orthodontics

1. Case presentation
Prepared by:
Dr. Ali M. Alsayani
3rd year orthodontic resident

2. Personal data
 Patient’s name : A. B
 Gender : Male
 Age: 14 years
 Occupation : Student
 Address : Marj alhamam
 Nationality: Jordanian

3. Medical & Dental History
 Medical History:
 Denied any medical problems .
 Dental History:
 Refer from routine clinic.
 Habits: No habits.
 Motivation: Internal motivated.

4. Chief Complaint
 I don’t like the appearance of my upper
anterior teeth.

5. Extra-Oral Photos
Frontal view

6. Profile view

7. Oblique view

8. Extra-Oral examination
Skeletal assessment:
 Anteroposterior assessment:
 Class III Skeletal pattern

9. Skeletal assessment
Transverse assessment :
 Symmetrical face

10. Skeletal assessment
Vertical assessment :
 Average LAFH .

11. Soft Tissue Examination
 Asymmetrical face.
 Straight profile.
 Competent lips.

12. Soft Tissue Examination
 Frontonasal angle:
130˚ (Normal 115⁰-135⁰)
 Nasolabial angle:
98˚ (Normal 90⁰-110⁰)
 Labio-mental angle
135˚ (Normal 114⁰-140)

13. Intra-oral photos

14. Intra-oral Examination:
 Teeth present
76543X1 1X34567
7654321 1234567
 Fair oral hygiene.
 High frenum attachment
between upper centrals

15. Lower Arch:
 U shape arch.
 Anterior segment :
well aligned teeth except LL3
rotated.
 Posterior segment:
rotated Lt 2nd premolar.
lingually tilted Rt 1st molar.

16. Upper Arch:
 U shape Arch
 Anterior segment:
Well aligned central incisors
with diastema.
Missing lateral incisors.
Upright Lt canine.
Rotated Rt canine .
 Posterior segment:
Rotated Rt & Lt 1st premolars.
Rotated Rt & Lt 1st molars.

17. Anterior segment
• Class III incisor relationship.
• Midline is coincident
• Overjet: 1mm.
• Overbite: reduce overbite
10%.

18. Buccal segment
 Molar relationship : class II full unit Rt side & class II ½ unit
Lt side.
 Canine relationship : class II ¾ unit Rt & Lt sides.

19. Study Models Views

20. Frontal View
• Class III incisor relationship.
• Midline coincident.
• Overjet: 1mm.
• Overbite: reduce overbite 10%.

21. Right Lateral View
 Molar relation : Cl II full unit.
 Canine relation : Cl II ¾ unit.
 No crossbite .

22. Left Lateral View
 Molar relation : Cl II ½ unit.
 Canine relation : Cl II ¾ unit.
 No crossbite .

23. Posterior Anterior View
 Incomplete reduce overbite 10 % .

24. Lower Occlusal View
 U shape arch .
 Inter canine width
(3—3 ) = 27 mm.
( Increased )
 Intermolar width
(6-6) = 42 mm.
( Normal )

25. Upper Occlusal View
 U shape Arch.
 Inter canine width
(3 – 3) = 28mm
( Reduced )
 Inter molar width
(6 – 6) = 45mm
( Normal )

27. Curve of Spee
Normal flat curve of spee in both sides.

28. Space analysis
Maxilla
Right Left
7 7 8 x 8.5 8.5 x 8 7 7
Mandible
5 4 3 2 1 1 2 3 4 5
7.5 7 7 6 5.5 5.5 6 7 7 7.5
 Lower arch:
space available = 65
space required = 66
(-1) Mild crowding
 Upper arch :
 in case of open space to replace the missing laterals , according to anterior
bolton ratio ; 37 = 2X + 33 x 0.772 so, X= 11.55/2 = 5.8mm.
space available =67
space required=61 + 11.55(space for laterals) = 72.55
(-5.55) Moderate crowding

29. Index Of Orthodontic Treatment Need (IOTN)
- Aesthetic Component -
Not available

30. Index Of Orthodontic Treatment Need (IOTN)
- Dental Health Component -
 Grade 4
 4h.less extensive
hypodontia
(one tooth per
quadrant)

31. -All teeth are present except upper laterals.
-Condyles are in normal shape and position.
-No bony pathology.
OPT

32. Cervical Vertebral Maturation
CS4 :
Peak of mandibular growth
has occurred within 1 or 2
yrs.' before this stage .
10% - 25% remaining.

