1.7
Reduced Anterio bolton ratio

39. Royal London space planning
UpperLower
-4-2Crowding and spacing
00Leveling of occlusal curve
00Incisors AP position
+2-1Inclination change
+20Arch width change
0-3Total

40. VTO – Visualized Treatment Objectives
Chart 1 : Midline Molar Position
Right
2 mm Left
Midline
mm1

41. VTO
Chart 2: Lower Arch Discrepancy
LTRT
-2
-2
0
0
Crowding 3-3
6-
6
-0.5-0.5Protrusion
00Curve of Spee
-1+1Midline
-1
-3.5
+0.5
+0.5
Total 3-3
6-6
IPR: Space gained = 3mm.
Buccal uprightening of posterior teeth= 1mm

42. VTO
Chart 3: Anticipated Treatment Change
Rt Lt
2MM
1 mm

43. Pre – treatment (IOTN)
Aesthetic Component
( No matching figure Can be
found ) Pt is Class III incisor
classification.

44. Dental Health Component:
Grade 5i
“ Extreme Need Treatment “
5i Impeded eruption of teeth
due to crowding.

45. Diagnostic Summary :-
R.S is 13 years old female patient with a history of
previous tonsillectomy, presented with a concern of (
my upper teeth are sticking out “pointing to the upper
centrals” ) .
Fair oral hygiene.
Upon examination she has class I incisor on class II
skeletal base , increase LFH , straight profile,
complicated by:
Bilateral crossbite
Sever crowding in the upper arch with palatally
instanding upper lateral incisors & buccally erupting
canines.

46. ……..Continued
V- shaped narrow upper arch .
Severly crowded lower arch , with rotated lower
canines
Upright lower incisor, labially displaced lower
left central incisor.
The lower midline shifted to the right 1mm.
Both canines ¼ unit class II
Buccally erupting upper second molars

47. Problem List:-
Pathological Problem:-
1- Fair oral hygiene.
Patient’s concern:-
R.S. is complaining that “my upper teeth are sticking out
“pointing to upper incisors”
Skeletal Problems:-
1- Class II skeletal base.
2- Mild mandibular deviation to the right side.
3- increase LFH.
4-bilateral crossbite.

48. ……..Continued
Soft tissue problems :-
2- Wide buccal corridor.
3- Improper smile arc i.e upper incisors does not
parallel to the lower lip.
4-upper incisors are not close neither touching
the lower lip.
5-Obtuse labiomental angle.

49. Dental problems :
1- severly crowded lower arch.
2-rotated Rt & Lt canines.
3- upright lower incisors.
4- ligually tipped Rt & Lt buccal segment.
5- labially displaced lower left central incisor.
6- V- shaped upper arch.
7- narrow upper arch.
8- severly crowded upper arch.
9-palatally instanding upper lateral incisors.
10- buccally erupting upper canines.

50. 11- Reduced OJ.
12- Lower midline shifted to the Rt by 1mm.
13- LL1, LR3 in CX bite,
14- Lateral open bite in

51. Treatment Aims:-
- Improve oral hygiene.
- Restoration of carious U6’s.
- Accept Pt skeletal base.
- Accept Pt soft tissue problems.
- Improve Pt smile giving him wider and symmetric smile.
- Level and align arches .
- Correct U and L midline.
- Provide space for UL3.
- Expose and tract UL3.
- Enhance space for UR3 and monitor for spontaneous eruption, if not
expose and tract.
- Close spaces after canine traction .
- Keep class I molar relationship.
- Relieve crowding.

52. - Correct crossbite .
- Correct incisors inclination.
- Correct incisor relationship.
-Achieve class I canine relationship.
- Correct OJ and OB
- Monitor the root of UL2 to avoid resorption .
- Correct anterior bolton discrepancy
-Retain the corrected results

53. Treatment Plan
( Camouflage, Non-Extraction case)
- Improve oral hygiene .
- Referral to conservative department to treat U6’s.
- High pull HG : for:-
Anchorage purpose (A-P).
Force:- 200-250 9m side
Duration:- 10-12 hours.
- Transpalatal arch.
-U and L fixed appliance ( SWA ),MBT, slot 0.0 22 )
- Open space for U3’S.
- Exposure and Traction for UL3,and UR3 if not spontaneously
erupted.
.-Stripping of lower incisors
.-Stripping in the upper arch to correct the anterior bolton discrepancy
-Retention.