33. Cephalometric Analysis
normalPre-
treatment
variable
81 +/-378SNA
78 +/-377.2SNB
3 +/-10.8ANB
8+-34SN-MX
1mm-1.5mmWits
appraisal
27+/- 424FMPA
109 +/-6110UI/Mx plane
93 +/-697LI/Mand
plane
133 +/-10126Interincisal
angle
27 +/-425.5MM angle
55+/_257%Lower Face
height ratio
59-63%61%Jaraback
ratio

34.  Diagnostic summary
A 14 years old male, denied any medical problem, presented
with concern about the appearance of his upper anterior
teeth , fair oral hygiene and high frenum attachment .
He has a class III incisors relationship on class III skeletal
base, with straight profile, average lower anterior facial
height , competent lips and asymmetrical soft tissue face.
Dentally, he has missing upper laterals , reduce over jet
1mm, incomplete reduce overbite 10% ,mild crowding
lower arch , moderate crowding upper arch, rotated LL
3&5 , lingually tilted LR6, rotated UR 3,4&6, UL 4&6 ,
midline coincident .
He has cl II full unit in RT molar, cl II ½ unit in LT side &
cl II ¾ unit in canines both sides and normal curve of spee.

35.  Problem list
 Pathological problems:
◦ Fair O.H.
◦ High frenum attachment
 Patient’s concern:
◦ I don’t like the appearance
of my upper anterior teeth.
 Skeletal problems:
◦ Class III skeletal pattern.
 Soft tissue problems:
o Asymmetrical face.
 Dental problems:
• Missing upper laterals .
• Reduce overjet 1mm.
• Reduce overbite 10%.
• Mild crowding lower arch
• Moderate crowding upper arch.
• Rotated UR 3,4,6 & UL 4 and 6.
• Rotated LL 3&5 .
• Lingually tilted LR 6.
• Class III incisor relationship.
• Molars are cl II full unit Rt side
and cl II ½ unit in Lt side .
• Canines are cl II ¾ unit in both
sides .

36. Treatment Aims
 Improve oral hygiene and correct high
frenum attachment.
 correct the patient complaint.
 Accept skeletal cl III pattern.
 Accept soft tissue problem.
 Open space for prosthetic replacement of upper
missing laterals.
 Correct overjet and overbite.
 Relief crowding in upper and lower arches.
 Achieve class I incisor relationship.
 Achieve class I molar and canine relationship.
 Correction of rotated teeth and lingually tilted LR6.

37.  Treatment plan:- “ Non Extraction Case”
“ camouflage case ”
 Oral hygiene instructions.
 Modified TPA appliance.
 Upper & Lower Fixed Appliance: using SWA technique.
“ Pre-adjusted edgewise, MBT prescription, slot 0.022”
 Open space for upper missing teeth.
 Stripping in the lower anterior teeth.
 Distalization of upper first molars (by pendulum ).
 Refer to perio. clinic for frenectomy.
 Retention:-
o Lower fixed retainer (3-3) and upper fixed retainer (1-1).
o Conventional lower and upper Hawley retainer.

38.  Justification:-
I. Non extraction :
 In lower arch with mild crowding, space can be gained by
correction of rotated teeth and IPR.
 In upper arch with moderate crowding, space can be
gained by correction of rotated teeth, distalization of
molars and arch wire expansion.
II. Camouflage :
 Patient pass the peak of growth.
 Mild cl III skeletal.
 Good vertical facial proportion.
 No dental compensation.
 Minimal overbite and overjet.
 Normal SNA &SNB value.

39. III. Modified TPA appliance :
 Derotation of upper 1st molars .
 Control vertical movement of upper1st molars.
 As anchorage to retract canines in class I.
IV. Fixed appliance using MBT prescription :
 For 3D tooth movement.
 Maxillary centrals palatal torque.
 Retroclination of lower incisors.

40. V. Open space for missing upper laterals:
 according to patient willing.
 Class III skeletal pattern.
 More esthetic.
 Age of the patient.
VI. Stripping in lower ant. teeth to retract the lower anterior
teeth to correct overbite and over jet.
VII. Refer patient to perio. clinic for frenectomy
(before debonding).

41. VIII. Retention :
 Long term :
Lower fixed retainer (3-3) to stabilize the position of
anterior teeth.
Upper fixed retainer (1-1) to stabilize the position of
central incisors.
 Short term :
Lower Hawley retainer.
Upper Hawley retainer with temporary prosthetic
replacement to preserve space of laterals.
For more settling and stability of incisor relationship.
Upper and Lower Hawley 6month full time wearing
followed by 6 month night time wearing.

42.  Mechanics :
 Chinch back and laceback in lower arch to avoid
proclination of lower labial segment.
 Use MBT to get further proclination of ULS and Lingual
crown torque on LLS.
 Swapping of lower canines brackets to avoid mesial tipping
of canines.
 Distalization of upper 1st molars to get CL I molar
relationship (by pendulum).
 Push-pull mechanics involving open-coil spring in the 2
region (push) and lacebacks to retract the canine (pull).
 Stripping on a round wire in the lower arch will facilitate
retroclination of the lower incisors.
 Use of anterior elastic to correct reduce overbite.

43. THANK YOU