54. Retention protocol
Upper arch:
Long term retention: fixed retainer (3 to 3)
Short term retention: Hawley retainer.
Lower arch:
long term retention: fixed retainer (3 to 3 ) short term:
Hawley retainer.
Upper and lower Hawley Retainers 6 months full time
wearing followed by 6 months night time wearing.

55. Justification
A. Non – extraction :-
- In lower arch with mild crowding space can be gained by
IPR.
- In upper arch with moderate crowding space can be
gained by IPR, arch wire expansion and proclination of upper
incisors.
- -Aesthetics :- give pt wider smile
-Class III grower.
B. Camouflage:-
- No dental compensation.
- Skeletal proportions aren't severe ( no need for surgery).
- Pseudo class III malocclusion.

56. Justification
C. TPA Appliance:-
- Control vertical movement of upper canines.
-To prevent buccal flaring of the upper molars by HG.
D. High pull HG:-
High anchorage demand
Preserve Cl I molar relationship
E. Fixed appliance using “ MBT “ prescription:-
1- 3-D tooth movement .
2- Maxillary incisors palatal root torque .
3- Retroclination of lower incisors.

57. Justification
F. Open space for U3’s:-
1- Class III incisor relationship.
2- More aesthetic .
3- Age of the patient.
4- Canine is a cornerstone tooth for optimum occlusion.
5-Good prognosis of the canines.
G. Stripping of lower ant teeth:-
To retract lower ant teeth to correct OJ and OB.
H. Stripping in the upper arch to correct the anterior bolton discrepancy:-
Reduced anterior bolton ratio (74.8%)
The M-D width of the upper incisors is larger than the average according to
(Berkowitz et al, 2009)

58. Justification
I. Retention:-
A. Lower fixed ( 3-3) to stabilize the position of lower
anterior teeth.
Prevent late mandibular crowding.
B. Upper fixed ( 3-3) to :-
1- Stabilize the position of upper anterior teeth.
2- Impacted canines, median diastema.
C. Hawely Retainer:- for more settling and stability of
incisor relationship and other posterior teeth.

59. Mechanics
- Cinch back and lace back in lower arch to avoid
proclination of lower labial segment .
- Postpone lower DB after the upper to avoid creation of reverse
overjet.
- Swapping lower canine bracket to avoid mesial tipping of lower
canines.
- Push-pull mechanics involving lace- back ( pull )and open- coil
spring between 2 and 4 region ( push ) with second order bend to
avoid distal tipping of lateral incisor root and so avoid root resorption
by upper canines.

60. Mechanics
- Stripping on around wire in lower arch will facilitate
retroclination in lower incisors.
- Consider using of anterior elastics to correct reduced bite.
- Don’t reach lower working arch wire before upper arch.
- Use of high pull H.G help intrusion of upper posterior teeth
and control of positive overbite.
- Arrange open exposure of UL3 & Closed exposure of UR3
and apply attachment -after reaching rigid arch wire and
opening enough space.

61. Mechanics
- Don’t start traction until rigid A.W is reached to avoid
bite opening .
- Attachment should be placed on labial surface, if not
applicable change its position immediately when
possible.
- Use MBT prescription since class III camouflage benefit
from lingual root torque of the upper incisors and
lingual crown torque of lowers .
- Apply third order bend to achieve proper inclination of
the canines roots.

62. Treatment Details
- Anchorage Preparation:-
1- Impression for TPA after band selection.
2- fitting of high pull HG.
- Bond up upper arch ( MBT 0.022 ) in conventional position
without modification to:- achieve tooth movement 3D.
- Alignment stage start with 0.014 superelastic Niti full
engagement ( bypass U3s ), then 0.018 superelastic Niti.
- Bond up lower arch MBT and start alignment by 0.014 Niti
superelastic.
- 0.016 * 0.022 Niti A.W.

63. Treatment Details
- Working A.W in upper arch 0.019 * 0.025 S.S.
- Open coil spring between U2’s and U4’s and second
order bend to counteract distal root tipping of U2’s (if
needed).
- Periodic follow up by PA x- rays to avoid lateral incisor
root resorption.
- If canines didn’t erupt spontaneously expose and tract
using gold chain. RT: open exposure, Lt:close exposure.

64. Treatment Details
- -Stripping in the lower arch and place 0.018 SS A.W and close
spaces using P.C .
- -Consider ant elastics for more bite control .
- When canines close to the line of the arch consider piggy-back.
- Finishing A.W ( 0.019 *0.025 TMA ) .
- 0.014 Niti with settling elastics.
- -Debonding
- -Impressions for U and L HR
- Permanent retainer placement .